GROUP 11 /Problem 1

GASTROINTESTINAL TRACT
Faculty of Medicine
Tarumanagara University
2016
 Group 11/Problem 1
• Tutor : dr. Irma
• Leader: Kent Harlendo
• Secretary : Siti Suryani
• Writer : Agustina Cynthia Cesari S

• Member:
-Arianto Salim
-Nailah Rahmah
-Ivany Lestari Goutama
-Chyntia Winata
-Richard Anderson
-Katherine Chia
-Egie Madgani Ainul Kamil
-David William
-Callista Harlim
 Problem 1
A 60-year-old man presented to his family physician complaining of
feeding difficulty since 3 months ago. Everytime he eats,he feels that
his food,especially solids,are not going down easily. Only by repeated
swallowing that he is able to get the food down. More recently,he
noticed the spontaneous regurgitation of clear,foamy liquid and
undigested food into his mounth,especially when bending over after his
dinner. His wife noted that he often coughs at night and has lost 3 to
4kg since the problem started. His past medical history includes a 5-
year history of hypertension. He denies any history of CVD.

The patient denies either hearburn or odynophagia but does report an

inability to belch. He smokes 2 packs per day. Oral examination
showed oral ulcers. Other physical examination were unremarkable.

What can you learn from the problem?

 Unfimiliar Terms
• Odynophagia : pain on swallowing
• Regurgitation : movement of undigested or partially digested
food upward through the esophagus without nausea and strong
gastric contraction
• Oral ulcer : is a break in the skin or mucous membrane with
loss of surface tissue and the disintegration and necrosis of
epithelial tissue
 Problems
1. what is the relationship of smoking and a history of hypertension
in the patient's complaints?
2. why can occur spontaneous regurgitation especially when bending
after eating?
3. what causes weight decreased 3 to 4kg?
4. why the patient inability to belch and what to do with the patient's
symptoms?
5. What DD of the case?
6. What is the relationship of cough at night in the patient’s
complaints?
7. Why can occur oral ulcer?
8. Why the patient’s complaining of feeding difficulty ?
9. What the investigation of the case?
 Brainstorm
1. Exposure to cigarette smoke  weaken the LES  sphincter does not function
properly  regurgitation
2. -After eating, food can not enter the stomach for a weak LES -> regurgitation
-when bent, esophagus so much flattereasily happen regurgitation
3. Weight loss because the food is not digested, coughing exertion, decreased appetite
because of difficulty swallowing
4. Because the LES is not functioning properly, the gas from the stomach can not get
out -> can not a belch
5. Achalasia,gerd
6. GERD -> stomach acid up to the top -> cause sore throat -> chronic dry cough
7. Because of the age factor, the teeth are destroyed, spontaneous bacterial infection
regurgitation
8. Difficulty swallowing because: abnormalities in the esophagus to move the
peristaltic disturbed, because he is already old
9. -Esophageal Manometry to see esophageal motility and LES function
-upper endoscopy to see the damage to the esophagus
Review
Governance

Signs And Epidemiology

Symptoms

Dysphagia
Pathophysiology
Differential
Diagnosis

Examination Type Of Food

etiology
Learning Objectives (to explain and learn about...)
1. Anatomy and Histology of Upper GIT,
Biochemistry in Digestive Tract
2. Physiology of swallowing and Pathogenesis in
difficulty of swallowing
3. Terminology and Pathophysiology of
Dysphagia & Odynophagia
4. Feeding difficulty

8
LO 1 ANATOMY OF UPPER GIT 9
 Mouth

http://medicalterms.info/anatomy/Digestive-System/

Sumber : http://www.yourarticlelibrary.com/biology/human-beings/mouthuseful-notes-on-mouth-human-anatomy/9702/ 10
Muscles of the tongue
Teeth anatomy

13
 Anatomy of upper GIT

15
Sumber: 2000.WebMD; http://www.mountnittany.org/articles/healthsheets/7131
Histology of Upper GIT
Junqueira’s basic histology text & atlas 13th ed
Taste Bud
Junqueira’s basic histology text & atlas 13th ed
 Biochemistry in Digestive Tract

Mechanical and chemical digestive process by teeth, saliva, and

enzymes:
 α-amylase: secreted by salivary gland, needs Ca2+ to break carbohydrate to
mono-/disaccahrides
 lipase: secreted by serous Von Ebner gland to break short or medium chain
triglycerides to 1,2-diacylglycerol + fatty acid
 mucin: glycosylated protein secreted by epithelium cells of salivary gland to
lubricate food
 Lysozyme: as non-specific antiseptic by hydrolyzing bacterial cell wall
 IgA: secreted by plasma cells in lamina propria and is the only antibody which
is made in digestive tract
FOOD TYPE ENZYME SOURCE PRODUCTS

CARBOHYDRATES Salivary amylase Salivary glands Maltose

Pancreatic amylase Pancreas Maltose
Maltase Small intestine Glucose

PROTEINS Pepsin Stomach mucosa Peptides

Trypsin Pancreas Peptides
Peptidases Intestinal mucosa Amino acids

FATS Lipase Pancreas Fatty acids and glycerol

SOURCE ENZYME FOOD PRODUCT

MOUTH (salivary Salivary amylase Polysaccharides Maltose

glands)

STOMACH Pepsin Proteins Peptides

PANCREAS Pancreatic amylase Polysaccharides Maltose

Trypsin Proteins Peptides
Lipase Fats Fatty acids
and glycerol

SMALL INTESTINE Maltase Maltose Glucose

Peptidases Peptides Amino acids
 Enzymes involved in digestion

32
Reference: "Biochemistry" by Lubert Stryer
 Hormones involved in digestion

1. Gastrin: The presence of food in the stomach stimulates specific

receptors which in turn stimulates endocrine cells in the stomach to
secrete the hormone gastrin into the circulatory system. Gastrin
stimulates the stomach to secrete gastric juice.
2. Secretin: Secretin is produced by cells of the duodenum.
 It’s production is stimulated by acid chyme from stomach.
 It stimulates the pancreas to produce sodium bicarbonate, which neutralizes
the acidic chyme. It also stimulates the liver to secrete bile.
3. CCK (cholecystokinin): CCK production is stimulated by the presence
of food in the duodenum. It stimulates the gallbladder to release bile and
the pancreas to produce pancreatic enzymes.
4. GIP (Gastric Inhibitory Peptide):Food in the duodenum stimulates
certain endocrine cells to produce GIP.
 It has the opposite effects of gastrin; it inhibits gastric glands in the stomach
and it inhibits the mixing and churning movement of stomach muscles. This
slows the rate of stomach emptying when the duodenum contains food.
33
Physiology of swallowing and Pathogenesis
in difficulty of swallowing
 Digestive system
• The primary function of the digestive system:
to transfer nutrients, water and electrolytes
from the food we eat into the body’s internal
environment
• There are four basic digestive processes:
Motility
Secretion
Digestion
Absorption
 Basic digestive processes
• Motility: muscular contractions that mix and
move forward the contents of the digestive tract
• Secretion: a number of digestive juices secreted
into the digestive tract lumen by exocrine glands
along the route, each with its own specific
secretory product. Each digestive secretion
consists of water, electrolytes, and specific
organic contituents important in the digestive
process, such as enzymes, bile salts, or mucus.
• Digestion: biochemical breakdown of the
structurally complex foodstuffs of the diet into
smaller, absorbable units by the enzymes
produced within the digestive system
• Absorption: in the small intestine, digestion is
completed and most absorption occurs. Through
the process of absorption, the small absorbable
units that result from digestion, along with water,
vitamins, and electrolytes, are transferred from
the digestive tract lumen into the blood or lymph
 Digestive system
• The digestive system • Acessory digestive
consists: organs:
 Digestive tract  Salivary glands
 Accessory digestive organs  Exocrine pancreas
• Digestive tract:  Biliary system (liver and
 Mouth galbladder)
 Pharynx
 Esophagus
 Stomach
 Small intestine (duodenum,
jejunum, and ileum)
 Anus
 Digestive tract wall
• The digestive tract wall has the same general
structure through-out most of its length from
the esophagus to the anus, with some local
variations characteristics for each region
• From the innermost layer outward they are:
Mucosa
Submucosa
Muscularis externa
Serosa
 Regulation of digestive function
• Digestive motility and secretion carefully
regulated to maximize digestion and
absorption of ingested food
• Four factors are involved in regulating
digestive system function:
Autonomous smooth muscle function
Intrinsic nerve plexuses
Extrinsic nerves
Gastrointestinal hormones
• The digestive tract wall contains three types of
sensory receptors that respond to loval changes
in the digestive tract:
Chemoreceptors sensitive to chemical components
within the lumen
Mechanoreceptors sensitive to stretch or tension
within the wall
Osmoreceptors sensitive to the osmolarity of the
luminal contents
 Mouth (motility)
• Entry to the digestive tract is through the mouth or oral
cavity
• The first step in the digestive process is mastication, or
chewing, the motility of the mouth that involves the
slicing, tearing, grinding, and mixing of ingested food
by the teeth
• The functions of chewing are:
 To grind and break food up into smaller pieces to facilitate
swallowing and to increase the food surface area on which
salivary enzymes will act
 To mix food with saliva
 To stimulate the taste buds
 Mouth (secretion)
• Saliva, the secretion associated with the
mouth, is produced largely by three major
pairs of salivary glands that lie outside the oral
cavity and discharge saliva through short ducts
into the mouth
• Saliva is about 99,5% H2O and 0,5%
electrolytes and protein
• The most important salivary proteins are
amylase, mucus, and lysozyme
 Mouth
Digestion Absorption
• Digestion in the mouth • No absorption of foodstuff
involves the hydrolysis of occurs from the mouth
polysaccharides into • Importantly some drugs can
diaccharides by amylase be absorbed by the oral
mucosa, a prime example
being nitroglycerin
 Pharynx and esophagus (motility)

• The motility associated with the pharynx and

esophagus is swallowing
• Swallowing is the entire process of moving
food from the mouth through the esophagus
into the stomach
 Esophagus (secretion)
• Esophageal secretion is entirely mucus
• Mucus is secreted throughout the length of the
digestive tract by mucus-secreting gland cells in
the mucosa
• By lubricationg the passage of food, esophageal
mucus lessens the likelihood that the esophagus
will be damaged by any sharp edges in the newly
entering food
• Furthermore, it protects the esophageal wall from
acid and enzymes in gastric juice if gastric reflux
occurs
 Esophagus (digestion & absorption)

• The entire transit time in the pharynx and

esophagus averages a mere 6-10 seconds, too
short a time for any digestion or absorption in
this region
 Figure 23.13 Deglutition (swallowing). Slide 1
Bolus of food

Tongue
Uvula
Pharynx Bolus
Epiglottis
Epiglottis
Glottis

Trachea Upper
esophageal Bolus
Esophagus sphincter

1 During the buccal phase, the upper
esophageal sphincter is contracted.
The tongue presses against the hard
palate, forcing the food bolus into the
oropharynx.
2 The pharyngeal-esophageal phase
begins as the uvula and larynx rise to prevent
food from entering respiratory passageways.
The tongue blocks off the mouth. The upper
esophageal sphincter relaxes, allowing food
to enter the esophagus.
3 The constrictor muscles of the
pharynx contract, forcing food into
the esophagus inferiorly. The upper
esophageal sphincter contracts
(closes) after food enters.

Relaxed muscles 4 Peristalsis moves 5 The gastroesophageal

food through the Relaxed sphincter surrounding the
Circular muscles esophagus to the muscles cardial oriface opens, and
contract stomach. food enters the stomach.

Bolus of food

Longitudinal muscles
Circular muscles contract
contract

Gastroesophageal
sphincter closed Gastroesophageal
sphincter opens

Stomach

© 2013 Pearson Education, Inc.

DESCRIBES THE TERMINOLOGY OF DYSPHAGIA (FEEDING DIFFICULTY)
AND ODYNOPHAGIA
 DYSPHAGIA
• Medical terms for difficulties in swallowing
• May arise in 2 forms :
– Problems in transferring food bolus from the
oropharynx to the upper esophagus →
oropharyngeal dysphagia
– Impaired transport of the bolus through the body
of the esophagus → esophageal dysphagia
 ODYNOPHAGIA
• Sharp substernal pain on swallowing → may
limit oral intake
 Definition
• A condition in which disruption of the
swallowing process interferes with a patient’s
ability to eat.
• It can result in aspiration pneumonia,
malnutrition, dehydration, weight loss, and
airway abstruction.
Differential Diagnosis

Vahabzadeh B, Early DS. Common gastrointestinal complaints. Available from:

https://www.inkling.com/read/washington-manual-outpatient-internal-medicine-1st/chapter-24/dysphagia-and-odynophagia
 Dysphagia
Definition People with dysphagia have difficulty swallowing and may even
experience pain while swallowing (odynophagia), may be completely
unable to swallow or may have trouble safely swallowing liquids, foods,
or saliva
Risk - Problem with the neural control or the structures
Factors - Weak tongue or cheek muscles
- A stroke or other nervous system disorder
- After cancer surgery
Etiology - Any condition that weakens or damages the muscles and nerves used
for swallowing
- Stroke or head injury
- People born with abnormalities of the swallowing mechanism
- Cancer of the head, neck, or esophagus
- An infection or irritation
- Disorders of the esophagus

http://www.nidcd.nih.gov/health/voice/pages/dysph.aspx
 Symptoms
Oral Phase Pharyngeal Phase Esophageal Phase
- Drooling - Foamy phlegm, nasal - Sticking
- Oral regurgitation - Pain
retention - Coughing while eating / - Regurgitation
- Difficulty in drinking - Hiccups
chewing or - Coughing before / after - More difficulty
inadequately swallow with solids
chewed food - Wet / hoarse / breathy
- Stranded voice, weak cough,
phlegm inappropriate breathing
- Food sticking - Swallowing in-
coordination
- Aspiration, food sticking
www.entlectures.com
Diagnosis - Transnasal esophagoscopy
- Cervical auscultation
- Blood tests  including TSH, vit B12, CK
- Imaging studies  videofluoroscopy, CT scan, MRI, chest radiography
- Endoscopic examination
- Esophageal pH monitoring
- Pulmonary function tests
Treatments - Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST)
- Videofluoroscopic swallow study (VFSS)
- Muscle exercises to strengthen weak facial muscles or to improve
coordination
- Exercise and facilitates technique
• Indirect (eg, exercises to strengthen swallowing muscles)
• Direct (eg, exercises to be performed while swallowing)
- Surgical intervention
Complications - Aspiration pneumonia
- Loss weight
- The development of a pocket outside the esophagus

http://www.nidcd.nih.gov/health/voice/pages/dysph.aspx
 Dietary treatment
• Dysphagia diet 1 : Thin liquids (eg: fruit juice, coffee, tea)
• Dysphagia diet 2 : Nectar-thick liquids (eg: cream, soup, tomato juice)
• Dysphagia diet 3 : Honey-thick liquids (eg: liquids that are thickened to
ahoney consistency)
• Dysphagia diet 4: Pudding-thick liquids/foods (eg: mashed bananas,
cooked cereals, purees)
• Dysphagia diet 5 : Mechanical soft foods (eg: meat loaf, baked beans,
casseroles)
• Dysphagia diet 6 : Chewy foods (eg: pizza, cheese, bagels)
• Dysphagia diet 7 : Foods that fall apart (eg: bread, rice, muffins)
• Dysphagia diet 8 : Mixed textures
Classification
 Caries Dentis
Definition A common problem that occurs when acids in your mouth
dissolve the outer layers of your teeth
Risk Factors - Diet (food and drink high in carbohydrats)
- Poor oral hygiene
- Smoking and alcohol
- Dry mouth
Sign and - Toothache
Symptoms - Tooth sensitivity (tenderness or pain)
- Grey, brown or black spots
- Bad breath
- Unpleasant taste in mouth
Physical - Early sign: chalky white appearance of the enamel surface
Examinations - If the caries progresses: enamel surface becomes dark brown or
black
- Late sign: holes or cavites in the affected tooth
Diagnosis X-ray
http://www.nhs.uk/conditions/Dental-decay/Pages/Introduction.aspx
http://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html
http://www.nhs.uk/Conditions/Dental-decay/Pages/Causes.aspx
http://www.myvmc.com/diseases/dental-caries/
 Pathogenesis of Caries Dentis
Mouth full of
bacteria Bacteria in plaque turn
The plaque soften the
the carbohydrates →
enamel, by removing
energy they need +
Consume minerals from the tooth
producing acid
carbohydrats

The plaque and

Plaque and bacteria
will enter the pulp
(contains nerves and
blood vessels
The process of tooth
bacteria can reach the
decay speeds up.
dentine

Toothache

http://www.nhs.uk/Conditions/Dental-decay/Pages/Causes.aspx
Treatments - Flouride : early stage
- Fillings and crowns : if the decay is more extensive → replaces
your missing enamel
- Root canal treatment : if tooth decay has spread to the pulp →
may have to be removed and replaced with an artificial pulp that
will keep the tooth in place
- Tooth extraction : may be removed to prevent the spread of
infection
Complications - Gum disease (gingivitis)
- Dental abscesses
Prognosis Depends on the health of the patient, oral health practices and
the extent of dental caries
Prevention - Brush twice a day with a fluoride toothpaste
- Clean the teeth daily with floss or interdental cleaner
- Eat nutritious and balanced meals and limit snacking
- Visit your dentist regularly for professional cleanings and oral
examination
- Check with your dentist about use of supplemental fluoride
http://www.nhs.uk/Conditions/Dental-decay/Pages/Treatment.aspx
http://www.hse.ie/eng/health/az/D/Dental-caries/Complications-of-tooth-decay.html
http://www.myvmc.com/diseases/dental-caries/
http://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html
 Mouth Ulcers
Definition Small lesions that develop in your mouth or at the base of your gums
Risk Factors - Woman
- Family history of mouth ulcers
Types - Simple canker sores  may appear three or four times a year and
last up to a week; occur in people between 10 and 20 years of age
- Complex canker sores  occur more often in people who have
previously had them
Etiology - Minor injury to mouth
- Toothpastes and mouth rinses that contain sodium lauryl sulfate
- Food sensitivities to acidic foods
- Lack of essential vitamins like B-12, zinc, folate, and iron
- Allergic response to mouth bacteria
- Hormonal influxes during menstruation
- Emotional stress
- Bacterial, viral, or fungal infections

http://www.healthline.com/symptom/mouth-ulcers
http://www.webmd.com/oral-health/guide/canker-sores
Sign and - Painful sore or sores inside your mouth
Symptoms - Tingling or burning sensation before the sores appear
- Round, white or gray, with a red edge or border
- Fever
- Physical sluggishness
- Swollen lymph nodes
Treatments - Rinse of saltwater and baking soda
- Applying ice to canker sores
- Using mouth rinse that contains steroid to reduce pain and
swelling
- Using topical pastes
- Using oral steroids
Complications - Cellulitis of the mouth
- Dental infections (tooth abscesses)
- Oral cancer
- Spread of contagious disorders to other people

http://www.healthline.com/symptom/mouth-ulcers
http://www.webmd.com/oral-health/guide/canker-sores
https://www.nlm.nih.gov/medlineplus/ency/article/001448.htm
Prevention - Avoiding foods that irritate your mouth
• Acidic fruits, nuts, chips, or anything spicy
• Choose whole grains and alkaline fruits and vegetables
- Try to avoid talking while you are chewing your food
- Reducing stress
- Good oral hygiene and brushing after meals
- Soft bristle toothbrushes and mouthwashes that contain sodium
lauryl sulfate
 Glossitis
Definition Problem in which the tongue is swollen and changes color, often
making the surface of the tongue appear smooth
Etiology - Allergic reactions to oralcare products, foods, or medicine
- Dry mouth due to Sjogren syndrome
- Infection from bacteria, yeast or viruses
- Injury
- Skin conditions that affect the mouth
- Irritants
- Hormonal factors
Symptoms - Problems chewing, swallowing, or speaking
- Smooth surface of the tongue
- Sore, tender, or swollen tongue
- Pale or bright red color to the tongue
- Tongue swelling
- Blocked airway

https://www.nlm.nih.gov/medlineplus/ency/article/001053.htm
• Treatments :
– Brush your teeth thoroughly at least twice a day
and floss at least once a day
– Antibiotics or other medicines to treat infection
– Diet changes and supplements to treat nutrition
problems
– Avoiding irritants (such as hot or spicy foods,
alcohol, and tobacco)
• Prevention : Good oral care

https://www.nlm.nih.gov/medlineplus/ency/article/001053.htm
 Oral Candidiasis
Definition A condition in which Candida albicans accumulates on the lining of your
mouth
Symptoms -Creamy white lesions on your tounge, inner cheeks, and sometimes on
the roof of your mouth, gums, and tonsils
- A cottage cheese-like appearance
- Redness or soreness
- Slight bleeding
- Cracking and redness at the corner of your mouth
- A cottony feeling in your mouth
- Loss of taste
Risk -Some health conditions  HIV/AIDS, cancer, DM, vaginal yeast
Factors infections
- Undergoing chemotherapy or radiation treatment for cancer
- Wearing dentures
-Taking antibiotics or oral or inhaled corticosteroids
http://www.mayoclinic.org/diseases-conditions/oral-thrush/basics/definition/con-20022381
http://www.mayoclinic.org/diseases-conditions/oral-thrush/basics/symptoms/con-20022381
http://www.mayoclinic.org/diseases-conditions/oral-thrush/basics/risk-factors/con-20022381
 Diagnosis Limited to your mouth  looking at the lesions
In your esophagus  throat culture (swabbed with sterile cotton),
endoscopic exam
Treatment - Patient with late-stage HIV infection  amfotericin B
- Practice good oral hygiene
- Try warm saltwater rinses
Prevention - Rinse your mouth
- Brush your teeth at least twice a day and floss daily
- Clean your dentures
- See your dentist regularly
- Watch what you eat
- Maintain good blood sugar control if you have DM
- Treat any vaginal yeast infections

http://www.mayoclinic.org/diseases-conditions/oral-thrush/multimedia/oral-
thrush/img-20006447
http://www.mayoclinic.org/diseases-conditions/oral-thrush/basics/tests-
diagnosis/con-20022381
http://www.mayoclinic.org/diseases-conditions/oral-thrush/basics/treatment/con-
20022381
http://www.mayoclinic.org/diseases-conditions/oral-thrush/basics/lifestyle-home-
remedies/con-20022381
http://www.mayoclinic.org/diseases-conditions/oral-thrush/basics/prevention/con-
20022381
 Leukoplakia
Definition Whitish patch or plaque that is associated with the use of tobacco
Etiology Idiopatic
Risk Factors - Tobacco use
- Alcohol consumption
- Chronic irritation
- Candidiasis
- Vitamin deficiency
- Endocrine disturbances
Treatments - Vitamin A and retinoids
- Systemic beta carotene
- Lycopene (a carotenoid)
- Ketorolac as mouthwash
- Local bleomycin
- Mixture of tea used both topically and systemically with a reduced benefit
- Surgical treatment

https://www.nlm.nih.gov/medlineplus/ency/article/001046.htm
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4268300/
 Homogenous leukoplakia of
Verrucous leukoplakia on the floor of
the lingual versant of the
the mouth
gingiva

Speckled leukoplakia on the right Nodular leukoplakia of the soft palate

retrocomisural mucosa in a hard smoker

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4268300/
 Achalasia
Definition A primary esophageal motility disorder characterized by the
absence of esophageal peristalsis and impaired relaxation of the
lower esophageal sphincter (LES) in response to swallowing
Sign and - Dysphagia (most common)
Symptoms - Regurgitation
- Chest pain
- Heartburn
- Weight loss
Diagnosis - Barium swallow
- Esophageal manometry
- Prolonged esophageal pH monitoring
- Esophagogastroduodenoscopy
Treatments - CCB and nitrates
- Endoscopic intrasphincteric injection of botulinum toxin
- Laparoscopic Heller myotomy
- Peroral endoscopic myotomy (POEM)
- Surgery fails  endoscopic dilatation first
http://reference.medscape.com/article/169974-overview
http://gi.org/guideline/diagnosis-and-management-of-achalasia/
 Angina Ludwig
Definition A bilateral infection of the submandibular space that consists of
two compartments in the floor of the mouth, the sublingual space
and the submylohyoid / submaxillary space
Etiology - Odontogenic infections
- Mandible fracture, neck trauma, tongue piercing, sialdenitis,
neoplasm, and other parapharyngeal infections
- Polymicrobial infection
- Patients with immunocompromising conditions
Symptoms - Dental pain
- Neck pain and swelling
- Dysphonia
- Dysphagia
- Dysarthria
- Respiratory distress with dyspnea, tachypnea, or stridor

http://www.medscape.com/viewarticle/551650_4
https://www.nlm.nih.gov/medlineplus/ency/article/001047.htm
 Congenital malformations of the GI
tract
• The GI tract is a common site of development
abnormalities. In these cases, defects of other organs
that develop in the same embryonic period should be
sought
• Atresia, and fistulae
• Stenosis
• Diaphragmatic hernia
• Ectopia
• The Meckel Diverticulum
• Congenital hypertrophic pyloric stenosis
• Hirshsprung disease

Kumar V, Abbas AK, Aster JC. Robbins and cotran pathologic basis of
disease 9th ed. Philadelphia: Saunders Elsevier; 2015.
 Atresia and fistulae
• Structural developmental anomalies that
disrupt normal gastrointestinal transit and
typically present early in life.
• Imperforate anus is the most common form of
congenital intestinal atresia, while the
esophagus is the most common site of
fistulization.

Kumar V, Abbas AK, Aster JC. Robbins and cotran pathologic basis of
disease 9th ed. Philadelphia: Saunders Elsevier; 2015.
Kumar V, Abbas AK, Aster JC. Robbins and cotran pathologic basis of
disease 9th ed. Philadelphia: Saunders Elsevier; 2015.
Medical Nutrition Therapy for Upper GIT Disorders

80
Sumber: Krausse, 13th Edition
Medical Nutrition Therapy for Upper GIT Disorders

81
Sumber: Krausse, 13th Edition
 82
Sumber: Krausse, 13th Edition
 Pharmacological treatment
• Motilin,
– doses of 2-4 pmol/kg/min
• cisapride,
– dose should remain as low as possible (ideally less
than 40 mg daily).
• Methoclopramide
– less potent prokinetic drug than cisapride, particularly
with prolonged use, but its antiemetic properties can
provide prolonged symptom relief in gastroparesis.

83
 84
Sumber: Krausse, 13th Edition
 References
• http://www.medscape.com/viewarticle/551650_4
• https://www.nlm.nih.gov/medlineplus/ency/article/001047.htm
• Kumar V, Abbas AK, Aster JC. Robbins and cotran pathologic basis of disease 9th ed. Philadelphia: Saunders
Elsevier; 2015.
• http://reference.medscape.com/article/169974-overview
• http://gi.org/guideline/diagnosis-and-management-of-achalasia/
• http://www.mayoclinic.org/diseases-conditions/oral-thrush/multimedia/oral-thrush/img-20006447
• Vahabzadeh B, Early DS. Common gastrointestinal complaints. Available
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