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Kelainan pada
Esofagus dan
Easter
Oleh :
Yunia Annisa, dr, SpPD,
MKes
1
Pendahuluan
Tujuan :
Mahasiswa mampu memahami dan
menjelaskan dan melakukan diagnosis,
penatalaksanaan terhadap penyakit
sistim digestive (esofagus dan gaster)
Dyspepsia
Definisi
acute,
Dyspepsia
Etiologi
Food or Drug Intolerance
Functional Dyspepsia (common cause)
Luminal Gastrointestinal Tract Dysfunction
Helicobacter pylori Infection
Pancreatic Disease
Biliary Tract Disease
Other cause (Diabetes mellitus, thyroid
disease, chronic kidney disease, myocardial
ischemia, intra-abdominal malignancy, gastric
volvulus or paraesophageal hernia, chronic
gastric or intestinal ischemia, and pregnancy)
Dyspepsia
Dyspepsia
Diagnosis
Lab:
blood count,
electrolytes,
liver enzymes,
calcium,
thyroid function tests
Age < 55yononinvasive test for H pylori
Dyspepsia
Penatalaksanaan
Empiric
General measures
Pharmacologic agents
Anti-H pylori treatment
Alternative therapies
Definisi
Nausea
10
Pemeriksaan Khusus
With vomiting that is severe or protracted:
serum electrolytes should be obtained
to
CT Scan
Endoscopy
MRI
USG
11
Komplikasi
dehydration,
hypokalemia,
Metabolic
alkalosis,
aspiration,
rupture of the esophagus (Boerhaave
syndrome),
bleeding secondary to a mucosal tear at
the gastroesophageal junction (MalloryWeiss syndrome)
12
Penatalaksanaan
Most causes of acute vomiting are mild, selflimited, and require no specific treatment.
Ingest clear liquids (broths, tea, soups,
carbonated beverages) and small quantities of dry
foods (soda crackers).
severe acute vomiting hospitalization
DehydratedHypokalemi+metabolic
alkalosisntravenous 0.45% saline solution with
20 mEq/L of potassium chloride maintain
hydration
nasogastric suction tube for gastric or mechanical
small bowel obstruction improves patient comfort
and permits monitoring of fluid loss.
13
Penatalaksanaan
Antiemetic Medications
Serotonin 5-HT3-receptor antagonistsOndansetron, granisetron,
dolasetron, and palonosetron, preventing chemotherapy- and radiationinduced emesis when initiated prior to treatment
Corticosteroids Corticosteroids (eg, dexamethasone)have antiemetic
properties, but the basis for these effects is unknown.
Neurokinin receptor antagonists Aprepitant and fosaprepitant are
highly selective antagonists for NK1- receptors in the area postrema.
combination +corticosteroids and serotonin antagonists acute and
delayed nausea and vomiting with highly emetogenic chemotherapy
regimens.
Dopamine antagonists The phenothiazines, butyrophenones, and
substituted benzamides have antiemetic properties that are due to
dopaminergic blockade as well as to their sedative effects.
Antihistamines and anticholinergics(eg, meclizine, dimenhydrinate,
transdermal scopolamine) prevention of vomiting arising from
stimulation of the labyrinth, ie, motion sickness, vertigo, and migraines.
Cannabinoids
14
Hiccups (Singultus)
Definisi
Though usually a benign and self-limited annoyance,
hiccups may be persistent and a sign of serious
underlying illness.
In patients on mechanical ventilation, hiccups can
trigger a full respiratory cycle and result in respiratory
alkalosis.
Causes of benign, self-limited hiccups include gastric
distention (carbonated beverages, air swallowing,
overeating), sudden temperature changes (hot then
cold liquids, hot then cold shower), alcohol ingestion,
and states of heightened emotion (excitement, stress,
laughing). There are over 100 causes of recurrent or
persistent hiccups due to gastrointestinal, central
nervous system, cardiovascular, and thoracic disorders.
15
Hiccups (Singultus)
Diagnosis
Patient with persistent hiccups should include:
detailed neurologic examination, serum
creatinine,
liver chemistry tests,
a chest radiograph.
When the cause remains unclear:
CT or
MRI of the head, chest, and abdomen,
echocardiography,
upper endoscopy
16
Hiccups (Singultus)
Terapi
Simple Treatment
Irritation of the nasopharynx by tongue traction, lifting the uvula with a
spoon, catheter stimulation of the nasopharynx, or eating 1 teaspoon of
dry granulated sugar.
Interruption of the respiratory cycle by breath holding, Valsalva
maneuver, sneezing, gasping (fright stimulus), or rebreathing into a
bag.
Stimulation of the vagus by carotid massage.
Irritation of the diaphragm by holding knees to chest or by continuous
positive airway pressure during mechanical ventilation.
Relief of gastric distention by belching or insertion of a nasogastric tube.
Drugs medication
Chlorpromazine, 2550 mg orally or intramuscularly, is most commonly
used
Other agents reported to be effective include anticonvulsant (phenytoin,
carbamazepine), benzodiazepines (lorazepam, diazepam),
metoclopramide, baclofen, gabapentin, and occasionally general
anesthesia
17 Zollinger-Ellison
syndrome
Definisi
Peptic
18 Zollinger-Ellison
syndrome
Definisi
Peptic ulcer disease caused by gastrin-secreting
gutneuroendocrine tumors
(gastrinomas)hypergastrinemia and Gastric acid
hypersecretionmay be severe and atypical.
Primary gastrinomas may arise in the pancreas (25%),
duodenal wall (45%), or lymph nodes (515%), and in
other locations or of unknown primary in 20%.
Approximately 80% arise within the gastrinoma
triangle bounded by the porta hepatis, the neck of the
pancreas, and the third portion of the duodenum.
Most gastrinomas are solitary or multifocal nodules that
arepotentially resectable.
Over two-thirds of gastrinomas are malignant, and onethird have already metastasized to the liver at initial
presentation.
19 Zollinger-Ellison
syndrome
20 Zollinger-Ellison
syndrome
Screening
Fasting gastrin levels should be obtained in patients
with ulcers that are refractory to standard
therapies, giant ulcers (> 2 cm), ulcers located
distal to the duodenal bulb, multiple duodenal
ulcers, frequent ulcer recurrences, ulcers associated
with diarrhea, ulcers occurring after ulcer surgery,
and patients with ulcer complications.
Ulcer patients with hypercalcemia or family
histories of ulcers (suggesting MEN 1) should also
be screened.
patients with peptic ulcers who are H pylori
negative and who are not taking NSAIDs should be
screened.
21 Zollinger-Ellison
syndrome
Diagnosis
The most sensitive and specific method for identifying Zollinger-Ellison
syndrome is demonstration of an increased fasting serum gastrin
concentration (> 150 pg/mL [> 150 ng/L]).
Levels should be obtained with patients not taking H2-receptor
antagonists for 24 hours or proton pump inhibitors for 6 days.
Withdrawal of the proton pump inhibitor may be accompanied by massive
gastric hypersecretion with serious consequences and should be closely
monitored.
The median gastrin level is 500700 pg/ mL (500700 ng/L), and 60% of
patients have levels < 1000 pg/mL (< 1000 ng/L).
Hypochlorhydria with increased gastric pH is a much more common cause
of hypergastrinemia than is gastrinoma. Therefore, a measurement of
gastric pH (and, where available, gastric secretory studies) is performed in
patients with fasting hypergastrinemia.
Most patients have a basal acid output of over 15 mEq/h.
A gastric pH of > 3.0 implies hypochlorhydria and excludes gastrinoma.
In a patient with a serum gastrin level of > 1000 pg/mL (> 1000 ng/L) and
acid hypersecretion, the diagnosis of Zollinger-Ellison syndrome is
established.
22 Zollinger-Ellison
syndrome
Diagnosis
CT
Scan
MRI
Somatostatin receptor scintigraphy
(SRS) with single photon emission
computed tomography (SPECT)
endoscopic ultrasonography
23 Zollinger-Ellison
syndrome
Terapi
Metastatic
Localized
Disease
Disease
24
GERD
Definisi
Suatu
25
GERD
Etiologi
Nikotin
Alkohol
Aspirin
Kelainan pada lambung (dilatasi lambung,
obstruksi gastrik outlet, delayed gastric
emptying)
Infeksi H.Pylori
Hiatus hernia
Obat2an antikolinergik, beta adrenegik,
theofilin, opiat, dll
Hipersensitivitas viseral
26
GERD
Gejala
Nyeri/ rasa tidak enak pada epigastrum atau
retrosternal bagian bawah dideskripsikan
sebagai heartburn
Disfagia (pada makanan padat striktur atau
keganasan yg berkembang dari Barrets
esophagus
Mual/regurgitasi
Rasa pahit di lidah
Odinofagiaa bisa timbul ulserasi esofagus berat
Kadang timbul rasa tidak enak retrosernal
Bisa muncul juga gejala ekstra esofageal (nyeri
dada non kardiak, suara serak, laringitis, batuk
karena aspirasi, bronkiektasis, asma)
27
GERD
Diagnosis
28
GERD
Penatalaksanaan
Modifikasi
Terapi
Terapi
Terapi
Terapi
Gaya Hidup
Medikamentosa
terhadap komplikasi
Bedah
Endoskopi
29
GERD
Penatalaksanaan
Modifikasi
Gaya Hidup
30
GERD
Penatalaksanaan
Terapi
Medikamentosa
Antasid
Antagonis reseptor H2
Sukralafat (Alumunium
hidroksida+sukrosa oktasulfat)
Penghambat Pompa Proton ( PPI)
31
GERD
Penatalaksanaan
Terapi
terhadap komplikasi
Striktur Esofagus
Jika
Esofagus Barret
32
GERD
Penatalaksanaan
Terapi
33
GERD
Penatalaksanaan
Terapi
Endoskopi
34
Striktus Esofagus
Definisi
Penyempitan
35
Striktus Esofagus
36
Striktus Esofagus
Heartburn
Rasa
37
Striktus Esofagus
Etiologi
Penyakit
38
Striktus Esofagus
Diagnosis
Anamnesis
Gangguan menelan makanan
39
Ulkus peptik
Definisi
Suatu
40
Ulkus peptik
Etiologi
Gangguan
41
Ulkus peptik
Gambaran Klinis
Mengeluh dispepsia
Nyeri ulu hati
Rasa tidak nyaman disertai muntah
Rasa sakit timbul saat pasien lapar, terasa di
sebelah kanan, bisa membangunkan pasien
tengah malam, rasa sakit hilang setelah
makan atau minum obat antasida (tukak
duodeni)
Rasa sakisa disebelah kirit timbul setelah
makan, terasa di sebelah kiri, terasa mulanya
pada satu titik dan menyebar sampai ke
punggung (tukak gaster)
42
Ulkus peptik
Diagnosis
Pemeriksaan Fisisk
Rasa nyeri ulu hati
Penurunan berat badan
Nyeri teka4-5 jam setelahjumpain perut
Perut diam tanpa terdengar peristaltik
Goncangan perut 4-5 jam setelah
makan disertai muntah-muntah
43
Ulkus peptik
Diagnosis
Pemeriksaan penunjang
Radiologi dengan barium meal kontras
ganda
Endoskopi
Biopsi
44
Ulkus peptik
Komplikasi
Perdarahan
Perforasi,
45
Ulkus peptik
Terapi
Non
medikamentosa
Istirahat
Diet
Menghindari obat2an OAINS
Medikamentosa
Antasida
Obat penangkal kerusakan mukus
Koloid
bismuth
Sukralafat
Prostaglandin
Antagonis reseptor H2/ARH2
PPI
Operasi
46
Akalasia
Definisi
Suatu
47
Akalasia
Etiologi
Akalasia
Akalasia
Primer
Sekunder
Infeksi
Tumor intraluminer
Obat antikolinergik
Pasca vogotomi
48
Akalasia
Manifestasi Klinis
Disfagia
Regurgitasi
Penurunan berat badan
Nyeri dada
49
Akalasia
Diagnosis
Radiologi (esofagogram)
Endoskopi
50
Akalasia
Penatalaksanaan
Medikamentosa
Dilatasi/
Peregangan SEB
Operasi (esofagomiotomi)
51
Definisi
Mallory-Weiss
syndrome is characterized
by a nonpenetrating mucosal tear at the
gastroesophageal junction that is
hypothesized to arise from events that
suddenly raise transabdominal pressure,
such as lifting, retching, or vomiting.
Alcoholism is a strong predisposing
factor.
52
53
Diagnosis
Endoscopy
after resusitation
54
Penatalaksanaan
fluid
resuscitation
blood transfusions
55
Gastritis
Definisi
Proses
56
Gastritis
Klasifikasi
Berdasarkan Update Sydney system:
Topografi
Mortologi
Etiologi
Klasifikasi umum:
Monahopik
Atropik
Bentuk khusus
57
Gastritis
Etiologi
plyori (HP) >90%
Penggunaan antibiotik infeksi paru
Ganguan fungsi imun
Virus enteric rotavirus dan calcivirus
JamurCandida Sp, Histoplasma
capsulatum dan Mukonaceae
Heliobacter
58
Gastritis
khas:
59
Diagnosis
Endoskopi
Hispatologi
Biopsi (bila perlu)
Gastritis
60
Gastritis
Penatalaksanaan
Radikasi Kuman
61
Gastropati
Definisi
erosive
62
Gastropati
asymptomatic.
When occur : anorexia, epigastric pain,
nausea, and vomiting.
There is poor correlation between symptoms
and the number or severity of endoscopic
abnormalities.
upper gastrointestinal bleeding, which
presents as hematemesis, coffee grounds
emesis, or bloody aspirate in a patient
receiving nasogastric suction, or as melena
hemodynamically significant bleeding is rare
63
Gastropati
Diagnosis
The
64
Gastropati
Klasifikasi
Berdasarkan penyebab
Stress Gastritis
NSAID Gastritis
Alcoholic Gastritis
Portal Hypertensive Gastropathy
65
Gastropati
Klasifikasi
Stress Gastritis
66
Gastropati
Klasifikasi
NSAID Gastritis
67
Gastropati
Klasifikasi
Alcohol
ic Gastritis
68
Gastropati
Klasifikasi
Pendarahan SCBA
Definisi
Manifestasi
Pendarahan SCBA
Etiologi
Pecahnya
Pendarahan SCBA
Manifestasi Klinis
Kemungkinan pasien datang dengan:
Anemia defisiensi besi akibat
pendarahan tersembunyi yg
berlangsung lama
Hematemesis dan atau melena disertai
atau tanpa anemia. Dengan atau tanpa
gangguan hemodinamik; derajat
hipovolemi menentukan tingkat
kegawatan pasien
Pendarahan SCBA
Pendekatan Diagnostik
Anamnesis akuratidentifikasi faktor
pencetuspenyakit dasar yg ada
Bila perlu pemasangan pipa nasogastrik
utk diagnostik dan dekompresi
Pemeriksaan fisik yg teliti identifikasi
penyakit dasar& penyerta
Pemeriksaan
esofagogastroduodenoskopi sarana
diagnostik definitif
Pendarahan SCBA
Pendekatan Diagnostik
Anamnesis akuratidentifikasi faktor
pencetuspenyakit dasar yg ada
Bila perlu pemasangan pipa nasogastrik
utk diagnostik dan dekompresi
Pemeriksaan fisik yg teliti identifikasi
penyakit dasar& penyerta
Pemeriksaan
esofagogastroduodenoskopi sarana
diagnostik definitif
Pendarahan SCBA
Pendarahan SCBA
Pemeriksaan awal
Tekanan
Pendarahan SCBA
Stabilisasi Hemodinamika
Berikan
Pendarahan SCBA
Pemeriksaan Lanjutan
Anamnesis
Sejak kapan terjadi perdarahan & perkiraan darah keluar
Riwayat perdarahan sebelumnya
Riwayat perdarahan keluarga
Ada tidaknya perdarahan di bag tubuh lain
Penggunaan obat antiinflamasi non-steroid dan anti koagulan
Kebiasaaan minum alkohol
Mencari kemungkinan penyakit hati kronik, demam berdarah, demam tifoid,
CKD, DM, Hipertensi, Alergi obat
Riwayat tranfusi sebelumnya
PF
Stigmata penyakit hati kronik
Suhu badan dan perdarahan di tempat lain
Tanda-tanda kulit dan mukosa penyakit sistematik yg bisa disertai
perdarahan saluran makanan
Pemeriksaan pelengkap
EKG
BUN, kreatinin serum
Pemeriksaan elektrolit (Na, K Cl)
Pemeriksaan lain yg diperlukan
Pendarahan SCBA
Pendarahan SCBA
Pendarahan SCBA
Endoskopi
Contact thermal
Non contact thermal
Non thermal
Pendarahan SCBA
Terapi
Radiologi
Pembedahan
82
Daftar pustaka
Buku
83
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