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Perdarahan saluran cerna

bagian atas

Dr. Soegiarto

Gani, SpPD

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PERDARAHAN SALURAN CERNA BAGIAN ATAS

common problem & world wide / cosmopoli!n

Emer"enc# / d!r$r!

%orbidi!s / mor!li!s

Insidensi ' USA ()*/(**+*** pop$l!si & (*+*** ,

-*+*** .em!i!n / !$n+

%or!li!s )0(- 1 m!n$l!

c!rdio2!s.$l!r / CH3

emodin!mi. ins!bili# C4PD

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5l!si6i.!si !.i6i!s perd!r!!n men$r$ 3orres

A.i6i!s perd!r!!n 5rieri! endos.opi.

3orres I! , Perd!r!!n !.i6

men#emb$r 7sp$rin"8

3orres Ib , Perd!r!!n !.i6

3orres II , Perd!r!!n bereni9

e!pi m!si diser!i

.el!in!n #!n" n#!!

3orres III , Perd!r!!n bereni9!np! men$n:$..!n

sis!

perd!r!!n !reri

perd!r!!n merembes

7oo;in"8

"$mp!l!n d!r! p!d!

d!s!r $.!.

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ETI4L4GI

TD / TL

Erosi l!mb$n"

5!n.er l!mb$n"

>!rises eso6!"$s

Eso6!"iis9 .!n.er eso6!"$s

D$odeniis

%!llor#0?eiss s#ndrome

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PSCA @* 1 bereni spon!n9 -* 1 rebleedin"

0 %elen! * cc d!r!

0 D!r$r! penin" s!$s emodin!mi.

0 si"ni6ic!n !emorr!"e s#mpoms s#ncope9 p$c!9

!.i.!rdi9 T> 9 ipoensi pos$r!l+

0 T!nd!- s#o. / perd!r!!n )* 1 blood 2ol$me TD

sisol (** mmH"9 !.i.!rdi9 peri6er din"in9 Hb (* "r19

H*1 rend!.!n .ep!l! / rendelenb$r"

I>3D cor RL / N!Cl / Aserin"

sirosis !i 6res 6ro;en pl!sm!F rombosi

$remi. F !spirin rombosi

emo6ili / 2on willibr!nd spesi6i.

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Res$si!si pd PSCA m!si6

P!s!n" in6$s / I>3D

Pem+ D!r!

Cross %!c

5ore.si .o!"$lop!i :i.! perl$

Tr!ns6$si d!r! :i.! perl$

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DIAGN4SIS

(+ An!mnese

Ideni6# pre0eisin" morbid condiion

riw!#! P is.emi. / CH3 / !rimi! :"9 C4PD9 GG59HT9 D%

riw!#! m$n!- eb! %!llor# , weiss s#nd+

SH >!rices bleedin" & non 2!rices 7* 18

NSAID

Sress $lcer diseb!b.!n perd!r!!n $lser!si

sress !.$ / pre0eisin" pepic$lcer dise!se / .ondisi p!olo"il!in #" ber$b d"n PSCA

serin" ber$b d"n l$.! b!.!r9

r!$m! m!#or9 r!$m! .!piis9m$li or"!n 6!il$re+

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-+ Pem+ 6isi.

Penil!i!n s!$s emodin!mi. & res$si!si

T!nd!-li2er si"m!! & HT por!l

!$ndice

Bleedin" di!esis p$rp$r!9 e.imosis9 pi.i!e

+ Endos.opi

H!r$s peri.s! E5G P59 !rimi! J

Psn "!"!l n!6!s / .om!beb!s.!n :!l!n n!6!s+

Bil! endos.opi bel$m dp s$mber PSCA!n"io"r!6i

!!$ l!belled red cell r!dion$clide sc!n

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TERAPI

I. ULKUS PEPTIC

(+ 3!rm!.olo"i ARH-9 PPI9-+ Endoscopic er!p# l!ser

ele.ro.o!"$l!si

e!er probe

opic!l spr!#s

in:ecion er!p# 7!dren!lin((*+***9 !l.ool & polido.!nol 8

+ R!diolo"ic er!p# embolis!si dii.$i .!eeris!si+ Prop#l!cic er!p# ' er!di.!si HP pd TD & TL

' empiric er!p# :i.! HP d.dier!di.!si+

' An!lo" PG 7misoprosol8

$.

NSAID F TL' S$r"er# $. rec$rren bleedin"

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PERDARAHAN SALURAN CERNA BAGIAN ATAS

HE%ATE%ESIS / %ELENA

DENGAN GANGGUAN HE%4DINA%I5 TANPA GANGGUAN

HE%4DINA%I5S#o. 7b!rin" )*19 d$d$. *18

A!si ipo2olemi In6$s / r!ns6$si ses$!i

0 N!Cl9 RL9 Pl!sm! ep!nder .eb$$!n

0 Tr!ns6$si d!r! bi!s! / PRC Sl!n" N!so"!sri.

Sl!n" N!so"!sri. Bil!s !ir es

0 Bil!s den"!n !ir es s!mp!i :erni 4b! emos!i.

4b! emos!i. %onior Hb/H9 ensi9 n!di9

%onior Hb/H9 ensi9 n!di9 .es!d!r!n .es!d!r!n

An!mnese & Pemeri.s!!n 3isi. An!mnese & Pemeri.s!!n 3isi.

Perd!r!!n er$s Perd!r!!n sop

G ! s r o s . o p i

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G!sros.opi

Den"!n 2!rises T!np! 2!rises

0 S.leroer!pi d!r$r!

0 Sl!n" S0B F G!sriis erosi6

0 Piressin I> -* U F -** ml Derose )1 Ul.$s Pepi.$m

diberi.!n -* meni %!llor# ?eiss

0 Ter!pi .onser2!i6 dier$s.!n T$mor

7!n!sid9 pen"!mb! H-9 emos!i.9 l!.$lose9 neomisin8 5onser2!i6

7!n!sid9 pen"!mb! H-9PPI

emos!i.8

Perd!r!!n er$s Perd!r!!n sop

4per!si 5onser2!i6

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Endoscopic er!p# o6 $pper GI bleedin"

T4PICAL THERAPK

-Tiss$e !desi2es

-Cloin" 6!cors

-Coll!"en

-3errom!"neic !mpon!de

%ECHANICAL THERAPK

-Sn!res

-S$$res

-B!lloons

-Hemoclips

INECTI4N THERAPK

->!rice!l bleedin"

-Non 2!rice!l bleedin"

0 E!nol

0 4er scleros!ns

THER%AL THERAPK

-Elecroco!"$l!ion

0 monopolo!r

0 elecro#droerm!l

bipol!r 7m$lipol!r8

-He!er probe

-L!ser

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3i"$re ( + %!n!"emen o6 bleedin" pepic $lcer

Pepic $lcer

Low ris. o6 rebleedin" Aci2e bleedin" or i" ris. o6rebleedin" 7soc.9 2isible

2essel8

% o n i o r Endoscopic er!p#

No 6$rer bleedin" Rebleed Un!ble o conrol bleedin"

Repe! endoscop# er!p#

Rebleed

S$r"er#

* n * n

Embolis!sion er!p#

Rebleed

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II. VARISCES ESOPHAGUS LEE!I"G

(+ Endos.opi S.leroer!pi & Li"!si

-+ 3!rm!.olo"i ' :i.! endos.opi d. dp di.er:!.!n+

' >!sopressin F niro"liserin

+ B!lloon T!mpon!de Sen"s!.en , Bl!.emore9

Linon $be+

+ TIPS 7 Tr!ns:$"$l!r Inr!ep!ic Poro0s#semic

Sen S$n 8

)+ Pro6il!.sis prop!nolol me

e.+ >+ por! pd SH

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>!rice!l Bleedin"

Tempor!r# %e!s$res

B!llon !mpon!de

>!soconsricors

In:ecion Scleroer!p#/>!rice!l li"!ion

H!emos!is !cie2ed Conin$ed bleedin"

Repe! ! 0 wee.s$p o )0 session

Repe! in:ecion scleroer!p# /2!rice!l li"!ion

Conin$ed bleedin"

TIPS / S$r"er#

3i"$re -+ Scem! 6or e m!n!"emen o6 bleedin" oesop!"e!l >!rices

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3i"$re + %!n!"emen o6 non bleedin" 2!rices

>!rices presen b$ no bleedin"

B!nd li"!ion

Rebleedin" No 6$rer bleedin"

Repe! b!nd li"!ion 7or scleroer!p#8

3$rer bleedin" No 6$rer bleedin" Repe! wiin ( wee.

Consider

0 Tr!nsc$!neo$s inr!ep!ic poros#semic s$n0 S$n s$r"er# / li2er r!nspl!n!ion

0 widr!w!l o6 er!p#

Repe! e2er# 0wee.s $nil 2!rices

!re oblier!ed

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5ESI%PULAN

Pen#eb!b $!m! perd!r!!n diseb!b.!n !cid rel!ed

dise!se 7erosi2!9 TD/TL9 NSAID9 "!srop!i pd $si!

l!n:$+

Di Indonesi! 2!rises bleedin" mor!li!s &

insidensin#! in""i +

Ter!pi iner2ensi "!sroinesin!l endos.opi sem!.in

l$!s di"$n!.!n 7 li"!si9 s.lero!r!pi9 clips9 e!er

probe9 l!ser dll 8

I i i

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In#estigati$nIn#estigati$n

May show angiodysplastic lesions even once bleeding

has ceased

Mostpatients are stable and can be investigated once bleeding has

stopped

In the actively bleeding patient consider

Colonoscopy - can be difficult

Selective mesenteric angiographyRequires continued bleeding of > ml!minute

%

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%anage&ent%anage&ent

If source of colonic bleeding unclear perform a subtotal

colectomy and end-ileostomy

"cute bleeding tends to be self limiting

Consider selective mesenteric embolisation if life threatening

haemorrhageIf bleeding persists perform endoscopy to e#clude upper $I cause

%roceed to laparotomy and consider on-table lavage an panendoscop

If right-sided angiodysplasia perform a right hemicolectomy

If bleeding diverticular disease perform a sigmoid colectomy