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FAILURE TO THRIVE
( FTT )
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F.T.T
Tidak optimal utk
bertambah
BBTB
SKILL
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MALNUTRISI
GENETIK
PSIKOSOSIAL
FTT
Malnutrisi : dalam tubuh tdk cukup
nutrient
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KALORI / NUTRIEN
Masukan
Tinja Absorpsi
Pemakaian
Kebutuhan
Metabolisme
basal
Pemakaian
perifer
Pertumbuhan
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PEMAKAIAN
PERIFER
TERGANGGU
KEBUTUHAN BASAL
NUTRIEN
MALABSORP
SI
INTAKE
NUTRITIONINADEQUATE
MALNUTRISI
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Penyebab gangguan pertumbuhan
1. Masukan kalori/nutrieninadekuat
2. Hilangnya kalori/nutrien darisaluran cerna
– Muntah
– Malabsorpsi
3. Metabolisme basal meningkat
– Demam
– Hipertiroidea
– Hiperkinesia
– Infeksi
4. Pemakaian periferterganggu
– Infeksi kronik
–Keganasan
– Kelainan jantungbawaan
– Anemia
–Inborn errors
– Hormonal
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KELAINANSAL.
CERNA YG
MENYEBABKAN FTT
INADEQUATE
CALORY INTAKE-MUTU
-KEBIASAAN
-ANOREKSIA
EXCESSIVE
CALORY LOSS-MUNTAH
-MALABSORPSI
-PROTEINLOSING
ENTEROPATHY
INCREASED
NEED DEMAM
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GANGGUAN PENCERNAAN
MALDIGESTI MALABSORPSI
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MALABSORPSI
SETIAP ADA KEGAGALAN MASUKNYA
HASIL PENCERNAAN DARI LUMEN USUS
MUKOSA
PEMBULUHDARAH
LIMFE
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KLASIFIKASI MALABSORPSI
1.SUBSTRAT
2.SELETIVE/GENERALIZED
3.PEROLEHAN –CONGENITAL
--- ACQUIRED
4.PATOFISIOLOGI5.PATOGENESA & ETIOLOGI
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SUBSTRAT
KARBOHIDRAT
LEMAK
PROTEIN
AIR & ELEKTROLIT
VITAMIN
CAMPURAN a KESELURUHAN
(PAN MALABSORPSI)
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Patogenesa
& etiologi
Congenital & genetik
Bacterial overgrowth
Bile acid def.
sensitisasi
nutritional
Drug induced
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MALDIGESTI
GANGGUAN
INTRALUMINAL MEMBRAN INTRASELULER-GASTER
-PANKREAS
-HEPAR
-USUS ENTEROKINASE(mengubah tripsinogen
menjadi tripsin)
- MALTASE
- LAKTASE
- SUKROSE
- GLUKOAMILASE
•PEPTIDASE
•LIPASE
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MALABSORPSI
1.MALDIGESTI
2.HIPEROSMOTIC
3.PERISTALSIS
4.AREA ABSORPSI-SHORT GUT
-RUSAK MUKOSA
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RUSAK MUKOSA
ENTEROSIT
-LUMINAL MEMBRANE
-INTRASEL / SITOPLASMA
-BASOLAT. MEMBRANE
-BASAL MEMBRANE
RONGGA INTERSELULER
LAMINA PROPRIA
-P.DRH/LIMFE
TIGHT JUNCTION
-SEKRESI
-MACROMOLEKULER ABSORPTION
SENSITISASI
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KARBOHIDRAT
1. INTRALUMINAL ENZYME : AMILASE
2. BRUSH BORDER ENZYME
OLIGO/DISACHARIDASE3. ABSORPSI
4. COLONIC BACTERIA
•GLUKOSA
•FRUKTOSA
•GALAKTOSA
SCFA
NUTRISI KOLON
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NUTRISI SAL. CERNA
USUS HALUSKOLON
70% INTRALUMINAL
30% INTRAVASAL
45% INTRALUMINAL
55% INTRAVASAL
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TRIGLISERIDA
ASAM LEMAK GLISEROL
SHORTCHAIN FATTY
ACID (SCFA)
MEDIUM CHAIN FATTY ACID
(MCFA)
LONG CHAIN FATTY ACID
(LCFA)
C<6
C=6-8(12)
C>12
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DIGESTI & ABSORPSI LEMAK
1.EMULSIFIKASI
2.LIPOLISIS LIPASE
3.MISELLE EMPEDU
4.MASUK KE MUKOSA
5.RE-ESTERIFIKASI
6.KILOMIKRON
7.PEMBULUH DARAH/LIMFE
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MCT(MEDIUM CHAIN
TRIGLYCERIDE)
C=6-8(12)
1.LIPASE 70%
2.TIDAK PERLU EMPEDU
3.TIDAK PERLU REESTERIFIKASI4.TIDAK PERLU PEMBENT. KILOMIKRON
5.VENA PORTA
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DIAGNOSA MALABSORPSI LEMAK
1. MIKROSKOPIK
2. FLOATING TEST (ROSSIPAL)
3. LIPIODOL ABSORPTION TEST
4. SERUM CAROTEN
5. FAT BALANCE (VAN DE KAMER)
6. STEATOCRITE
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DIGESTI & ABSORPSI
PROTEIN
1.INTRALUMINAL DIGESTION (HCL, PEPSIN)
2.ENZIM PANKREAS DIAKTIFKAN
ENTEROKINASE
3.PROTEOLISIS PEPTIDA & AS. AMINO
4.MUKOSA INTRACELLULER DIGESTION
5.V. PORTA
MALABSORPSI
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MALABSORPSI
AKUT KRONIK DEF. PERUT
GEMBUN
DEHIDRASI
-DIARE PERSISTENT
-FAILURE TO THRIVE
AVITAMINOSIS
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PENGOBATAN MALABSORPSI
1. ETIOLOGI-INFEKSI
-ENZIM
2. DIET
3. SUPPORTIVE- AIR DAN ELEKTROLIT
- VITAMIN DAN MINERAL- GIZI PERTAHANKAN BAIK
PREDIGESTED FORMULA
SINDROMA MALABSORPSI
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SINDROMA MALABSORPSI
1. INTOLERANSI LAKTOSA2. COW’S MILK PROTEIN INTOLERANCE
3. PCM
4. KOLESTASIS
5. INFESTASI PARASIT
6. ANTIBIOTIKA
7. POST ENTERITIS MALABSORPTION
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Terminologi
Intoleransi Laktosa
Defisiensi laktase :
Rendah / tidak ada aktifitas
laktase
enzyme ss y
Malabsorpsi laktosa :
Ketidakmampuan usus halus
mengabsorpsi laktosa
pemeriksaan yang sesuai
Intoleransi laktosa : gejala klinis
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LAKTOSA
Karbohidrat
Susu mammalia
ASI(7 %)
ASL(4 %)
Susu singa laut(0 %)
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LAKTOSAGlukosa &Galaktosa
Laktase• Di bagian luar brush border• Paling sedikit
• Bukan enzim adaptif
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Defisiensi
LAKTASE
Sekunder
Primer
KerusakanMukosa usus mis
rotavirus diaorrhoea
Developmental
Congenital alactasia
Late onset hypolactasia
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LAKTOSA TIDAK DISERAP
MENARIK AIR
KOLON
COLONIC
SALVAGE
• DIARE OSMOTIK
• BAHAN REDUKSI LAKTOSA) CLINITEST
• ASAM LAKTAT pH ASAM KERTAS LAKMUS
AIR LAKTOSAISERAP
FERMEN
TASI
GAS
ASAM LEMAK
RANTAI PENDEK
L - LACTATE
H2
CO2
CH4
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DIAGNOSA INTOLERANSI LAKTOSA
Uji toleransi laktosa
+Uji malabsorpsi laktosa
a. pH tinja & clini test
b. Uji muatan laktosa
(lactose loading test)
c. Uji hidrogen pernafasan
(breath hydrogen test)
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pH tinja & clini test
Uji saring
• Hanya laktosa diminum
• Waktu transit usus yang cepat
• Tinja segar
• Degradasi laktosa inkomplit
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Uji hidrogen
pernafasan
• Puasa malam hari
• Dosis laktosa : 2 gr/kgBB (max. 50
gr)
dalam bentuk larutan 20 %
• Setelah 30 menit minum laktosadiukur H2 pernafasan 3 jam
• Malabsorpsi : > 20 ppm di atas
fasting level
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PENGOBATAN
INTOLERANSI LAKTOSA
Primer Sekunder
1.Susu rendah/
bebas laktosa
2.Bayi prematur- ASI (+): teruskan
- ASI (-) : laktosa direndahkan
+ polimer glukosa
ASI tetap diberikan
ASI (-) ??
COW’S MILK PROTEIN INTOLERANCE
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COW S MILK PROTEIN INTOLERANCE
-BAYI KECIL
-DIARE
-ENTEROPATHY
LI CMPI
>>> >
(-) (+)
DOSE DEPENDENT DOSE INDEPEN.
1.FREK.
2.Gx di luar sal.
Cerna
3.Phenomenon
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RUSAK
MUKOSA
PROTEINLOSING
ENTEROPATHY
BIOPSI
UJI PERMEABILITAS
-Dxylose absorption test
-L/M excretion ratio
-Polyethylen glycol abs. test
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PROTEIN LOSING
ENTEROPATHY
RUSAK
MUKOSA
INFLAMATION
NON INFLAMATION
OBSTR. LIMFE
LIMFANGIEKTASIO
KEL. JANTUNG
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DIAGNOSIS PROTEIN LOSING
ENTEROPATHY
1. ISOTOP
2. FECAL ANTITRIPSIN