Yudith Setiati Ermaya - Hematemesis Melena in Children - Pegasus

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1 - 2 JUNE 2024
HEMATEMESIS MELENA IN CHILDREN:

WHAT SHOULD WE DO?
Y u d i t h S e t i a t i E r m a y a
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
UKK
Gastrohepatologi
INTRODUCTION
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• Gastrointestinal bleeding is a condition • There are many causes of

where blood is lost in abnormal amounts gastrointestinal bleeding (GIB) in
in the digestive tract from the oral cavity children, and this condition is not
to the anus, namely more than 0.5-1.5 mL rare, having a reported incidence of
per day. 6.4%.
• Most of the etiologies are mild and self- • Causes vary with age, but show
limited conditions but can life threatening considerable overlap; moreover,
if not treated properly. while many of the causes in the
• This condition is one of the emergency pediatric population are similar to
problems in the field of pediatric those in adults, some lesions are
gastroenterology. unique to children.
The ligament of Treitz is the
boundary for upper
gastrointestinal bleeding that
occurs when the source of
bleeding is located above

INTRODUCTION
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Gastrointestinal Bleeding
(GIB)
Not common Special attention
Ringan
Mengancam
jiwa
DIAGNOSIS APPROACH
And
PROPER HANDLING
Epidemiologi
Indonesia: no population-based
studies, no official data
USA:
UGI 6-25%
LGI 1%
UGI:
World: 20% GIB was Developing countries: 95% of UGI etiology is portal
UGI hypertension
Developed countries: 66% UGI= peptic ulcer & esophageal
bleeding
G
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• Gastrointestinal bleeding (GI Bleeding):

Gastrointestinal bleeding that occurs from the oral
cavity to the anus
• Divided into:
• Upper gastrointestinal bleeding (UGB)
• Lower gastrointestinal bleeding (LGB)
Upper gastrointestinal bleeding (UGB) is a

medical emergency caused by intraluminal
bleeding within the gastrointestinal tract
from the esophagus to the ligament of Treitz
Clinical approach
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• Is the patient stable or not?

• Is this really blood, and coming
from the digestive tract?
• Is the blood volume small or
large?
• Whether the child has had
previous episodes of bleeding

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PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM •J. Boyle, Gastrointestinal bleeding in infants and children, Pediatrics in review , DOI:10.1542/pir.29-2-39
•Corpus ID: 343864
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PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM John T. Boyle, Pediatrics in Review. 2008; Vol.29 No.2: 39-52
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Gastrointestinal
Anatomi salurantract anatomy
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Mucosal
Esofagitis Erosion The area is very large
BLEEDING: Lots of vascularity

Esophagitis
Mallory-weiss Peptic Ulcer
tears
Blood vessel
Mallory-Weiss
Homeostasis osmotik
disorders
Tear
Stress ulcers
Gastritis
• Body compensation _
Portal
hypertension portosystemic Absorption
collaterals
Peptic Ulcer/
Kolateral • Varises
stress ulcers
gastroesofageal esofagus
Often breaks • ➔ PERDARAHAN SALURAN CERNA

Most common etiology
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Upper GI Bleeding
• Varises esofagus
• Peptic Ulcer
• Gastritis
Lower GI Bleeding
• Diverticulum meckel
• Intususepsi
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM Omar NasherChildren 2017, 4(11), 95; https://doi.org/10.3390/children4110095
CLINICAL MANIFESTATION GASTROINTESTINAL BLEEDING
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= Muntah darah
Bleeding from the
upper GIB→ color
depends on how
long it has been in
contact with
stomach acid
Hematemesis
Fresh blood comes Black stools,
out through the distinctive odor. Hb is
anus and is the most
Melena
converted by bacteria
common into hematin/other
manifestation of LGI hemochromes
Hematochezia

Mclnerny dkk. Textbook of pediatric care. AAP.2009
Peacock P. Acad Emerg Med. 2003;10(10):1086-95.
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Imaging:
❖ Abdomen imaging
❖ Ultrasonography
❖ Air Enema
❖ Dopler ultrasonography
❖ Meckel’s Scan
❖ Labeled RBC
❖ Angiografi
❖ Enterography
Endoscopy
Colonoscopy

Varises esofagus 1 PEG SU
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Submucosal vein distension
Projected into the lumen of the esophagus
Portal hypertension --> 50% esophageal varices -->1/3

rupture --> bleeding
Mortality is higher than other GI Bleeding
Esofagogastroduodenoscopy

FISIOLOGY AND PATOFISIOLOGI UPPER GI BLEEDING
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Mclnerny dkk. Textbook of pediatric care. AAP.2009

Peacock P. Acad Emerg Med. 2003;10(10):1086-95.

Peptic Ulcer 1 PEG SU
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Ulkus Peptikum
• The most common cause of UGI in

children >1 year
• →Hematemesis
• Etiology:
• Due to damage to the protective mucous
membrane of the stomach
• Helicobacter pylori infection
• NSAID drugs
• Zollinger-Ellyson
• Crohn's disease

Gastritis
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• The second cause of pediatric

hematemesis
• Group:
• Primary → Helicobacter pylori
• Secondary → NSAIDs, Chron's,
Zollinger-Ellyson

Divertikulum Meckel
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• USA → 2-4% of the population

• boy more often (2.4:1)
• Incomplete vitelline duct degeneration
process
• Symptoms → if the size of the diverticulum is
> 2 cm
• Complications: bleeding, perforation,
intestinal obstruction and inflammation
• Definite diagnosis: Meckel scan

Divertikulum Meckel 1 PEG SU
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Meckel scan

Intususepsi 1 PEG SU
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• High
• Insidensi incidence
tinggi in (80%
pada bayi infants (80% in
pada
children
anak usia aged <1 year)
<1 tahun)
• Clinical
• Gejala Symptoms:
Klinis: keluar darah danblood and
lendir
mucus
dari anus, discharge
nyeri perut, from the anus,
• Pem. Fisis:
abdominal pain, massa usus
teraba/tampak
• Phisycalexaminaion:
seperti sosis, cembung, tegang (tanda
peritonitis)
palpable/visible intestinal mass
like a sausage, convex, tense
(sign of peritonitis)

Intususepsi
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Ultrasound:
Longitudinal: sandwich-like appearance
Sagittal: Dougnut sign → concentric
alternating echogenic and hypoechogenic
bands
Abdomen Photo:
With a contrast enema, it is obtained
Image of convex-shaped filling defect

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Algorithm Approach to the Diagnosis of Upper Gastrointestinal Bleeding st
Hematemesis
Stabilisasi sistem hemodinamik

Pendekatan diagnostik dini
Pipa nasogastrik
Perdarahan aktif Perdarahan banyak Curiga varises Perdarahan sedikit

tidak aktif tidak aktif
Endoskopi segera Evaluasi berencana
Kelainan (+): tatalaksana sesuai Kelainan (−): skintigrafi, bleeding

kelainan scanning, angiografi
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Algoritme Pendekatan Manajemen Pasien dengan Perdarahan Saluran Cerna Atas yang Signifikan
Penilaian airway, breathing, circulation: Nilai tanda syok
• Menjaga patensi jalan nafas, oksigen, support pernafasan dan • Penggantian volume cairan dengan kristaloid, pemberian transfusi
sirkulasi sesuai indikasi
• Pemasakan akses vascular IV 2 line • Perbaiki gangguan koagulopati : vitamin K, transfusi FFP/trombosit
• Pemeriksaan darah lengkap, cross match, apusan darah tepi • Pemasangan NGT : bilas lambung dan observasi perdarahan
• Monitor tanda vital dan saturasi oksigen • Terapi supresi asam lambung
Suspek Perdarahan Varises Suspek Ulser/Perdarahan Mukosa

Curiga hipertensi porta, penyakit hati kronis (hepatosplenomegali) (Riwayat obat NSAID, nyeri perut, disfagia )
Mulai terapi okreotide, konsul divisi Gastroenterologi Anak Terapi supresi asam-PPI dosis tinggi
Tidak Terkontrol Terkontrol Tidak Terkontrol

Terkontrol
• Endoskopi elektif Endoskopi
Emergency Endoscopic
Endoscopic sclerotherapy • PPI
sclerotherapy (EST)
(EST) atau variceal ligation • Tes dan terapi H.pylori Penemuan ulser
(EVL)
Tidak Terkontrol Manajemen endoskopi:
Terapi injeksi (adrenalin + saline)/hemostasis mekanik-endoklip
Tamponade balloon
Lanjut PPI – tes dan terapi H.pylori
Terkontrol Tidak Terkontrol
Tidak Terkontrol Tidak ada ulser/lesi
TISS (sirotik) atau devaskularisasi/operasi shunt Operasi/intervensi – konsul radiologi
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM PNPK Perdarahan saluran cerna 2024

Flow of diagnosis and management of UGI in children
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Flow of diagnosis and management of UGI in childrenst
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Flow of diagnosis and management of LGI in children
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Flow of diagnosis and management of LGI in childrenst
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Apakah Benar-benar Darah? Tes Darah Lambung:
Tes Darah Feses
Melena Atau Hematochezia Tube Nasogastrik
(−): Investigasi (+) (−) (+): Tatalaksana

Penyebab Lain Tatalaksana PSCB PSCA
Ringan Sampai Sedang Berat Stabilisasi

Hemodinamik Normal Hemodinamik Tidak
Normal
Tanpa Gejala Lain Anamnesis Dengan Gejala Lain (Gagal Tumbuh, Nyeri
Episode Pertama Pemeriksaan Fisis Perut, Purpura)
Investigasi Diagnostik Yang Tepat

Teridentifikasi: Hentikan
Investigasi Jika Tidak Ada
Kultur Feses Rekurensi
Usg
Proktosigmoidoskopi Tidak Teridentifikasi: Tatalaksana Jika PSCB Berulang Dan Atau
Perdarahan Hebat (Kolonoskopi, Scan Meckel, Scan Sumber
Perdarahan, Endoskopi Kapsul, Angiografi)

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MANAGEMENT
Indikasi dan kategori obat PSC
st
SU
Prevention of
recurrent
Active bleeding bleeding Oral inhibitor of
gastric acid
secretion
Oral Adhesive
Intravenous inhibitors Protection of
of gastric acid secretion Ulcerated
Mucosa
Intravenous vasoactive
agents ocreotide Oral Prevention
of variceal
Rebleeding
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Intravenous Inhibitor of
ACTIVE Gastric Acid Secretion H2 Blocker
iv continuous → 1mg/kgBW
BLEEDING • Ranitidin followed by 2-4mg/kgBW/day
PPI
• Pantoprazole Bolus 3-5mg/kgBB/day, every 8
hours
Intravenous Vasoactive
Agents
Somatostatin analog
• Octreotide <40kg → 0.5 – 1 mg/kgBB/day
(once daily)
>40kg→ 20-40mg/day
Antidiuretic hormone (max
• Vasopresin 40mg/day)
1mcg/kgbb IV (max 50mcg) followed
• Terlipresin by 1mcg/kgbb/hour up to 4
• Somatostatin mcg/kgbb/hour (max
250mcg/8hours)
Trafficking (-) reduced by 50%
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM every 12 hours, 24 to 48 hours
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Prevention of
recurrent
Oral inhibitor of gastric acid secretion
Antagonis H2:
bleeding • Ranitidin
Proton
2–3 mg/kgBW
Antagonis H2: perpump inhibitor:
dose 2–3x/day
• Famotidin (maximum, 1–1.5
0.5 mg/kgBW mg/kgBW
300per
mg/d) per day, 1–2x/day
dose 2x/day
• Lansoprazol Proton pump
(maximum, 40inhibitor:
(maximum, 30 mg 2x/day)
mg/day)
1–1.5 mg/kgBW per day, 1–2 times a day
• Omeprazol
(maximum, 20 mg twice a day)
Oral Adhesive Protection of Ulcerated Mucosa
• Sucralfat Local adhesive paste: 40–80 mg/kgBW per day divided into
4 doses (maximum, 1,000 mg/dose divided into 4 doses)
Oral Prevention of variceal Rebleeding

Reduced mesenteric blood flow (betaadrenergic blocker):
• Propanolol 0.6-0.8 mg/kg BW/day divided into 2 – 4 doses, can be increased every 3 to 7 days (maximum 8 mg/kg
BB/day
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https://kemkes.go.id/eng/pnpk-2023---tata-
laksana-perdarahan-saluran-cerna-

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CONCLUSION
❖ Gastrointestinal bleeding is one of the emergency problems in the field of

gastroenterology.
❖ Upper gastrointestinal bleeding (UGB) is bleeding from the gastrointestinal
tract proximal to the ligament of Treitz which is divided into varicose and non-
varicose bleeding. Symptoms can include vomiting fresh blood
(Hematemesis) and black stools (Melena).
❖ Lower gastrointestinal bleeding (LGB) is bleeding whose origin is located
downstream of the duodeno-jejunal junction at the ligament of Treitz, thus
including the small intestine, large intestine, rectum or anus and is most often
characterized by the presence of hematochezia

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CONCLUSION
❖ Diagnostic modalities for visualizing the location of gastrointestinal bleeding have now
developed, both from endoscopic and radiological techniques.
❖ Management of gastrointestinal bleeding requires multidisciplinary care involving experts
in gastroenterology, pediatric gastroenterology, digestive surgery, pediatric surgery,
anesthesia, radiology and other related professions with the main goal being diagnostics,
management and therapy of the source of bleeding.
❖ In general, treatment of gastrointestinal bleeding includes hemodynamic stabilization, fluid
resuscitation, NGT placement, PPI administration, blood transfusion if indicated,
prokinetics, therapeutic endoscopy, therapeutic colonoscopy and surgery.
https://kemkes.go.id/eng/pnpk-2023---tata-laksana-perdarahan-saluran-cerna-
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TERIMA
KASIH
UKK
Gastrohepatologi

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HEMATEMESIS MELENA IN CHILDREN:

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

• Gastrointestinal bleeding is a condition • There are many causes of

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

Not common Special attention

• Gastrointestinal bleeding (GI Bleeding):

Upper gastrointestinal bleeding (UGB) is a

• Is the patient stable or not?

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

BLEEDING: Lots of vascularity

Often breaks • ➔ PERDARAHAN SALURAN CERNA

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

Submucosal vein distension

Projected into the lumen of the esophagus

Portal hypertension --> 50% esophageal varices -->1/3

Mortality is higher than other GI Bleeding

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

Mclnerny dkk. Textbook of pediatric care. AAP.2009

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

• The most common cause of UGI in

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

• The second cause of pediatric

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

• USA → 2-4% of the population

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

Stabilisasi sistem hemodinamik

Perdarahan aktif Perdarahan banyak Curiga varises Perdarahan sedikit

Endoskopi segera Evaluasi berencana

Kelainan (+): tatalaksana sesuai Kelainan (−): skintigrafi, bleeding

Suspek Perdarahan Varises Suspek Ulser/Perdarahan Mukosa

Tidak Terkontrol Terkontrol Tidak Terkontrol

TISS (sirotik) atau devaskularisasi/operasi shunt Operasi/intervensi – konsul radiologi

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM PNPK Perdarahan saluran cerna 2024

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM PNPK Perdarahan saluran cerna 2024

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM PNPK Perdarahan saluran cerna 2024

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM PNPK Perdarahan saluran cerna 2024

(−): Investigasi (+) (−) (+): Tatalaksana

Ringan Sampai Sedang Berat Stabilisasi

Investigasi Diagnostik Yang Tepat

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

Oral Prevention of variceal Rebleeding

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

❖ Gastrointestinal bleeding is one of the emergency problems in the field of

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

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