Oleh :

Dr Hudiarso SpPD FINASIM

RS Puriasih Salatiga

Salatiga, 16 Agustus 2017

 Perdarahan SCBA : perdarahan sal cerna yg
dimulai dari Esofagus Duodenum / diatas
ligamentum Treitz dg manifestasi kx : hematemesis
melena , +/- hematokesia .
Ulkus peptikum : terputusnya kontinuitas mukosa
yg meluas sampai muskularis mukosa dg kedalaman
+/- 5 mm berhub dg asam lambung / pepsin .
Perdarahan ulkus peptikum : perdrhn sal cerna bag
atas yg disebabkan ol ulkus peptikum
Erosif gastritis : kerusakan jar yg terbatas pd
lapisan mukosa .
 Varices esofagus
Erosif gastritis
Tukak peptik / Ulcus Pepticum
Gastropathy kongestif
Sindroma Mallory-Weiss
Keganasan
AKTIFITAS PERDARAHAN KRITERIA ENDOSKOPI

F Ia : ulkus dg perdarahan Perdarahan arteri

aktif
menyembur
F Ib : ulkus dg perdarahan Perdarahan merembes
aktif merembes
F II a : ulkus dg pemb drh Gumpalan darah pd
visible tak berdarah
F II b : ulkus dg bekuan
dasar tukak / terlihat
adheren pemb darah
F II c : ulkus dg bintik
pigmentasi dasar Lesi tanpa sisa
F III : berhenti tanpa sisa perdarahan
perdarahan / bersih
Forrest I

Forrest IIa
Forrest IIb

Forrest IIc

Forrest III
 anemia from occult bleeding
Melena black or tarry stools
Hematemesis cofee ground
Hematochezia bright red blood
per rectum

Melena 50100 ml of blood in

the upper GI tract.
Hematochezia blood loss
>1,000 ml of blood from the lower
GI tract .
 Class I & II - The crystalloid replacement
Normal saline and Ringers lactate
sufficient to replace plasma losses + the
interstitial loss
3mL of crystalloid for each 1mL of estimated
blood loss-> every 15 30 minutes until the
clinical signs of shock have been corrected.

Class III & IV

The colloid replacement until crossmatched
blood is available

At the time of the insertion of IV catheters :

blood -> type and crossmatch
laboratory : CBC, electrolytes, BUN,
creatinine, LFT and a coagulation profile.
 Ax & Physical Examination- the source of
the bleeding :
Hematemesis Melena UGIB

Hematoschezia LGIB
 placing NGT lavaging the stomach with
saline ( no advantage between iced-saline
and room temperature lavage) bloody
gastric aspirate Over 90% UGIB
 Upper GIB

Lower GIB
 Stratifikasi Rasio dg skor Blatchford (0 23) dan Rockall
skore Blatchford > 6 terapi intervensi
Pemasangan NGT dilakukan pd perdarahan aktif dg
gangguan hemodinamik ( tdk pd semua pasien
perdarahan)
Lavage nasogastrik dg air suhu kamar
Resusitasi cairan (kristaloid / NaCl , koloid , darah )
Pemberian PPI sebelum endoskopi
Terpi endoskopik (epinefrin, klem hemostatik,
termokoagulasi dan elektrokoagulasi .
Variabel
Tek darah sistolik
100 - 109 1
90 99 2
< 90 3
Ureum
36,5 44,5 2
44,6 55,5 3
55,6 139,9 4
> 140 6
Hemoglobin
12 12,9 1
10 11,9 3
< 10 6
lain
nadi > 100 1
melena 1
peny hati (+) 2
gagal jantung (+) 2
 No Variable Poin No Variable Poin

1. Systolic Blood Pressure (mmHg) 4. Haemoglobin (g/dL)

for Women
100-109 1 12.0-12.9 1
90-99 2 10.0-11.9 3

< 90 3 < 10.0 6

2. Blood Urea (mg/dL) 5. Other Markers
36.5 44.5 2 Pulse > 100x/min 1
44.6 55.5 3 Melena present 1
55.6 139.9 4 Hepatic disease present 2

140 6 Cardiac failure present 2

3. Haemoglobin (g/dL)
for Men
12.0 12.9 1

10.0 11.9 3

< 10.0 6

Total Score

Score 0-5: no need intervention; Score > 6: need intervention

Konsensus Nasional Penatalaksanaan Perdarahan Saluran Cerna Atas non-Varises di Indonesia 2012;p.8-9
No Variable Score 0 Score 1 Score 2 Score 3

1. Age < 60 60 -79 > 80 -

(years old)

2. Shock - Tachycardia (Pulse>100X/min) Hypotension(Pulse>100X/min) -

Blood pressure normal Systolic blood pressure <
100mmHg
3. Comorbid - - Heart Failure Renal failure
Ischaemic heart disease, Liver failure,
Congestive heart failure, Metastatic
any other major comorbidity cancer

4. Diagnosis Mallory-Weis tear, Peptic ulcer,esophagitis, or Malignancy in the upper -

no lession, errosive GastroIntestinal
no SRH
(Stigmata of Recent
haemorrhage)
5. SRH Major None or dark spot only - Blood in the upper GI, Bleeding -
Active,Non Bleeding Vissible
Vessel,Adherent Clot,Flat
Pigmented Spot
Total Score

Note: Rockall score <3 related to good prognosis; score > 8 related to high risk of death2
SRH=stigmata of recent haemorrhage
1. Konsensus Nasional Penatalaksanaan Perdarahan Saluran Cerna Atas non-Varises di Indonesia 2012;p.8-9
2. British Society of Gastroenterology Endoscopy Committee. Gut 2002;51(Suppl IV):iv1iv6
 Terapi PPI lbh superior dari pd dg H2 blocker

Direkomendasikan PPI dosis tinggi : esomerasol

80 mg iv dilanjut perinfus 8 mg / kgBB/jam
selama 72 jam dilanjut oral .

PPIdosis tinggi bermanfaat unt mengatasi

perdarahan ulang ok : cepat menetralisir
asam lambung stabilisasi bekuan darah
mendukung penyembuhan mukosa .
Management of
Peptic Ulcer
Bleeding
Treatment of peptic ulcer bleeding aims to stabilize the
circulation, stop on-going bleeding and prevent re-bleeding and
includes:

Haemodynamic status should be assessed immediately

Blood transfusions should be administered to a patient with a

hemoglobin level of 7 g/dL 1,2

Endoscopy haemostatis therapy ( if necessary, based on risk

assessment and classification)

surgery, if bleeding cannot be controlled

by the above measures2

1. Laine L et al.Am J Gastroenterol.2012;107:345-360 .

2. Konsensus Nasional Penatalaksanaan Perdarahan Saluran Cerna Atas non-Varises di Indonesia 2012;p.16-17
 The Aims:
to stabilize the haemodynamic state,
to stop ongoing bleeding,
to prevent re-bleeding
The Principles:
fluid replacement (blood tranfusion if needed)
PPI therapy
Prompt endoscopic (endosc. haemostasis if needed)
Surgery, if bleeding cannot be controlled
 Active Spurting Flat Pigmented Spot or
Bleeding or Oozing or Adherent Clot Clean Base
Vissible Vessel

Can be considered Without Endoscopic

Endoscopy Therapy Endoscopic therapy therapy

Intravenous PPI Intravenous PPI Oral PPI

Bolus + Drip Bolus + Drip

*If facility of endoscopic available

1. Konsensus Nasional Penatalaksanaan Perdarahan Saluran Cerna Atas non-Varises di Indonesia 2012;p.19
2. Laine L et al Am J Gastroenterol 2012;107:345-360
 Recommendation 15: H2-receptor antagonists are not recommended in
the management of patients with acute upper GI bleeding.
Recommendation: D (vote: a, 92%; b, 8%)

Recommendation 16: Somatostatin and octreotide are not

recommended in the routine management of patients with acute
nonvariceal upper GI bleeding. Recommendation: C (vote: a, 96%; b,
4%); Evidence: I

Recommendation 17: An intravenous bolus followed by continuous-

infusion proton-pump inhibitor is effective in decreasing rebleeding in
patients who have undergone successful endoscopic therapy.
Recommendation: A (vote: a, 100%); Evidence: I

Recommendation 18: In patients awaiting endoscopy, empirical therapy

with a high-dose proton pump inhibitor should be considered.
Recommendation: C (vote: a, 40%; b, 32%; c, 16%; d, 12%); Evidence: III

Barkun Alan, et al. Ann Intern Med. 2003;139:843-857.

Gastric Acid inhibits
haemostasis in
Peptic Ulcer Bleeding
 Agregasi (%)
0

20 ADP pH=6,0
Disagregasi=77%

40

60 Buffer
pH=6,4
Disagregasi =16%
80 pH=7,3
Disagregasi =0%
100
0 1 2 3 4 5 Waktu (menit)

ADP, adenosine diphosphate Green FW, et al. Gastroenterology 1978;74:3843

 Median pH Nexium i.v.,
7 40 mg infus
Hari I sekali sehari
6
pantoprazole
5 i.v., 40 mg
infus sekali
4 sehari
baseline
3

0
0 1 2 3 4
Waktu setelah pemberian (jam)

Wilder Smith et al. Aliment Pharmacol Ther 2004;20:1099-1104

 Nexium i.v.,
Median pH 40 mg infus
7 Hari 5 sekali sehari
pantoprazole
6 i.v., 40 mg
infus sekali
5
sehari
4 baseline

0
0 1 2 3 4
Waktu setelah pemberian (jam)
Wilder Smith et al. Aliment Pharmacol Ther 2004;20:1099-1104
Esomeprazole
for Prevention of
Recurrent
Peptic Ulcer
Bleeding
The need to investigate the efficacy of
PPI in heterogenous population of
patients with PUB with an
appropriately designed, multicentre,
controlled study

Sung JJ, et al. Ann Intern Med 2009;150:455-464

 IV treatment oral treatment
(72 hours) (27 days)

Enrollment phase:
Endoscopic therapy
Esomeprazole iv,
80 mg for 30 minutes Esomeprazole oral,
followed by
40 mg once daily
esomeprazole iv, 8
mg/hour for 71.5 hours

(0max 24 R
hours) Placebo iv for
30 minutes followed Esomeprazole oral,
by placebo iv for 40 mg once daily
71.5 hours

Conduct in 91 centers in 16 countries multicenter

Including 3 ethnic (Asian, African and Caucasian) - heterogeneous
Used placebo as control controlled study

IV = intravenous Sung JJ et al. Ann Intern Med 2009;150:455-464

Patients with re-bleeding (within 72 hours)
(%)
esomeprazole iv, 80
15
mg + 8 mg/hour

12
43% placebo

9 10.3
*p=0.026
6 *
5.9
3

Sung JJ et al. Ann Intern Med 2009;150:455-464

Patients with re-bleeding
(%)
esomeprazole iv,
15 80 mg + 8 mg/hour
for 3 days then
44% 43% 13.6 esomeprazole oral,
12 12.9 40 mg once daily,
for 27 days
9 placebo iv for
**
** 3 days then
7.7 esomeprazole oral,
6 7.2
40 mg once daily,
for 27 days
3
**p=0.01
0
Within 7 days Within 30 days

IV = intravenous Sung JJ et al. Ann Intern Med 2009;150:455-464

 Patients requiring endoscopic
re-treatment (%)
esomeprazole iv,
15 80 mg + 8 mg/hour
for 3 days then

12 45% esomeprazole oral,

40 mg once daily,
for 27 days
11.6
9 placebo iv for
3 days then
* esomeprazole oral,
6 40 mg once daily,
6.4
for 27 days
3
*p=0.012
0

IV = intravenous Sung JJ et al. Ann Intern Med 2009;150:455-464

Total units of blood transfused
(within 30 days)
esomeprazole iv,
1000 80 mg + 8 mg/hour
37% for 3 days then
935 esomeprazole oral,
800 40 mg once daily,
for 27 days
*
600 placebo iv for
589 3 days then
esomeprazole oral,
400 40 mg once daily,
for 27 days
200
*p=0.034

IV = intravenous Sung JJ et al. Ann Intern Med 2009;150:455-464

 Total number of additional days in hospital
for re-bleeding (within 30 days) esomeprazole iv,
600 80 mg + 8 mg/hour
for 3 days then
500 43% esomeprazole oral,
40 mg once daily,
500 for 27 days
400
placebo iv for
300 * 3 days then
* esomeprazole oral,
284 40 mg once daily,
200 for 27 days

100 **p=0.008

IV = intravenous Sung JJ et al. Ann Intern Med 2009;150:455-464

 30-day overall surgery rate with esomeprazole iv
followed by esomeprazole oral was 2.7% of patients
compared with 5.4% with placebo (not significant)

30-day mortality rate with esomeprazole iv followed by

esomeprazole oral was 0.8% of patients compared with
2.1% with placebo (not significant)

Result : Numerical, but not statistically significant, differences in favour of

the esomeprazole in peptic ulcer bleeding therapy regimen were
obtained for surgery and mortality

IV = intravenous Sung JJ et al. Ann Intern Med 2009;150:455-464

Esomeprazole, given as an i.v. infusion followed
by esomeprazole oral, after successful
endoscopic haemostasis was:

effective in reducing re-bleeding1

well tolerated2

IV = intravenous 1. Sung JJ et al. Ann Intern Med 2009;150:455-464

2. Kuipers EJ et al. Gut 2008:57(Suppl II):A352
Latest pharmacological in PUB Management
Normal hemostatic mechanism are impaired in an acidic
environment, need to increase pH > 6
Compared to pantoprazole iv, esomeprazole is more effective
in acid control at pH > 6
Intravenous bolus followed by continuous infusion PPI
therapy is recommended for patients with high risk stigmata
Patients should be discharged with single dose oral PPI
New study on PUB with esomeprazole with multicenter,
controlled study reduced recurrent re-bleeding at 72 hours
and has sustained clinical benefits for up to 30 days
Terimakasih