Pendarahan Saluran Cerna

Citra Pratiwi (10-017)

ANATOMY OF GIT
FOREGUT
Abdominal esophagus Major duodenal
papilla

MIDGUT
Major duodenal papilla
Junction B/w prox.
2/3 and distal
1/3
HINDGUT of tranverse colon.
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
common jejunal and rectal artery
hepatic ileal Left colic
artery arteries artery
middle
colic artery
right colic
artery
ileocolic 3/81
artery
INTRODUCTION
Gastrointestinal bleeding
describe every form of
haemorrhage in the GIT,
from the pharynx to the
rectum.

Can be divided into 2

LIGAMENT OF
TREITZ 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 hemodinamik
instability COPD

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
11/81
- cardiopulmonary resuscitation
 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 SIGNS & SYMPTOMS
pylori infection
-Zollinger-ellison - epigastric
syndrome pain
-NSAIDs - haematemesis
-others: stress, - Melaena
smoking,alcohol, - heartburn
steroid 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
- when?
MODE - have u vomited blood/passed black tarry stools?
OF - had both haematemesis & malaena?
- have u had, bleeding from the nose? Bloody
ONSET expectoration? A dental extraction?

- what is the color, the appearance of the

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

EXTENT - have u vomited blood only once/several times?

- has the bleeding been abrupt/massive?
AND
- have u had >1 black, tarry stool within a 24-h
RATE period?
- for how long have the tarry stools persisted?
15/81
PHYSICAL EXAMINATION:
UPPER GI BLEED
GENERAL RECTAL
INSPECTION Perianal Skin
Anaemic Lesion
Bruishing/ Purpura Masses
Cachexia Melaena
Dehydrated LYMPH NODES
Jaundice
ABDOMEN Supraclavicular
Inspection - LN
distension, scar, Cervical LN
prominent vein. Axillary LN
Palpation - Inguinal LN
tenderness, mass/ CNS
organomegaly
Percussion - shifting
dullness, fluid thrill. Confusion 16/81
( Shock, liver
 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)

No obvious
Varices Peptic Ulcer
cause
Major Minor
Management Minor Major
SRH SRH
Varices Eradicat Bleed Bleed
Endosco e Other
pic H.pylori colonoscopy
Treatme & Risk or
nt Reductio angiography
n
Failure
OVERVIEW:
Surgical 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
ITCHINESS
HABIT
Normal bowel Causes: Allergic, anal
warts, anal leak of mucus
Intermittent bouts of in haemorrhoid, excessive
constipation interrupted used of liquid paraffin,
by diarrhoea: Carcinoma generalized disorder. eg:
or Diverticular disease. jaundice, diabetes mellitus.
Diarrhoea: Inflammatory
bowel disease or rectal
villous tumour. ANAL PAIN
Tenesmus: Irritable bowel
syndrome or abnormal During
mass of rectum or anal pregnancy/childbirth:
canal (e.g. CA, polyps or Fissure-in-ano,
thrombosed haemorrhoid) haemorrhoids.
Throbbing, severe pain
occur during 21/81
defaecation: Fissure-in-
 HISTORY TAKING
ALTER BOWEL
ITCHINESS
HABIT
Normal bowel Causes: Allergic, anal
warts, anal leak of mucus
Intermittent bouts of in haemorrhoid, excessive
constipation interrupted used of liquid paraffin,
by diarrhoea: Carcinoma generalized disorder. eg:
or Diverticular disease. jaundice, diabetes mellitus.
Diarrhoea: Inflammatory
bowel disease or rectal
villous tumour. ANAL PAIN
Tenesmus: Irritable bowel
syndrome or abnormal During
mass of rectum or anal pregnancy/childbirth:
canal (e.g. CA, polyps or Fissure-in-ano,
thrombosed haemorrhoid) 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
1. Vasoconstrictive agents:
vasopressin
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
SURGICAL
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
 Referensi
Buku kuning Esofagus
IPD jilid 1
http://www.ncbi.nlm.nih.gov/books/N
BK411/