TK Hematemesis Dan Melena

8/19/2019 TK Hematemesis Dan Melena

1/25

TUTORIAL KLINIKHEMATEMESIS DAN MELENA PADA PASIEN

SIROSIS HEPATIS

REZKY MAWARNI

20100310187UMY

Pembimbing : dr. Ferry K !.P"


2/25

ir#$i$ %&'i mer(!&)&n $'&di(m &)%ir)er($&)&n $e*+$e* %&'i y&ng )em(di&n

men,&di ,&ring&n -ibr#$i$. Ker($&)&n 'er$eb('di'&nd&i deng&n di$'#r$i &r$i'e)'(r %e!&r d&n!emben'()&n n#d(*($ regener&'i- &)ib&'ne)r#$i$ $e*+$e* %&'i. e*&n,('ny& di$'#r$i

&r$i'e)'(r %e!&r d&n !ening)&'&n/&$)(*&ri$&$i )e %&'i menyeb&b)&n /&ri$e$&'&( !e*eb&r&n !emb(*(% d&r&% di d&er&%g&$'er m&(!(n e$#-&g($ N(rd,&n&% et al;200.


3/25

Manifestasi klinis dari sirosis hepatis

antara lain :Pembe$&r&n %&'ib$'r()$i !#r'&* d&n &4i'e$

5&ri$e$ g&$'r#e$#-&g($Edem&Kem(nd(r&n men'&*


4/25

5&ri$e$ g&$'r#e$#-&g($ &d&*&% !e*eb&r&n!emb(*(% d&r&% di g&$'er &'&( e$#-&g($

y&ng 'er,&di $em&)in be$&r. Pe4&%ny&/&ri$e$ 'er$eb(' &)&n menimb(*)&n!erd&r&%&n %em&'eme$i$ d&n me*en& .5&ri$e$ 'er,&di !&d& %&m!ir 60 !&$iendeng&n $ir#$i$ %&'i &r4i&+9$ et al 2007.


5/25

Heateesis :;em&'eme$i$ &d&*&% m(n'&% d&r&% )&ren&

erd&r&%&n in'ern&*Mi$&* !&d& '()&) *&mb(ng g&$'r#!&re$i$

!em&)&i&n #b&'+#b&'&n &4e'&min#-enW&rn& %em&'eme$i$ 'erg&n'(ng !&d& *&m&ny&

%(b(ng&n )#n'&) &n'&r& d&r&% deng&n &$&m*&mb(ng d&n be$&r d&n )e4i*ny& !erd&r&%&n

;em&'eme$i$ 'er,&di bi*& &d& !erd&r&%&n did&er&%!r#)$im&* ,e,(n(m

Mer(!&)&n $(&'( )eg&


6/25

Melena :Me*en& &d&*&% !enge*(&r&n -e$e$ = 'in,& y&ng

ber


7/25

Etiolo!i Heateesis elena :

"# Kelainan di esofa!$s.%arises esofa!$s :

(m(mny& !erd&r&%&n 'er,&di $!#n'&n d&n m&$i- &)ib&'!e4&% ny& /&ri$e$ e$#-&g($ '&n!& )e*(%&n !edi%die!ig&$'ri(m ."&r&% dim(n'&%)&n berebi% $ering menimb(*)&n me*en& d&ri!&d& %em&'eme$i $Ke*(%&n di$-&gi& ber&' b&d&n ber)(r&ng b&d&n m&)in)(r($ &nemi& d&n $e$e)&*i m(n'&% d&r&%


8/25

(# Kelainan dila)$n!.*astritis erosi%a heora!ika : %em&'eme$i$ ber$i-&'

'id&) m&$i- d&n 'imb(* $e'e*&% m&)&n #b&'+#b&'&n y&ng

menyeb&b)&n iri'&$i *&mb(ng )e*(%&n nyeri (*( %&'i..T$kak la)$n! : )e*(%&n m(&* m(n'&% nyeri (*(%&'i

d&n $ebe*(m imb(* %em&'eme$i$ bi&$&ny& did&%(*(ir&$& nyeri = !edi% die!ig&$'ri(m y&ng ber%(b(ng&n

deng&n m&)&n&n .$i-&' %em&'eme$i$ 'id&) begi'( m&$i- d&n me*en& *ebi%d#min&n d&ri!&d& %em&'eme$i$.

+# Kelainan darah

? P#*i$i'emi& /er&e

? *im-#m&

? *e()emi&

? &nemi& %em#-i*i&

? 'r#mb#$i'#!eni& !(r!(r&.


9/25

(# Kelainan dila)$n!.*astritis erosi%a heora!ika : %em&'eme$i$ ber$i-&'

'id&) m&$i- d&n 'imb(* $e'e*&% m&)&n #b&'+#b&'&n y&ng

menyeb&b)&n iri'&$i *&mb(ng )e*(%&n nyeri (*( %&'i..T$kak la)$n! : )e*(%&n m(&* m(n'&% nyeri (*(%&'i

d&n $ebe*(m imb(* %em&'eme$i$ bi&$&ny& did&%(*(ir&$& nyeri = !edi% die!ig&$'ri(m y&ng ber%(b(ng&n

deng&n m&)&n&n .$i-&' %em&'eme$i$ 'id&) begi'( m&$i- d&n me*en& *ebi%d#min&n d&ri!&d& %em&'eme$i$.

+# Kelainan darah

? P#*i$i'emi& /er&e

? *im-#m&

? *e()emi&

? &nemi& %em#-i*i&

? 'r#mb#$i'#!eni& !(r!(r&.


10/25

Manifestasi klinis Heateesis dan Melena:

•

M(n'&% d&r&% heateesis,• Menge*(&r)&n 'in,& y&ng )e%i'&m&n elena,-

• Menge*(&r)&n d&r&% d&ri re4'(m.heatoske/ia

• "eny(' n&di 4e!&'

• 9e)&n&n d&r&% rend&%

• A)r&* 'er&b& dingin d&n b&$&%

• Nyeri &bd#men

• N&-$( m&)&n men(r(n

• P&d& !erd&r&%&n !&n,&ng d&!&' 'er,&di &nemi&$e%ingg& m(d&% *e*&% !(4&' nyeri d&d& d&n!($ing


11/25

Patofisiolo!i Perdarahan 0arises *astroesofa!$s

5&ri$e$ g&$'r#e$#-&g($ mer(!&)&n &)ib&' *&ng$(ng %i!er'en$i!#r'& )&ren& !ening)&'&n '&%&n&n &*ir&n !#r'& d&n !ening)&'&n

&*ir&n d&r&% y&ng m&$() )e /en& !#r'&. ;&* 'er$eb(' $e,&*&ndeng&n %()(m %m y&ng menyeb(')&n b&%


12/25

Penyeb&b !ening)&'&n &*ir&n d&r&% @ &d&*&% !ening)&'&n

4(r&% ,&n'(ng d&n !en(r(n&n '&%&n&n /&$)(*er $i$'emi). ;&*'er$eb(' meng&)ib&')&n $ir)(*&$i mening)&' deng&n /&$#di*&'&$i

&r'eri $i$'emi) d&n $!*&ni) y&ng $em&)in mem!erb(r()%i!er'en$i !#r'&. e*&in i'( $eb&g&i ($&%& mende)#m!re$i$i$'em /en& !#r'& -&)'#r+-&)'#r &ngi#geni) &)&n memben'()!emb(*(% d&r&% )#*&'er&* $e%ingg& 'er,&di %(b(ng&n &n'&r&$ir)(*&$i $i$'emi) deng&n !#r'& "ib N et al 2006).

;&* 'er$eb(' ,($'r( men&mb&% &*ir&n d&r&% y&ng &)&nmem!erb(r() %i!er'en$i !#r'&. Pening)&'&n 'e)&n&n !#r'&%i!er'en$i !#r'& menyeb&b)&n di*&'&$i !emb(*(% d&r&%'er('&m& y&ng ber&$&* d&ri /en& &Cyg#$ y&ng )em(di&nmenyeb&b)&n /&ri$e$. 5&ri$e$ 'er,&di ,i)& 'erd&!&' !ening)&'&n!erbed&&n 'e)&n&n &n'&r& /en& !#r'& d&n /en& %e!&'i)& *ebi%

d&ri 10 mm;g. 5&ri$e$ &)&n $em&)in ber)emb&ng &)ib&'!ening)&'&n &*ir&n d&r&% )e 'em!&' /&ri$e$ d&n 'er,&di r(!'(r.


13/25

Dia!nosis Heateesis Melena Pada PasienSirosis Hepatis :

Ananesis :e,&) )&!&n 'er,&di !erd&r&%&n !er)ir&&n ,(m*&% d(r&$i d&n

-re)(en$i !erd&r&%&n.Ri


14/25

Peeriksaan fisik :Menen'()&n ber&'ny& !erd&r&%&n deng&n mem-#)($)&n !&d& $'&'($%em#din&mi). Pemeri)$&&n me*i!('i :

9e)&n&n d&r&% d&n n&di !#$i$i b&ringPer(b&%&n #r'%#$'&'i) 'e)&n&n d&r&% d&n n&diAd& 'id&)ny& /&$#)#n'ri)$i !eri-er &)r&* dingin Ke*&y&)&n n&-&$9ing)&' )e$&d&r&nPr#d()$i (rin

Perd&r&%&n &)(' d&*&m ,(m*&% be$&r me*ebi%i 20 /#*(mein'r&/&$)(*er &)&n meng&)ib&')&n )#ndi$i %em#din&mi) 'id&) $'&bi*deng&n '&nd& D '&nd& $eb&g&i beri)(' :;i!#'en$i 0=0 &'&( MAP 70 m;g deng&n -re)(en$i n&di

100B=meni'9e)&n&n di&$'#*i) #r'%#$'&'i4 '(r(n 10 mm;g &'&( $$i$'#*i) '(r(n

20mm;gFre)(en$i n&di #r'%#$'&'i4 mening)&' 16 B=meni'A)r&* dinginKe$&d&r&n men(r(n

An(ri& &'&( #*ig(ri& !r#d()$i (rin G 30 m>= ,&m


15/25

Periksaan Pen$n1an! :

9e$ d&r&% : d&r&% !eri-er *eng)&!4r#$$+m&'4% ,i)&

di!er*()&n 'r&n-($i.;em#$'&$i$ *eng)&! (n'() menying)ir)&n )e*&in&n -&)'#r

!embe)(&n !rimer &'&( $e)(nder : H99 P9=PP9 AP994.E*e)'r#*i' : N& K H*d.F&&* %&'i : 4%#*ine$'er&$e &*b(min= g*#b(*in 9=P9e.

Pemeri)$&&n r&di#*#gi : di*&)()&n deng&n !emeri)$&&ne$#-&g#gr&m (n'() d&er&% e$#!&g($ d&n di'er($)&ndeng&n !emeri)$&&n d#(be* )#n'r&$ !&d& *&mb(ng d&nd(#den(m. Pemeri)$&&n 'er$eb(' di*&)()&n !&d& berb&g&i!#$i$i 'er('&m& !&d& d&er&% 1=3 di$'&* e$#!&g($ )&rdi&

d&n -(nd($ *&mb(ng (n'() men4&ri &d& 'id&)ny& /&ri$e$Pemeri)$&&n end#$)#!i : d&!&' menen'()&n deng&n 'e!&'

'em!&' &$&* d&n $(mber !erd&r&%&n .


16/25

Tatalaksana heateesis elena pada pasien sirosishepatis- ter$taa &an! dise)a)kan oleh %arises esofa!$sterdiri atas :

A#Tindakan U$1.Re$($i'&$iP&$ien deng&n !erd&r&%&n 600 D 1000 44 !er*( diberi in-($

"eB'r#$e 6 Ringer *&)'&' &'&( N&4* 0 . P&d& !enderi'&

$ir#$i$ %e!&'i$ deng&n &$4i'e$ = edem& '(ng)&i $eb&i)ny&diberi in-($ deB'r#$e 6

P&$ien deng&n !erd&r&%&n y&ng m&$i- *ebi% d&ri 1000 44deng&n ;b G 8 !er*( $eger& di'r&n-($i

P&d& %i!#/#*emi) ring&n diberi 'r&n-($i $ebe$&r 26 d&ri

/#*(me n#rm&*$eb&i)ny& d&*&m ben'() d&r&% $eg&rP&d& %i!#/#*emi) ber&' = $y#) )&d&ng di!er*()&n 'r&n-($i

$&m!&i J0D 60 d&ri /#*(me n#rm&*. Ke4e!&'&n 'r&n-($iber)i$&r !&d& 80 D 100 'e'e$ &'&( d&!&' *ebi% 4e!&' bi*&!erd&r&%&n m&$i% 'er($ ber*&ng$(ng $eb&i)ny&di b&


17/25

P&d& !erd&r&%&n y&ng 'id&) ber%en'i !er*( di-i)ir)&n&d&ny& "IH de-i$ien$i -&)'#r !embe)(&n !&d&$ir#$i$ %e!&'i$ y&ng *&n,(' &'&( -ibrin#*i$i$ !rimer.

i)& d&r&% be*(m 'er$edi& d&!&' diberi in-($ !*&$m&e)$!&nder m&)$im&* 1000 44 $e*&ng $e*ing deng&n"eB'r#$e 6 )&ren& !*&$m&e)$!&nder mem!eng&r(%i &greg&$i 'r#mb#$i'.

e'i&! !emberi&n 1000 44 d&r&% !er*( diberi 10 44)&*$i(m g*()#n&$ i./.(n'() me4eg&% 'er,&diny&)er&4(n&n &$&m $i'r&'.


18/25

2.>&/&$ *&mb(ng deng&n &ir e$

e'e*&% )e&d&&n (m(m !&$ien $'&bi* di!&$&ng !i!&n&$#g&$'ri) (n'() &$!ir&$i i$i *&mb(ng d&n *&/&$ &ir e$

m(*& D m(*& $e'i&! 30 meni' %ingg& 1 ,&m. i*& &ir )(r&$&n*&mb(ng 'e'&! mer&% !&$ien 'er($ di!(&$&)&n. e$(d&% &ir)(r&$&n men,&di mer&% m(d& &'&( ,erni% di$&r&n)&n (n'()me*&)()&n !emeri)$&&n end#$)#!i (n'() menen'()&n*#)&$i !erd&r&%&n. P&d& !erd&r&%&n /&ri$e$e$#-&g($ y&ng

'id&) ber%en'i $e'e*&% *&/&$ &ir e$ di!er*()&n 'ind&)&nmedi) in'en$i-.

3.;em#$'&'i)&

Y&ng di&n,(r)&n &d&*&% !emberi&n /i'&min K d&*&m d#$i$

10 D J0 mg $e%&ri !&ren'er&* )&ren& berm&n-&&' (n'()mem!erb&i)i de-i$ien$i )#m!*e)$ !r#'r#mbin. Pemberi&n&$&m 'r&ne)$&m&' d&n )&rb&C#)r#m d&!&' !(*& diberi)&n.


19/25

2#Tindakan kh$s$s

"#Medik intensif'eri*i$&$i ($($ d&n *&/emen' ($($

9er('&m& !&d& !enderi'& $ir#$i$ %e!&'i$ deng&n !erd&r&%&n/&ri$e$e$#-&g($ !er*( di*&)()&n 'ind&)&n !en4eg&%&n 'er,&diny&)#m& %e!&'i)(m= en$e-&*#!&'i %e!&'i) y&ng di$eb&b)&n &n'&r&*&in #*e% !ening)&'&n !r#d()$i &m#ni&) !&d& !eme4&%&n !r#'eind&r&% #*e% b&)'eri ($($. ;&* ini d&!&' di*&)()&n deng&n ,&*&n :'reri*i$&$i ($($ deng&n &n'ibi#'i)& y&ng 'id&) d&!&' di$er&!

mi$&*ny& Ne#mi$in J L 1 gr&m &'&( )&n&my4in J L 1 gr&m !er%&ri $e%ingg& !emb(&'&n &m#ni&) #*e% b&)'eri ber)(r&ng

"&!&' diberi)&n *&)'(*#$& &'&( $#rbi'#* 200 gr&m = %&ri d&*&mben'() *&r('&n J00 44 y&ng ber$i-&' *&)$&n$i& ring&n&'&(m&gne$i(m$(*-&' 16 g=J00 44me*&*(i !i!& n&$#g&$'ri). e*&in

i'( !er*( di*&)()&n *&/emen' ($($ deng&n &ir bi&$& $e'i&! 12D 2J ,&m.Un'() !en4eg&%&n en$e-&*#!&'i %e!&'i) d&!&' diberi in-($Amin#-($in %e!&r 1000 D 1600 44 !er %&ri. i*& !&$ien 'e*&%ber&d&d&*&m )e&d&&n !re)#m& &'&( )#m& %e!&'i)(mdi&n,(r)&n !emberi&n in-($ H#m&-($in ;e!&r 1000 D 1600 44 !er%&ri.


20/25

e'& *#4)er

#*#ng&n #b&' ini &)&n menyeb&b)&n !en(r(n&n 4(r&% ,&n'(ng $e%ingg& &*ir&n d&r&% )e %&'i d&n g&$'r#in'e$'in&* &)&n

ber)(r&ng $e%ingg& 'e)&n&n /en& !#r'&* d&!&' ber)(r&ng.

In-($ 5&$#!re$in

5&$#!re$#r mem!(ny&i e-e) )#n'r&)$i !&d& #'#' !#*#$$e*(r(% $i$'em /&$)(*er $e%ingg& 'er,&di !en(r(n&n &*ir&n

d&r&% di d&er&% $!*&n)ni) y&ng $e*&n,('ny& menyeb&b)&n!en(r(n&n 'e)&n&n !#r'&*. K&ren& !emb(*(% d&r&% &r'erig&$'ri)& d&n me$en'ri)& i)(' meng&*&mi )#n'r&)$i m&)& $e*&indi e$#-&g($ !erd&r&%&n di *&mb(ng d&n d(#den(m ,(g& i)('ber%en'i.

5&$#!re$in 'er('&m& diberi)&n !&d& !er&d&r&%&n /&ri$e$e$#-&g($ y&ng !erd&r&%&nny& 'e'&! ber*&ng$(ng $e'e*&% *&/&$*&mb(ng deng&n &ir e$.H&r& !emberi&n /&$#!re$in i&*&% 20(ni' di*&r(')&n d&*&m 100 D 200 44 "eB'r#$e 6 diberi)&nd&*&m 10 D 20 meni' in'r&/en&.


21/25

E-e) $&m!ing !&d& !emberi&n $e4&r& 4e!&' ini y&ng!ern&% di*&!#r)&n &d&*&% &ngin& !e)'#ri$ in-&r) mi#)&rd-ibri*&$i /en'ri)e* d&n %en'i ,&n'(ng !&d& !enderi'&

,&n'(ng )#r#ner d&n ($i& *&n,(' )&ren& e-e)/&$#)#n'ri)$i d&ri/&$#!re$in !&d& &r'eri )#r#ner. K&d&ng

,(g& di)e*(%)&n )#*i) &bd#menmm(&* d&n di&re.

eber&!& &%*i *&in meng&n,(r)&n !emberi&n

in-($/&$#!re$in deng&n d#$i$ rend&% y&i'( 02 (ni'/&$#!re$in !er meni' (n'() 1 ,&m !er'&m& d&n bi*&!erd&r&%&n ber%en'i $e'e*&% i'( d#$i$ di'(r(n)&n 01 (ni'!er meni' (n'() 8 ,&m beri)('ny&. P&d& 4&r& !emneri&n/&$#!re$in d#$i$ rend&% *ebi% $edi)i' e-e) $&m!ing y&ng

di'em()&n. E-e) /&$#!re$in d&*&m meng%en'i)&n!erd&r&%&n $&*(r&n 4ern& b&gi&n &'&$ ber)i$&r &n&'r& 36D 100 !erd&r&%&n ber(*&ng 'imb(* !&d& 21 D 80

d&n m#r'&*i'&$ ber)i$&r &n'&r& 21 D 80 .


22/25

K#&g(*&$i *&$er end#$)#!i)

i)& 4&r& D 4&r& $ebe*(mny& g&g&* d&!&' di'er&!)&n'er&!i )#&g(*&$i deng&n Arg#n = Ne#dynm Y&g >&$er $e4&r&

end#$)#!i). Keber%&$i*&nny& di*&!#r)&n %ingg& 13 .;&ny& $&,& &*&' ini $&ng&' m&%&*.

Emb#*i$&$i /&ri$e$ 'r&n$%e!&'i)

H&r&ny& deng&n (*'r&$#n#gr&-i dim&$())&n ,&r(m )e

d&*&m %&'i $&m!&i men4&!&i /en& !#r'& y&ng me*eb&r)em(di&n di$#r#ng )&'e'er me*&*(i m&ndrin 'er$eb('$e!&n,&ng /en& !#r'& %ingg& men4&!&i /en& )#r#n&ri&g&$'ri)& d&n di$(n'i))&n )#n'r&$ &ngi#gr&-in. P&d&'r&n$%e!&'i) !#r'&* /en#gr&-i ini &)&n 'er*i%&' /en& D /en&

)#*&'er&* ('&m& 'erm&$() /&ri$e$ e$#-&g($. e*&n,('ny&$eb&ny&) 30 D 60 44 "eB'r#$e 60 di$(n'i))&n me*&*(i)&'e'er dii)('i deng&n $(n'i)&n 'r#mbin di'&mb&% ge* -#&m&'&( #'#*ein. 9&!i )#m!*i)&$i d&ri !r#$ed(r ini bi$&menyeb&b)&n !erd&r&%&n in'r&!eri'#ne&* d&ri be)&$

'($()&n ,&r(m 'er$eb('.


23/25

(# Tindakan 2edah

i)& !erd&r&%&n m&$i% ber*&ng$(ng m&)& !er*(di*&)()&n 'ind&)&n bed&% d&r(r&' $e!er'i

!in'&$&n !#r'#$i$'emi) &'&( 'r&n$e)$i e$#-&g($(n'() !erd&r&%&n /&ri$e$ e$#-&g($.


24/25

PRO*NOSIS &*&% $&'( !eg&ng&n (n'() mem!er+)ir&)&n !r#gn#$i$ !enderi'&$ir#$i$ d&!&' mengg(n&)&n )ri'eri& H%i*d y&ng di%(b(ng)&n deng&n)em(ng)in&n meng%&d&!i #!er&$i. Un'() H%i*d A m#r'&*i'&$ &n'&r&10+16 H%i*d )ir&+)ir& 30 d&n H%i*d H *ebi% d&ri 0.K*&$i-i)&$i ir#$i$ ;e!&'i$ Men(r(' Kri'eri& H%i*d :

Pr#gn#$i$ ,e*e) ,(g& di%(b(ng)&n deng&n %i!#!r#'r#mbinemi&!er$i$'en &$i'e$ 'er('&m& bi*& memb('(%)&n d#$i$ di(re'i) 'inggi(n'() meng#n'r#*ny& giCi b(r() i)'er($ mene'&! &d&ny& )#m!*i)&$ine(r#*#gi$ !erd&r&%&n d&ri /&ri$e$ e$#!%&g($ d&n &*b(min y&ngrend&%

No# A 2 3

1 A$i'e$ Neg&'i- "&!&' "i)#n'r#* 9id&)

2 N('ri$i &i) ed&ng e*e)

3Ke*&in&n Ne(r#*#gi Neg&'i- Minim&* >&n,('

Ji*ir(bin mg 16 16 + 3 3

6 A*b(min gr&m 36 30 + 36G 3


25/25

"AF9AR PU9AKA• "ib N ber'i F H&*e$ P. H(rren' m&n&gemen' #- '%e

4#m!*i4&'i#n$ #- !#r'&* %y!er'en$i#n: /&ri4e&* b*eeding &nd

&$i'e$. HMA. 20017J:1J33+J3.

• &r4i&+9$ &ny&* A r&4e N" H&rey W &nd '%e

Pr&4'i4e (ide*ine$ H#mmi''ee #- '%e Ameri4&n A$$#4i&'i#n

-#r '%e '(dy #- >i/er "i$e&$e$ '%e Pr&4'i4e P&r&me'er$

H#mmi''ee #- '%e Ameri4&n H#**ege #- &$'r#en'er#*#gy.

Pre/en'i#n &nd m&n&gemen' #- g&$'r#e$#!%&ge&* /&ri4e$&nd /&ri4e&* %em#rr%&ge in 4irr%#$i$. ;e!&'#*#gy.

2007J:22+38.

• &r4i&+9$ #$4% . M&n&gemen' #- /&ri4e$ &nd /&ri4e&*

%em#rr%&ge in 4irr%#$i$. N Eng* Med. 201032:823+32.

• N(rd,&n&% . ir#$i$ %&'i. In: (d#y# AW e'iy#%&di A*

TK Hematemesis Dan Melena

Documents