Upper GI Bleeding

Epidemiologi

Insiden upper GI bleeding: 48-145/100,000 populasi [Gilbert,1990].

Rawat Inap: 102/100,000 populasi [Longstreth,1995].

Rawat Inap: 149-172/100,000 populasi [Lewis,2002].

DIAGNOSIS IN PATIENTSWITH UPPER GI HEMORRHAGE

• Peptic ulcer 47 % Duodenal 24 % Gastric 21 % Stomal 2 %• Gastric erosions 23 %• Varices 10 %• Mallory-Weiss tears 7 %• Esophagitis 6 %• Erosive duodenitis 6 %• Tumors 3 %• Esophageal ulcers 2 %• Angiodysplasia 0.5 %• Others lesions 6 %

Silverstein, FE et al, Gastrointest Endosc 1981; 27: 73

OTHERS (7.8%) PUD (9.4%) Acute erosive gastro-duodenitis (35.9%)NSAID (17.2%)

SRMD (29.7%)

(Hernomo, 2003)

NSAIDsNSAIDs = NSAID’s Gastropathy= NSAID’s GastropathySRMDSRMD = Stress Rel. Muc. Damage= Stress Rel. Muc. DamagePUDPUD = Peptic Ulcer Dis.= Peptic Ulcer Dis.

NSAIDsNSAIDs = NSAID’s Gastropathy= NSAID’s GastropathySRMDSRMD = Stress Rel. Muc. Damage= Stress Rel. Muc. DamagePUDPUD = Peptic Ulcer Dis.= Peptic Ulcer Dis.

Endoscopic ExaminationIn 64 pts with Non-variceal UGI Bleeding (Jan-Jun 2003)

Other NON-VARICEAL BLEEDINGOther NON-VARICEAL BLEEDING

1. PORTAL HYPERTENSIVE CONGESTIVE GASTROPATHY

2. ACUTE EROSIVE ESOPHAGITIS

Patogenesis: Stress Related Mucosal Patogenesis: Stress Related Mucosal DamageDamagePatogenesis: Stress Related Mucosal Patogenesis: Stress Related Mucosal DamageDamage

Offensive factors: asam lambung, pepsin

+

Defensive factors: hipoperfusi aliran darah ke mukosa

gaster

(akibat Shock, Sepsis, Trauma, Critical Illnes)

Peningkatan permeabilitas mukosa

Ulkus

Pathogenesis of Stress-Related Mucosal Damage (SRMD)

Faktor Kontributor

• Uremia

• Reflux empedu dari ileus (usus halus)

• Corticosteroids

• Perubahan produksi mukus akibat puasa

Pasien Resiko thd Stress Ulcer

1. ICU patients :- intubated for resp. failure- coagulopathy- on corticosteroid/NSAID’s- on anticoagulation- multiple organ failure- intracranial hypertension- GCS < 10

2. Surgical patients in the ICU :- multiple trauma- spinal cord injury- major infectious complication

3. Inpatients :- acute renal failure- hepatic failure- major burn injury (> 35%)

Am. Soc. Of Health-System Pharmacists (ASHP), 1999

Stress Ulcer Prophylaxis

1. Start enteral feeding as soon as possible

2. Antacids

3. H-2 receptor antagonists

4. PPI

5. Sucralfate

6. Prostaglandins

Am. Soc. Of Health-System Pharmacists (ASHP), 1999

UGI Bleeding

• 80% perdarahan akan stop secara spontan tanpa kekambuhan

• 20% akan kambuh

• Goal: mengidentifikasi pasien resiko tinggi(menggunakan gejala klinis, lab & endoskopi)

Consensus Recommendations : Upper GI Bleeding, non-variceal    Annals of Internal Medicine. 2003;193:843-857.

Resiko Re-bleeding/Continued Bleeding

Clean ulcer base                    <5%

Ulcer with flat spot                10%

Ulcer with adherent clot        22%

Non-bleeding visible vessel    43%

Active bleeding (ooze,spurt) 55%

Consensus Recommendations : Upper GI Bleeding, non-variceal    Annals of Internal Medicine. 2003;193:843-857

Terapi Non-variceal Bleeding

1. General treatment :– Resuscitation– Nasogastric tube aspiration– Treat underlying cause

2. Specific treatment :– Increase intraluminal pH > 7

(H-2 blockers, PPI, antacid)– Sucralfate, Trepenon– Somatostatin

3. Endoscopic treatment :– Injection therapy– Electrocoagulation– Laser therapy– Topical therapy– Hemoclips

4. Angiographic therapy :– Vasopressin infusion– Selective occlusion techniques/ Transcatheter embolization

Terapi Non-variceal Bleeding

pH versus Platelet Disaggregation

BLEEDING PEPTIC ULCERSEffectiveness of Intravenous Omeprazole vs Ranitidine BLEEDING PEPTIC ULCERSEffectiveness of Intravenous Omeprazole vs Ranitidine

0102030405060708090

100

TOT DU GU ANAST

PER

CE

NT

AG

E (%

)

OME RAN

Brunner and Chang, 1990 Brunner and Chang, 1990

Consensus Recommendations : Upper GI Bleeding, non-variceal

1. Rekomendasi: terapi PPI

Terapi H2 blocker tidak direkomendasi

2. Dosis Omeprazole or pantoprazole IV

bolus 80 mg

infus 8 mg/jam selama 72 jam

Annals of Internal Medicine. 2003;193:843-857

ENDOSCOPIC METHOD TO STOP BLEEDING

Clip method Method to stop bleeding by directly closing the blood vessel which bleeds with clip

Coagulating method by high this method to stop bleeding by using thermal coagulating frequency electricity action of high frequency electric current which has been used

since long time ago

Pure ethanol dehydrating This method to stop bleeding by chemical and fixing action by local injection method local injection of pure ethanol. It has high efficiency to stop

bleeding, easy to handle, and portable, so is being used widely.

Hypertonic Na-epinephrine local This method is similar to that of pure ethanol local injectioninjection method method. It stop bleeding by the action of epinephrine to shrink the

blood vessel and by pressuring action of hypertonic Na liquid.

Laser coagulation method This method to stop bleeding by coagulating and denaturalizing the tissue with thermal power of laser beam. There are argon laser, YAG laser, etc.

Heat probe method This is the method developed as thermal coagulating method which uses the semiconductor.This is noted for its effectiveness to stop bleeding and for the portability.

Microwave method This is method to stop bleeding by using thermal coagulating action, and uses the heat which the microwave generates.

APC method This method is non-touching coagulating method which uses high frequency electric current and was introduced to our country recently. It has high safety, easy to use, and effective for wide range

of bleeding.