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UPPER

GASTROINTESTINA
L BLEEDING
by
Siti Nurdjanah
Gastroenterology-Hepatology Division, Internal Medicine,
Faculty of Medicine, University of Gadjah Mada,
Dr. Sardjito Hospital, Yogyakarta

DEFINITIONS
* HEMATEMESIS : is vomiting fresh red blood

A site of bleeding proximal to the duodenaljejunal junction ( Upper Treitz Ligament )


The Colour of vomitus depends on how long
the blood has been in the stomach
* Coffee ground vomiting is vomiting of
altered black blood
* Melaena is the passage of black tarry stools

Causes of Haematemesis
and Melaena
Oesophagus
Oesophageal Varices
Mallory-Weiss tear
Oesophageal carcinoma
Reflux oesophagitis
Foreign body

Causes of Haematemesis
and Melaena
Stomach
Peptic ulcer
Erosions/ Gastritis
Gastric varices
Portal hypertensive gastropathy
Gastric carcinoma
Lymphoma
Leiomyoma
Angiodysplasia (including Oslers disease)
Dieulatorys erosion

Causes of Haematemesis
and Melaena
Duodenum/jejunum
Peptic ulcer
Erosions/ Gastritis
Vascular malformations
Haemobilia
Polyps (including Peutz-Jeghers
syndrome and other polyposis
syndromes)

Causes of massaive upper


gastrointestinal bleeding
Oesophageal or gastric varices
Gastric ulcer
Duodenal ulcer
Stress ulceration
Dieulatorys erosion
Aorto-enteric fistula

Aetiology of Non-Variceal Upper


Gastrointestinal Bleeding
Oesophagus

Mallory-Weiss tear, Reflux Oesophagitis, Oesophageal Ulcer,


Barrets ulcer, Cameron ulcer within hiatus hernia*, Oesophageal
neoplasm

Mallory

* Important causes of obscure UGIB

Aetiology of Non-Variceal Upper


Gastrointestinal Bleeding
Stomach

Gastric ulcer, Gastric erosions, Haemorrhagic gastritis, Gastric


carcinoma, Gastric lymphoma, Leiomyoma, Gastric polyp, Hereditary
haemorrhagic telangiectasia, Dieulafoy lesion*, Gastric Antral
Vascular Ectasia (GAVE)*, Angiodysplasia*

A gastric ulcer caused by H. pylori

* Important causes of obscure UGIB

Aetiology of Non-Variceal Upper


Gastrointestinal Bleeding
Duodenum

Duodenal Ulcer, Duodenal erosions, Vascular malformation, Aortaduodenal fistula, Polyp (including Peutz-Jeghers syndrome and
other polyposis syndromes), Carcinoma of ampulla, Carcinoma
of pancrease, Haemobilia*

A duodenal ulcer caused by H pylori

Two angiodysplasias (arrows)


in the duodenum

Aetiology of Non-Variceal Upper


Gastrointestinal Bleeding
Small
bowl

Stomal ulcer, Diverticulum (including Meckels diverticulum),


Vascular malformation, Tumor

Treatment of a bleeding diverticulum

Endoscopic stigmata associated with


high risk of further gastrointestinal bleeding.
Top left : an active, spurting haemorrhage from
a peptic ulcer is associated with an 80% risk of
Continuing bleeding or rebleeding in shocked
patients. Top right : a non-bleeding, visible vessel
Represents either a pseudoaneurysm of an eroded
artery or a closely adherent clot, and 50% of such
patients rebleed in hospital. Left: large varives
with red spots are also strongly associated with bleed

Klasifikasi V.E.
I.
II.
III.
IV.

Kl. Degradi
Kl. Palmer & Brick
Kl. Omed
Kl. Perhimpunan Endoskopi GI
Jepang

Kl. Perhimpunan Endoskopi GI


Jepang
1. Warna (colour)
2. Tanda Warna merah (red colour
sign)
3. Bentuk (form)
4. Lokalisasi

Warna
Colour White (CW)
Colour Blue (CB)

Tanda warna merah


(red colour sign/RCS)
Red Wale Marking (RMW)
gambar 1
Cherry Red Spot (CRS) gambar 2
Hemato Cystic Spot (HCS)
gambar 3
Diffuse Redness (DR)

(RWM)
Red Wale Marking)

Gambar 1

(CRS)
Cherry Red Spot

Gambar 2

(HCS)
Hemato Cystic Spot

Gambar 3

(DR)
Diffuse Redness

Gambar 4

Bentuk
Tingkat I : VE lurus (straight line
varises/F1) gambar 5
Tingkat 2 : VE bentuk untaian
tasbeh menempati 1/3 lumen (F2)
gambar 6
Tingkat 3 : VE yang besar, berkelokkelok >1/3 lumen (F3) gambar 7

Tingkat 1, varises yg lurus


(Straight line varicess/F1)

Tingkat 2, varices berbentuk


untaian manik-manik (rosary like varicess)
yg menempati 1/3 lumen(F2)

Tingkat 3, varices yg besar dan berkelo-kelok


Menempati lebih dari 1/3 lumen (F3)

Lokalisasi
VE sp diatas bifurkasi trakhea (LS)
VE yg menempati daerah dibawah
bifurkasi trakhea (Lm)
VE yg menempati daerah dibawah
1/3 distal (Li)
VE yang menempati cardia
lambung (lg)

Ls
superior

Lm
middle
Li
inferrior

Lg
gastric

PENATALASANAAN AWAL
Anannesis & pemeriksaan fisis
Tanda vital, Jalan infus yg sangat besar
Selang nasogastrik Hb, Ht, trombosit,
hemostaisis
Hemodinamik stabil
Tidak ada perdarahan aktif

Hemodinamik tidak stabil


Perdarahan aktif
RESUSITASI

Pengobatan empirik

Cairan krostaloid, cairan koloid,


Transfusi darah, koreksi
faktor koagulasi
Hemodinamik stabil
Perdarahan berhenti

Hemodinamik stabil
Perdarahan tetap berlangsung

Perdarahan berhenti
Elektif
Endoskopi SCBA

Pengobatan
definitif

Emergensi atau Dini


Endoskopi SCBA

Bedah

Varises esophagus
lambung
Skleroterapi
Atau ligasi
Atau SB tube

Jika
gagal

Tukak
Injeksi,
hemostatik
Atau bedah segera

Obat Vasoaktif
Octreotide, Somat ostatin,
Vasopressin

Sumber perdarahan
Tak tervisualisasi
Radiologi, Intervensional
Diagnostik & terapeutik
Atau bedah segera

Resuscitation
a. Mild or Moderate Bleed
* Pulse and blood pressure : N
* Hb > 10 mg/ml
* Without comorbidity
* Less than 60 years of age

b. Severe Bleed
Pulse > 100 beats/min
Sistolic blood pressure < 100
mmHg
Hb < 10 mg/ml
Aged > 60 years

Table 1. Hypovolaemic shock: symptoms, sign, and fluid replacement


Blood loss (ml)
Blood loss (%bv)
Pulse rate
Blood pressure
Pulse pressure
Respiratory rate
Urine output
Mental status
Fluid replacement

<750
<15%
<100
Norma
Normal or
increased
14-20
>30
Slightly anxious
Crystalloid

750-1500
15-30%
>100
Norma
Decreased
20-30
20-30
Mildly anxious
Crystalloid

1500-2000
30-40%
>120
Decreased
Decreased
30-40
30-40
Anxious &
confused
Crystalloid &
blood

>2000
<40%
>140
Decreased
Decreased
>35
>35
Confused &
letargic
Crystalloid blood

Adapted from Grenvick A, Ayres SM, Holbrook PR,


et al. Textbook of critical care. 4th edition. Philadelphia WB Saunders Company; 4

Minnesota tube

Endoscopic treatment of varices. Intravariceal injection of sclerosant


(left) and band ligation of oesophageal varices (right)

Endoscopic Treatment For Non-variceal


Thermal
Upper
Gastrointestinal
Bleeding
Heater probe
multipolar electrocoagulation (BICAP, Gold Probe)
Argon plasma coagulation
Laser

heter probe

Laser application
for bleeding ulcer
Argon_plasma_coagulation

Heater probe application


for bleeding erosion

Endoscopic Treatment For Non-variceal


Upper Gastrointestinal Bleeding
Injection
Adrenaline (1:10000)
Procoagulants (fibrin glue, human thrombin)
Sclerosants (ethanolamine, 1% polidoconal)
Alcohol (98%)

Sclerotherapy of bleeding spot

AdrenalineUlcer-active_bleeding

Endoscopic Treatment For Non-variceal


Upper Gastrointestinal Bleeding

Mechanical
Clips
Band Ligation
Endoloops
Staples
Sutures

Methods rarely used are depicted in italics.

Hemoclip application of bleeding erosion

Banding of bleeding spot

Conclusion
Early upper gastrointestinal Endoscopy ( within
24 hours). Is the cornerstone of management of
AUGB
Early Endoscopy
has 3 major roles
- Diagnosis
- Treatment
- Risk Stratification