Pendarahan Saluran Cerna

Citra Pratiwi (10-017)

ANATOMY OF GIT

FOREGUT
Abdominal esophagus

MIDGUT
Major duodenal papilla

HINDGUT
Junction B/w prox 2/3 and
distal 1/3 of tranverse colon

Major duodenal
papilla

Junction B/w prox.

2/3 and distal
1/3
of tranverse colon.

Midway of anal
canal
2/81

ARTERIAL SUPPLY

Mostly by anterior branch of abdominal

aorta
Superior
Inferior
Celiac trunk Mesenteric
Mesenteric
Foregut
Artery Artery Midgut
Hindgut
left gastic
inferior
sigmoid
artery
pancreatico
arteries
splenic
duodenal
superior
artery
artery
rectal artery
common
jejunal and
Left colic
hepatic
ileal
artery
artery
arteries
middle
colic artery
right colic
artery
ileocolic
artery

3/81

INTRODUCTION
Gastrointestinal bleeding
describe every form of
haemorrhage in the GIT,
from the pharynx to the
rectum.
LIGAMENT OF
TREITZ

Can be divided into 2

clinical syndromes:- upper GI bleed
(pharynx to ligament of
Treitz)
- lower GI bleed (ligament
of Treitz to rectum)
6/81

PERDARAHAN SALURAN CERNA BAGIAN

ATAS

common problem & world wide / cosmopolitan

Emergency / darurat

Morbiditas / mortalitas

Insidensi : * USA 150/100.000 populasi & 10.000

20.000 kematian / tahun.
Mortalitas : 5-12 % manula
cardiovaskular / CHF
instability
COPD

hemodinamik

Penyebab tersering adalah Varises esofagus, Mallory Weiss

syndrome, erosi gaster, ulser gaster, varises gaster, ulser
duodenal.

CLINICAL FEATURES
Haematemesis : muntah darah
sumber: SCBA. berwarna hitam
Melena :berak darah berwarna hitam.
Coffee ground vomiting :darah dari
muntahan. Berwarna coklat. Hasil
konversi merah Hb ke coklat Hematin
o/k as. Lambung
Hematochezia :berak darah warna
merah segar.
8/81

Etiologi hematemesis &

melena

Ruptur varises esofafus

Erosif gastritis
Ulkus peptikum
Malignancy
Sindroma Mallory Weiss

OESOPHAGEAL VARICES
Abnormal dilatation of subepithelial
and submucosal veins due to
increased venous pressure from portal
hypertension (collateral exist between
portal system and azygous vein via
lower oesophageal venous plexus).
Most commonly : lower esophagus.
10/81

MALLORY-WEISS
TEAR
Longitudinal tears at the oesophagogastric
junction.
may occur after any event that provokes a
sudden rise in intragastric pressure or gastric
prolapse into the esophagus.
Clinical features:
- An episode of haematemesis
following retching or vomiting.
- melaena
- hematochezia
- syncope
- abdominal pain.
Precipitating factors:
- hiatus hernia
- retching & vomiting
- straining
- hiccuping
- coughing
blunt abdominal trauma
cardiopulmonary resuscitation

11/81

ESOPHAGEAL CANCER
8th most common cancer seen
throughout the world.
40% occur in the middle 3rd of the
oesophagus and are squamous
carcinomas.
adenoCA (45%) occur in the lower 3rd
of the oesophagus and at the cardia.
Tumours of the upper 3rd are rare
(15%)
12/81

PEPTIC ULCER
gastric ulcer & duodenal ulcer
Caused by imbalance between
secretion of acid and pepsin,
and mucosal defence
mechanism.
AETIOLOGY

-Helicobacter
pylori infection
-Zollinger-ellison
syndrome
-NSAIDs
-others: stress,
smoking,alcohol,
steroid

SIGNS & SYMPTOMS

- epigastric
pain
- haematemesis
- Melaena
- heartburn
13/81

PEPTIC ULCER: COMPLICATION

Haemorrhage
- posterior duodenal ulcer erode the
gastroduodenal
artery
- lesser curve gastric ulcers erode the left
gastric artery

Perforation
- generalized peritonitis
- signs of peritonitis

Pyloric obstruction
- profuse vomiting, LOW, dehydrated,
weakness, constipation
14/81

HISTORY TAKING
MODE
OF
ONSET

when?
have u vomited blood/passed black tarry stools?
had both haematemesis & malaena?
have u had, bleeding from the nose? Bloody
expectoration? A dental extraction?

CHARACT
ER

what is the color, the appearance of the

vomited
blood?
red? Dark red? Brown? Black?
coffee ground appearance?
bright red & frothy?
what is the color of the stool? Bright red? Black
tarry?

EXTENT
AND
RATE

have u vomited blood only once/several times?

has the bleeding been abrupt/massive?
have u had >1 black, tarry stool within a 24-h
period?
for how long have the tarry stools persisted?
15/81

PHYSICAL EXAMINATION:
UPPER GI BLEED
GENERAL
INSPECTION

Anaemic
Bruishing/ Purpura
Cachexia
Dehydrated
Jaundice

ABDOMEN

Inspection distension, scar,

prominent vein.
Palpation
tenderness, mass/
organomegaly
Percussion - shifting
dullness, fluid thrill.

RECTAL

Perianal Skin
Lesion
Masses
Melaena
LYMPH NODES

Supraclavicular
LN
Cervical LN
Axillary LN
Inguinal
LN
CNS
Confusion
( Shock, liver

16/81

PHYSICAL SIGN

Clinical shock
Systolic BP < 100mmHg
Pulse rate > 100 bpm
Postural sign: patient place in a
upright position
pulse rate rises 25% or more
- systolic BP alls 20mmHg or more
Sign of liver disease & portal
hypertension
Sign of GI disease
Sign of bleeding abnormalities
Bloody / black stools on per rectal
examination.
17/81

Acute Upper Gastrointestinal

Bleed
Routine Blood Test
Resuscitation and Risk Assessment
Endoscopy (within 24 hrs)

Varices
Management
Varices

Peptic Ulcer
Major
SRH
Endosco
pic
Treatme
nt

Failure
Surgical

Minor
SRH
Eradicat
e
H.pylori
& Risk
Reductio
n

No obvious
cause
Minor
Bleed

Major
Bleed
Other
colonoscopy
or
angiography

OVERVIEW:
MANAGEMENT OF UPPER GI
BLEED
18/81

Pendarahan saluran cerna bagian

bawah

Hamorrhoids
Proctitis
Inflamatory bowel disease
Diverculosa
Ischemic culitis
Angiodysplasia
Recini 0r colony polyps.

HISTORY TAKING:
RECTAL BLEEDING

Blood on its own or streaking the stool:

Rectum
: polyps or carcinoma, prolapsed
Anus : Haemorrhoids, Fissure-in-ano, Anal carcinoma.
Stool mixed with blood:
GIT above sigmoid colon.
Sigmoid carcinoma or diverticular disease.
Blood separate from the stool:
Follows defaecation : Anal condition eg: Haemorrhoids.
Blood is passed by itself : Rapidly bleeding carcinoma,
inflammatory bowel disease, diverticulitis, or passed down
from high up in the gut.
Blood is on the surface of the stool: suggest a lesion such as
polyp or carcinoma further proximally either in the rectum or
descending colon
Blood on the toilet paper: Fissure-in-ano, Heamorrhoids.
Loose, black, tarry, foul smelling stool: from the proximal of DJ
flexure
20/81

HISTORY TAKING
ALTER BOWEL
HABIT
Normal bowel
Intermittent bouts of
constipation interrupted
by diarrhoea: Carcinoma
or Diverticular disease.
Diarrhoea: Inflammatory
bowel disease or rectal
villous tumour.
Tenesmus: Irritable bowel
syndrome or abnormal
mass of rectum or anal
canal (e.g. CA, polyps or
thrombosed haemorrhoid)

ITCHINESS
Causes: Allergic, anal
warts, anal leak of mucus
in haemorrhoid, excessive
used of liquid paraffin,
generalized disorder. eg:
jaundice, diabetes mellitus.

ANAL PAIN
During
pregnancy/childbirth:
Fissure-in-ano,
haemorrhoids.
Throbbing, severe pain
occur during
21/81
defaecation: Fissure-in-

HISTORY TAKING
ALTER BOWEL
HABIT
Normal bowel
Intermittent bouts of
constipation interrupted
by diarrhoea: Carcinoma
or Diverticular disease.
Diarrhoea: Inflammatory
bowel disease or rectal
villous tumour.
Tenesmus: Irritable bowel
syndrome or abnormal
mass of rectum or anal
canal (e.g. CA, polyps or
thrombosed haemorrhoid)

ITCHINESS
Causes: Allergic, anal
warts, anal leak of mucus
in haemorrhoid, excessive
used of liquid paraffin,
generalized disorder. eg:
jaundice, diabetes mellitus.

ANAL PAIN
During
pregnancy/childbirth:
Fissure-in-ano,
haemorrhoids.
Throbbing, severe pain
occur during
22/81
defaecation: Fissure-in-

HAEMORRHOIDS
M>F
Female- late pregnancy, puerperium
Supine lithotomy position- 3 ,7, 11
oclock positions
Classification:
1st degree : never prolapse
2nd degree: prolapse during
defaecation but
return spontaneously
3rd degree : remain prolapse but
can be reduced digitally
4th degree : long-standing
prolapse cannot be
reduced
23/81

ANAL FISSURE
Longitudinal tear in mucosa & skin of anal
canal
M>F
Common site: midline in posterior anal margin
Clinical features:
- acute pain during defaecation
- fresh bleeding at defaecation

24/81

DIVERTICULAR DISEASE
Rare < 40 years old
F>M
Causes:
-Chronic lack of dietary fibre
-Genetic
Common site: sigmoid colon
Clinical features:
-diverticulosis (asymptomatic)
-chronic grumbling diverticular
pain (chronic constipation &
episodic diarrhoea)
25/81

MANAGEMENT
MEDICAL

SURGICAL

1. Vasoconstrictive agents:
vasopressin

The bleeding point is

localized, perform a
limited segmental
resection of the small or
large bowel
Poor prognostic features:
-age over 60 years
-chronic history
-relapse on full medical
treatment
-serious coexisting
medical conditions
-> 4 units of blood
transfusion required26/81
during resuscitation

2. Therapeutic embolization:
-Embolic agents: Autologous
clot, Gelfoam, polyvinyl
alcohol, microcoils,
ethanolamine, and
oxidized cellulose
-Selective angiography
3. Endoscopic therapy:
-Diathermy / laser coagulation
-Short term control of
bleeding during resuscitation

Referensi
Buku kuning Esofagus
IPD jilid 1
http://www.ncbi.nlm.nih.gov/books/N
BK411/