Download - HEMATEMESIS-MELENA
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HEMATEMESIS-MELENA
ARNELISSubdivisi Gastroenterohepatologi
Ilmu Penyakit Dalam FK UNAND / RS M Jamil Padang
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Defenisi :
Perdarahan dari saluran cerna, mulai dari esofagus sampai dengan duodenum (Lig Treitz)
- Hematemesis : Muntah darah
- Melena : Bab yang lembek dengan warna
hitam pekat seperti ter (aspal)
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Penyebab / sumber perdarahan :
Perdarahan SCBA
Varises – Varises esofagus – Varises fundus
Non varises – Esofagitis – Tukak peptik – Stress ulcer – Mallory-Weiss tear – Duodenitis / esofagitis – Tumor / Carcinoma – Telengectasia herediter – Hemostatic defect – Angiodisplasia – dll
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PATOGENESIS
Varises esofagus / gastropati kongestif
- hipertensi portal NSAID
- efek topikal langsung
- jalur hambatan prostaglandin
Tukak peptik
- Hp
- aspirin / NSAID
- hipersekresi asam lambung
- iskemia mukosa
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Mallory Weiss
- laserasi mukosa esofagogastric
junction
- ok muntah-muntah Esofagitis
- refluk
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Gambaran Klinis
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Sinkop : takikardia, kepala pusing, melayang Syok : - tekanan darah turun (sistolik < 100 mmHg) nadi cepat (> 100x/ mnt) - muka (kulit, mukosa) pucat - acral dingin
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Postural Signs :Prinsip : Kehilangan darah = kehilangan volume intravaskuler : – Kardiak output & tekanan darah menurun – Nadi menjadi cepat – Perdarahan > 1000 cc kompensasi postural tekanan darah dan nadi tidak cukup
Cara : Pasien tidur terlentang (ukur tensi & nadi) dudukkan (ukur tensi & nadi) – Jika nadi meningkat > 20 / mnt atau TDS turun > 10 mmHg Kehilangan darah sekitar 20 % (1 Ltr)
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PERDARAHAN BERMAKNA
Kebutuhan tranfusi 2 unit atau lebih dalam 24 jam sejak MRS
Tekanan sistolik < 100 mmHg Penurunan tekanan darah > 20 mmHg
dengan perubahan posisi Nadi > 100 x/menit saat MRS
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DIAGNOSIS
Anamnesis : aspirin / NSAID riwayat tukak peptik obat tradisional penghilang nyeri
Pemeriksaan fisik : RT stigmata peny hati kronis diatesis hemoragik
NGT Laboratorium Ba meal Endoskopi
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Karsinoma esofagus
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Perdarahan varises
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Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm
Ulcer
Acute peptic ulcerAcute peptic ulcer
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Martin & Lyons, The Atlas of Gastrointestinal Endoscopy. www.mindspring.com/~atlsouthgastro/stul01.html
Bleeding gastric ulcerBleeding gastric ulcer
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Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm
Duodenal ulcerDuodenal ulcer
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Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm
Bleeding duodenal ulcerBleeding duodenal ulcer
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Singh. Am J Med. 105:31S–38S, 1998.Singh. Am J Med. 105:31S–38S, 1998.
NSAID-induced gastropathyMorbidity, mortality, costs in USA
Total hospitalizations per year– 107,000
Deaths – 16,500
Total annual costs ($10,000 – $15,000 per hospitalization)– >$1 billion
Total hospitalizations per year– 107,000
Deaths – 16,500
Total annual costs ($10,000 – $15,000 per hospitalization)– >$1 billion
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NSAIDs administration
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? Virulence Host Environment
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PENATALAKSANAAN UMUM
Penilaian hemodinamik + resusitasi cairan Penilaian onset dan derajat perdarahan Usaha menghentikan perdarahan Identifikasi sumber perdarahan Mengatasi sumber perdarahan secara
defenitif Meminimalisasi komplikasi Mencegah perdarahan ulang
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PENATALAKSANAANPerdarahan SCBA non varises
Penatalaksanaan medis
- non farmakologis
- farmakologis
H2RA / PPI, obat hemostatik
sitoprotektor, antibiotika
- penatalaksanaan khusus
terapi hemostatik perendoskopik
somatostatin jangka pendek
embolisasi arteri daerah ulkus Penatalaksanaan bedah / operasi
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Penatalaksanaan perdarahan tukak peptik berdarah
Tukak peptik
Risiko perdarahan rendah Perdarahan aktif / risiko tinggiPerdarahan (syok/visible vessel)
Monitor
Perdarahan berhenti
Terapi endoskopi
Perdarahan ulang
Ulang terapi endoskopi
Perdarahan ulang
Tidak dapat mengontrolperdarahan
Operasi / bedah
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PENATALAKSANANPerdarahan SCBA oleh varises
Penatalaksanaan umum Vasoaktif (vasopresin, somatostatin,
octreotide) Antibiotika Pengobatan komplikasi Pengobatan defenitif : SB tube, STE, LVE,
TIPS, Profilaksis sekunder : beta bloker, ISMN
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Sengstaken-Blakemore tube
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BALON LAMBUNG
BALON ESOFAGUS
SENGSTEKEN BLACKMORE TUBE( SB TUBE )NG TUBE