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 PATIENTS
WITH 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)
NSAIDs = NSAIDs Gastropathy
SRMD = Stress Rel. Muc. Damage
PUD = Peptic Ulcer Dis.
Endoscopic Examination
In 64 pts with Non-variceal UGI Bleeding (Jan-Jun 2003)
Other NON-VARICEAL BLEEDING
1. PORTAL HYPERTENSIVE CONGESTIVE GASTROPATHY

2. ACUTE EROSIVE ESOPHAGITIS

Patogenesis: Stress Related Mucosal Damage
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/NSAIDs
- 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 ULCERS
Effectiveness of Intravenous Omeprazole vs Ranitidine
0
10
20
30
40
50
60
70
80
90
100
TOT DU GU ANAST
P
E
R
C
E
N
T
A
G
E

(
%
)
OME RAN
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 injection
injection 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.