Penyakit dan kelainan sistem gastroenterologi dan pankreatobilier (Diseases and Abnormalities in the Gastroenterological and Pancreatobiliary System) Marcellus Simadibrata K MD PhD SpPD KGEH FACG FINASIM Department of Medical Education Faculty of Medicine University of Indonesia Division Gastroenterology Department of Internal Medicine Faculty of Medicine University of Indonesia Lecture Module Gastrointestinal May 2013
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Penyakit dan kelainan sistem gastroenterologi dan pankreatobilier(Diseases and Abnormalities in the Gastroenterological and Pancreatobiliary System)
Marcellus Simadibrata K MD PhD SpPD KGEH FACG FINASIM
Department of Medical Education Faculty of Medicine University of IndonesiaDivision Gastroenterology Department of Internal Medicine Faculty of Medicine University of Indonesia
Lecture Module Gastrointestinal May 2013
Introduction
Gastrointestinal Diseases and Abnormalities: Upper and Lower border: Treitz ligament
Diseases in upper GI tract: Syndrome of dyspepsia, Gastroesophageal Reflux Disease(GERD), dysphagia, peptic ulcer, upper gastrointestinal bleeding(Hematemesis-Melena), polyp and cancer of the gaster/duodenum, cholangitis, bile duct Stone, pancreatitis.
Diseases in lower GI tract: diarrhea, irritable bowel syndrome, collitis infective-non Infective, Inflammatory Bowel Disease, polyp and cancer of the colon, hemoroid
Buku ajar Ilmu Penyakit Dalam. PIP Penyakit dalam jilid 1. 2005
Syndrome of Dyspepsia
Definition : persistent or recurrent upper abdominal pain or discomfort characterized by postprandial fullness, early satiety, nausea, and bloating.
Classification: Functional and organic , or ulcer and non ulcer(NUD)
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Management of Syndrome Dyspepsia:
Avoid/stop -decrease the aggravating/agresive factors, increase the defensive factors.
Young patients < 45 years, no NSAID consumer nor alarm symptoms : empiric therapy 2-4 weeks: Ulcer like: antacids or h2 receptor antagonist or proton pump inhibitor. Dysmotility like: prokinetic or h2 receptor antagonist. Nonspecific: antifatulent antacids, simethicone, antianxiety-depression.
Peptic ulcer: H2RA or PPI with/without cytoprotector Upper GI malignancies: operation.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
DEFINITION: a pathologic consequences of the effortless movement of gastric contents to the esophagus, including symptoms or signs referable to the esophagus, pharynx, larynx, and respiratory tract.
CLINICAL FEATURES: Heartburn, substernal chest discomfort, regurgitation bitter or acid-tasting liquid, water brash or hypersalivary, solid dysphagia, odynophagia, oropharynx damage(sorethroat, erache, gingivitis, poor dentition, and globus), reflux damage of the larynx and respiratory tract (hoarseness, wheezing, bronchitis, asthma, pneumonia).
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Pathophysiology of GERD
Spectrum Of Endoscopic Findings with GERD
Normal esophagus Grade 3 esophagitis
Grade 4 esophagitis Barrett’s esophagus
MANAGEMENT of GERD
Lifestyle modification: Head elevation, stop smoking/alcohol, reduce meal size and intake of fat/carminative/chocolate/coffee, carbonated beverages, tomato juice, citrus products, stop medications reducing LES pressure (anticholinergics, theophylline etc.)
Simadibrata M. Penatalaksanaan tukak peptik MKI 2007Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
CLINICAL FEATURES of PUD
Abdominal pain 94%: epigastric in location, does not radiate, occurs 2-3 hours postprandially, and relieved by food or antacids. Some time awakens the patient between midnight and 3 AM.
Some patients have no symptoms Complications: hemorrhage(melena)(15%),
perforation(7%), penetration, and obstruction(2%).
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
FINDINGS ON DIAGNOSTIC TESTING of PUD routine blood(Hb, leukocyte) & stool(occult blood test) Upper gastrointestinal barium radiography: gastric &
History: distinguish oropharyngeal / esophageal in location and if it is structural or neuromuscular in origin. Etc.
Physical examination: The head and neck sensory and motor function of the cranial nerves, masses, adenopathy, or spinal deformity. Examine systemic disease.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Management of Dysphagia
The management depend on the cause. Neuromuscular disease—myotomy(surgical) Benign strictures—dilatation by bougienage Early malignancies –surgically resected Unresectable malignancies – dilatation, cautery, laser or stenting Achalasia—medications(calcium channel antagonists), botulinum
toxin injection into the LES, by endoscopic dilation, and by surgical myotomy.
Other primary esophageal dysmotilities respond to nitrates, calcium channel antagonist, surgical myotomy.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
ACHALASIA-1
The most easily recognized & best-defined motor disorder of the esophagus
Incidence 1 per 100.000 population per year in US. Classification: Primary & Secondary. Neuropathology: LES failure to relax completely &
aperistalsis smooth muscle esophagus damage innervation loss of ganglion cells within myenteric(Auerbach) plexus, degeneration vagus nerve & degeneration dorsal motor nucleus vagus.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
UPPER GASTROINTESTINAL
BLEEDING(HEMATEMESIS-MELENA)
DEFINITION: Upper gastrointestinal bleeding/ hematemesis melena refers to bleeding source from the upper gi tract. The blood in stool – tarry stools, the blood vomiting—black tarry vomiting
EPIDEMIOLOGY: - The frequent cause of upper gi bleeding in Indonesia is rupture of esophageal varices. - The frequent cause of upper gi bleeding in Europe is peptic ulcer.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Bad Predictor in upper gastrointestinal bleeding Age > 60 years Other comorbid Hypotension or shock Coagulopathy Bleeding onset in hospital Transfusion requirement > 6 unit Fresh bleeding from stomach Recurrens bleeding from the same lesion
Triadapafilopoulos G. Aliment Pharmacol Ther 2005;22(suppl.3): 53-8
WORKUP/DIAGNOSIS of Hematemesis Melena Resuscitation History Physical examination Upper gi endoscoopy Scintigraphy and angiography: the rate of blood loss
must exceed 0.5 ml per minute. Other radiographic studies: for aortoenteric fistula
abdominal computed tomographic or magnetic resonance imaging studies
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
MANAGEMENT of Hematemesis Melena
Blood Transfusion Medications: PUD/gastritis: H2RA, or PPI; varices or portal
gastropathy: vasopressin / terlipressin / somatostatin or octreotide . Angiodysplasia: intravenous or oral estrogens with or without progesterone.
Therapeutic endoscopy: thermal and nonthermal methods. Emergency upper endoscopy ; esophageal banding or
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
DIAGNOSIS/WORKUP
Resuscitation: correction of volume deficits & stabilization of hemodynamic variables. If suspected upper gi bleeding ngt, Laboratory studies
History & Physical examination: GI diseases such as IBD, malignancy(weight loss, anorexia, lymphadenopathy, or palpable masses) etc
Additional testing: Endoscopy, Scintigraphy & angiography, Other radiologic studies(Barium enema).
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
MANAGEMENT LOWER GI BLEEDING-1 Medications. Therapeutic endoscopy. Therapeutic angiography. Surgery
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
ACUTE ABDOMEN
DEFINITION: Acute abdomen refers to any acute intra & extra abdominal disease processes. Many cases require urgent surgical management, although some can be managed nonsurgically.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
ETIOLOGY/CAUSES/DIFFERENTIAL DIAGNOSIS OF ACUTE ABDOMEN
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
DIAGNOSIS OF DIARRHEA-1 - History: Duration of diarrhea, recent travel, sexual practices, ingestion
of well water and poorly cooked food and shellfish, and exposure to high-risk persons in day care centers, hospitals, mental institutions, and nursing homes.
The characteristics of the diarrhea causative organism. Watery diarrhea+nausea, little paintoxin producing bacteria. Invasive bacteria pain, bloody diarrhea. Viruses watery diarrhea, pain significant, fever, mild-
moderate vomiting. Homosexual men, prostitutes, iv drug abusers diarrhea
disease. Serum albumin and globulin reduced malabsorption,
malnutrition, or protein losing enteropathy. Additional blood testsfor malnutrition: carotene, iron,
folate, vitamin B12, cholesterol, alkaline phosphatase and prothrombin time.
Flexibel sigmoidoscopy exclude proctitis, pseudomembranes and melanosis coli due to laxative abuse.
Biopsy for normal appearance microscopic and collagenous colitis or irritable bowel syndrome.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
MANAGEMENT OF DIARRHEA
Intravenous resuscitation Agents for mild diarrhea: antidiarrheal, bismuth subsalicylate,
diphenoxylate, codeine. Antibiotics for acute infectious diarrhea Therapy for osmotic diarrhea: carbohydrate malabsorption
lactase deficiency or fructose or sorbitol intolerance dietary modification, lactase supplements
Therapy of secretory diarrhea somatostatin analog(octreotide), parenteral calcitonin, indomethacine.
Therapy for inflammatory diarrhea anti-inflammatory drugs(aminosalicylate and corticosteroid. Refractory cases azathioprine, 6mercaptourine, methotrexate.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Polyp and Cancer of the gaster/duodenum Definition: tumor of the gaster/duodenum,
benign and malignant(cancer) Management: polypectomy per endoscopic or
operation
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Cholangitis
Definition: Infection of the common bile duct due to obstruction like biliary stone or cholangiocarcinoma or papillary tumor.
Management: - Antibiotic - ERCP diagnostic and therapetic(sphincterotomy + stone extraction or stenting) - Operative: laparoscopic cholecystectomy & stone extraction or laparotomy biliodigestive procedure
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Bile duct Stone
Definition: Stone of the common bile duct. Management:
ERCP or operation
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Pancreatitis
Definition: Inflammation or infection of the pancreas
Classification: Acute and Chronic Management:
1. Conservative: Fasting, total parenteral nutrition, antibiotics, octreotide/somatostatin, anti TNF).
2. Surgery
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Acute pancreatitis with pancreatic enlargement& Peripancreatic edema & pseudocysts
Diagnosis of Acute Pancreatitis
• Clinical Features: abdominal pain, vomiting• Elevation of plasma amylase - lipase recommendation grade A 3 or 4 x normal (must not always rely on this value)• Plain radiograph• Abdominal Ultrasonography: pancreatic swelling(25-50% patients), CBD/gall bladder stones, dilatation of the CBD• Abdominal CT-scan(recommendation grade C)• Abdominal Magnetic Resonance Imaging(MRI)• CBD stones: ERCP & MRCP
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Severity of Acute Severity of Acute pancreatitispancreatitis Mild ( Edema type ): fat necrosis of the