ANEMIA ec PERDARAHAN SALURAN CERNA

General Approach to Anemias

Anemia is present in adults if the hematocrit is < 41% (hemoglobin < 13.5 g/dL [135
g/L]) in males or < 36% (hemoglobin < 12 g/dL [120 g/L]) in females. The most common cause
of anemia is iron deficiency.
Poor diet may result in folic acid deficiency and contribute to iron deficiency, but bleeding is the
most common cause of iron deficiency in adults.
Anemias are classified according to their pathophysiologic basis, ie, whether related to
diminished production (relative or absolute reticulocytopenia) or to increased production due to
accelerated loss of red blood cells (reticulocytosis) and according to red blood cell size. A
reticulocytosis occurs in one of three pathophysiologic states: acute blood loss, recent
replacement of a missing erythropoietic nutrient, or reduced red blood cell survival (ie,
hemolysis). A severely microcytic anemia (mean corpuscular volume [MCV] < 70 fL) is due
either to iron deficiency or thalassemia, while a severely macrocytic anemia (MCV < 125 fL) is
almost always due to either megaloblastic anemia or to cold agglutinins in blood analyzed at
room temperature.

Gastrointestinal Bleeding
1. Acute Upper Gastrointestinal Bleeding

General Considerations
There are over 250,000 hospitalizations a year in the United States for acute upper
gastrointestinal bleeding, with a mortality rate of 410%. Approximately half of patients are over
60 years of age, and in this age group the mortality rate is even higher. The most common
presentation of upper gastrointestinal bleeding is hematemesis or melena. Hematemesis may be
either bright red blood or browncoffee grounds material.Melena develops after as little as 50
100 mL of blood loss in the upper gastrointestinal tract, whereas hematochezia requires a loss of
more than 1000 mL.
Etiology
Acute upper gastrointestinal bleeding may originate from a number of sources:
1. Peptic Ulcer Disease

Peptic ulcers account for half of major upper gastrointestinal bleeding with an overall
mortality rate of 6%. However, in North America the incidence of bleeding from ulcers is
declining, perhaps due to eradication of H pylori and prophylaxis with proton pump
inhibitors in high-risk patients.
2.

Portal Hypertension
Portal hypertension accounts for 1020% of upper gastrointestinal bleeding. Bleeding
usually arises from esophageal varices and less commonly gastric or duodenal varices or
portal hypertensive gastropathy. Approximately 25% of patients with cirrhosis have medium
to large esophageal varices, of whom 30% experience acute variceal bleeding within a 2year period

3.

Mallory-Weiss Tears
Lacerations of the gastroesophageal junction cause 510% of cases of upper gastrointestinal
bleeding. Many patients report a history of heavy alcohol use or retching. Less than 10%
have continued or recurrent bleeding.

4.

Vascular Anomalies
Vascular anomalies are found throughout the gastrointestinal tract and may be the source of
chronic or acute gastrointestinal bleeding. They account for 7% of cases of acute upper tract
bleeding. The most common are angioectasias (angiodysplasias) which are 110 mm
distorted, aberrant submucosal vessels caused by chronic, intermittent obstruction of
submucosal veins. They have a bright red stellate appearance and occur throughout the
gastrointestinal tract but most commonly in the right colon. Telangiectasias are small,
cherry red lesions caused by dilation of venules that may be part of systemic conditions
(hereditary hemorrhagic telangiectasia, CREST syndrome) or occur sporadically. The
Dieulafoy lesion is an aberrant, large-caliber submucosal artery, most commonly in the
proximal stomach that causes recurrent, intermittent bleeding.

5. Gastric Neoplasms
Gastric neoplasms result in 1% of upper gastrointestinal hemorrhages.
6. Erosive Gastritis
Because this process is superficial, it is a relatively unusual cause of severe gastrointestinal
bleeding (< 5% of cases) and more commonly results in chronic blood loss. Gastric mucosal

erosions are due to NSAIDs, alcohol, or severe medical or surgical illness (stress-related
mucosal disease).
7. Erosive Esophagitis
Severe erosive esophagitis due to chronic gastroesophageal reflux may rarely cause
significant upper gastrointestinal bleeding, especially in patients who are bed bound longterm.
8. Others
An aortoenteric fistula complicates 2% of abdominal aorticgrafts or, rarely, can occur as the
initial presentation of a previously untreated aneurysm. Usually located between the graft or
aneurysm and the third portion of the duodenum, these fistulas characteristically present
with a herald nonexsanguinating initial hemorrhage, with melena and hematemesis, or with
chronic intermittent bleeding. The diagnosis may be suspected by upper endoscopy or
abdominal CT. Surgery is mandatory to prevent exsanguinating hemorrhage. Unusual causes
of upper gastrointestinal bleeding include hemobilia (from hepatic tumor, angioma,
penetrating

trauma),

pancreatic

malignancy,

and

pseudoaneurysm

(hemosuccus

pancreaticus).
Initial Evaluation & Treatment
A. Stabilization
The initial step is assessment of the hemodynamic status. Asystolic blood pressure < 100 mm Hg
identifies a high-risk patient with severe acute bleeding. A heart rate over 100 beats/min with a
systolic blood pressure over 100 mm Hg signifies moderate acute blood loss. A normal systolic
blood pressure and heart rate suggest relatively minor hemorrhage. Postural hypotension and
tachycardia are useful when present but may be due to causes other than blood loss. Because the
hematocrit may take 2472 hours to equilibrate with the extravascular fluid, it is not a reliable
indicator of the severity of acute bleeding. In patients with significant bleeding, two 18-gauge or
larger intravenous lines should be started prior to further diagnostic tests. Blood is sent for
complete blood count, prothrombin time with international normalized ratio (INR), serum
creatinine, liver enzymes, and blood typing and screening (in anticipation of need for possible
transfusion). In patients without hemodynamic compromise or overt active bleeding, aggressive
fluid repletion can be delayed until the extent of the bleeding is further clarified. Patients with
evidence of hemodynamic compromise are given 0.9% saline or lactated Ringer injection and

crossmatched for 24 units of packed red blood cells. It is rarely necessary to administer typespecific or O-negative blood. Central venous pressure monitoring is desirable in some cases, but
line placement should not interfere with rapid volume resuscitation. Placement of a nasogastric
tube is not routinely needed but may be helpful in the initial assessment and triage of selected
patients with suspected active upper tract bleeding. The aspiration of red blood or coffee
groundsconfirms an upper gastrointestinal source of bleeding, though up to 18% of patients
with confirmed upper tract sources of bleeding have nonbloody aspiratesespecially when
bleeding originates in the duodenum. An aspirate of bright red blood indicates active bleeding
and is associated with the highest risk of further bleeding and complications, while a clear
aspirate identifies patients at lower initial risk. Erythromycin (250 mg) administered
intravenously 30 minutes prior to upper endoscopy promotes gastric emptying and may improve
the quality of endoscopic evaluation when substantial amounts of blood or clot in the stomach is
suspected. Efforts to stop or slow bleeding by gastric lavage with large volumes of fluid are of no
benefit and expose the patient to an increased risk of aspiration.
B. Blood Replacement
The amount of fluid and blood products required is based on assessment of vital signs, evidence
of active bleeding from nasogastric aspirate, and laboratory tests. Sufficient packed red blood
cells should be given to maintain a hemoglobin of 79 g/dL, based on the patients hemodynamic
status, comorbidities (especially cardiovascular disease), and presence of continued bleeding. In
the absence of continued bleeding, the hemoglobin should rise approximately 1 g/dL for each
unit of transfused packed red cells. Transfusion of blood should not be withheld from patients
with massive active bleeding regardless of the hemoglobin value. It is desirable to transfuse
blood in anticipation of the nadir hematocrit. In actively bleeding patients, platelets are
transfused if the platelet count is under 50,000/mcL and considered if there is impaired platelet
function due to aspirin or clopidogrel use (regardless of the platelet count). Uremic patients (who
also have dysfunctional platelets) with active
bleeding are given three doses of desmopressin (DDAVP), 0.3 mcg/kg intravenously, at 12-hour
intervals. Fresh frozen plasma is administered for actively bleeding patients with a coagulopathy
and an INR > 1.8; however, endoscopy may be performed safely if the INR is < 2.5. In the face

of massive bleeding, 1 unit of fresh frozen plasma should be given for each 5 units of packed red
blood cells transfused.
C. Initial Triage
A preliminary assessment of risk based on several clinical factors aids in the resuscitation as well
as the rational triage of the patient. Clinical predictors of increased risk of rebleeding and death
include age > 60 years, comorbid illnesses, systolic blood pressure < 100 mm Hg, pulse > 100
beats/min, and bright red blood in the nasogastric aspirate or on rectal examination.
1. High riskPatients with active bleeding manifested by hematemesis or bright red
blood on nasogastric aspirate, shock, persistent hemodynamic derangement despite fluid
resuscitation, serious comorbid medical illness, or evidence of advanced liver disease require
admission to an intensive care unit (ICU). After adequate resuscitation, endoscopy should be
performed within 224 hours in most patients but may be delayed in selected patients with
serious comorbidities (eg, acute coronary syndrome) who do
not have signs of continued bleeding.
2. Low to moderate riskAll other patients are admitted to a step-down unit or medical
ward after appropriate stabilization for further evaluation and treatment. Patients without
evidence of active bleeding undergo nonemergent endoscopy usually within 24 hours.