DR. Dr. DR. Dr. DR. Dr. DR. Dr. JUWITA SEMBIRINGJUWITA SEMBIRINGJUWITA SEMBIRINGJUWITA SEMBIRING, SpPD, SpPD, SpPD, SpPD----KGEHKGEHKGEHKGEHDR. Dr. DR. Dr. DR. Dr. DR. Dr. JUWITA SEMBIRINGJUWITA SEMBIRINGJUWITA SEMBIRINGJUWITA SEMBIRING, SpPD, SpPD, SpPD, SpPD----KGEHKGEHKGEHKGEH

DIVISI GASTROENTERODIVISI GASTROENTERODIVISI GASTROENTERODIVISI GASTROENTERO----HHHHEEEEPPPPAAAATTTTOOOOLLLLOOOOGGGGIIII

DEPARTEMEN DEPARTEMEN DEPARTEMEN DEPARTEMEN IIIILLLLMMMMUUUU PPPPEEEENNNNYYYYAAAAKKKKIIIITTTT DDDDAAAALLLLAAAAMMMM

FK. USUFK. USUFK. USUFK. USU //// RSUP. H. ADAM MALIK MEDANRSUP. H. ADAM MALIK MEDANRSUP. H. ADAM MALIK MEDANRSUP. H. ADAM MALIK MEDAN

DEFENISI :DEFENISI :DEFENISI :DEFENISI :

RadangRadangRadangRadang PankreasPankreasPankreasPankreas DenganDenganDenganDengan SimtomSimtomSimtomSimtom SakitSakitSakitSakit PadaPadaPadaPada UluUluUluUlu HatiHatiHatiHati

MenjalarMenjalarMenjalarMenjalar KeKeKeKe PunggungPunggungPunggungPunggung ((((95959595%%%%)))) DanDanDanDan GangguanGangguanGangguanGangguan ExocrinExocrinExocrinExocrin

Pankreas,Pankreas,Pankreas,Pankreas, Mual,Mual,Mual,Mual, MuntahMuntahMuntahMuntah ((((85858585%%%%))))

TerdiriTerdiriTerdiriTerdiri daridaridaridari :::: akutakutakutakut dandandandan kronikkronikkronikkronik

AkutAkutAkutAkut :::: morfologi/strukturmorfologi/strukturmorfologi/strukturmorfologi/struktur dandandandan fungsifungsifungsifungsi pankreaspankreaspankreaspankreas

sebelumnyasebelumnyasebelumnyasebelumnya normalnormalnormalnormal

KronikKronikKronikKronik :::: sebelumnyasebelumnyasebelumnyasebelumnya adaadaadaada kerusakankerusakankerusakankerusakan strukturstrukturstrukturstruktur dandandandan

fungsifungsifungsifungsi pankreaspankreaspankreaspankreas

Figure 1. Normal pancreatohepatobiliary system

ETIOLOGI :

GGGGall all all all SSSStone tone tone tone (Batu Empedu) & Alkohol(Batu Empedu) & Alkohol(Batu Empedu) & Alkohol(Batu Empedu) & Alkohol (Terbanyak)(Terbanyak)(Terbanyak)(Terbanyak)

---- Mekanikal : Mekanikal : Mekanikal : Mekanikal : GGGGall all all all SSSStonetonetonetone, Mikro Litiasis, Mikro Litiasis, Mikro Litiasis, Mikro Litiasis //// 80 % 80 % 80 % 80 %

Ca. PankreasCa. PankreasCa. PankreasCa. Pankreas

---- Infeksi :Infeksi :Infeksi :Infeksi : Mumps Flaxsechi, AscarisMumps Flaxsechi, AscarisMumps Flaxsechi, AscarisMumps Flaxsechi, Ascaris ----Lumbricoedes, Lumbricoedes, Lumbricoedes, Lumbricoedes,

Chlonorchies SineusisChlonorchies SineusisChlonorchies SineusisChlonorchies Sineusis

---- ObatObatObatObat----obatan : Steroid, Thiazide, Azobatan : Steroid, Thiazide, Azobatan : Steroid, Thiazide, Azobatan : Steroid, Thiazide, Azaaaathioprinthioprinthioprinthioprin

---- Metabolik : Hyperlipidemia, HypericelsenMetabolik : Hyperlipidemia, HypericelsenMetabolik : Hyperlipidemia, HypericelsenMetabolik : Hyperlipidemia, Hypericelsen

---- Trauma : Trauma : Trauma : Trauma : Post Operasi Post Operasi Post Operasi Post Operasi

---- MiscellanMiscellanMiscellanMiscellaneeeeus us us us :::: Gigitan ScorpioGigitan ScorpioGigitan ScorpioGigitan Scorpio

Perforasi Tukak DuodeniPerforasi Tukak DuodeniPerforasi Tukak DuodeniPerforasi Tukak Duodeni

GAMBARAN KLINIK :GAMBARAN KLINIK :GAMBARAN KLINIK :GAMBARAN KLINIK :

Sakit perut tipical, daerah epiSakit perut tipical, daerah epiSakit perut tipical, daerah epiSakit perut tipical, daerah epigastriumgastriumgastriumgastrium, l, l, l, lower ower ower ower uuuupper pper pper pper qqqquadrantuadrantuadrantuadrant

menjalar ke punggung, sakit seperti disayatmenjalar ke punggung, sakit seperti disayatmenjalar ke punggung, sakit seperti disayatmenjalar ke punggung, sakit seperti disayat----sayat, sakit sayat, sakit sayat, sakit sayat, sakit

berkurang bila membungkuk kedepanberkurang bila membungkuk kedepanberkurang bila membungkuk kedepanberkurang bila membungkuk kedepan //// dudukdudukdudukduduk

CemasCemasCemasCemas,,,, kelihatan sakit berat, takikardi, kelihatan sakit berat, takikardi, kelihatan sakit berat, takikardi, kelihatan sakit berat, takikardi, demam (60%) dan demam (60%) dan demam (60%) dan demam (60%) dan

hipotensi (40%), mual, muntah, ikterus, peristaltik hipotensi (40%), mual, muntah, ikterus, peristaltik hipotensi (40%), mual, muntah, ikterus, peristaltik hipotensi (40%), mual, muntah, ikterus, peristaltik ↓↓↓↓....

Perdarahan retrosternal : echymose Perdarahan retrosternal : echymose Perdarahan retrosternal : echymose Perdarahan retrosternal : echymose ----periumbilikal = Cullen’s periumbilikal = Cullen’s periumbilikal = Cullen’s periumbilikal = Cullen’s Perdarahan retrosternal : echymose Perdarahan retrosternal : echymose Perdarahan retrosternal : echymose Perdarahan retrosternal : echymose ----periumbilikal = Cullen’s periumbilikal = Cullen’s periumbilikal = Cullen’s periumbilikal = Cullen’s

Sign,Sign,Sign,Sign, panggulpanggulpanggulpanggul //// paha. Grey Tunner’s Signpaha. Grey Tunner’s Signpaha. Grey Tunner’s Signpaha. Grey Tunner’s Sign

DDDDiagnosa iagnosa iagnosa iagnosa : Klinik, Lab Amilase, Lipase: Klinik, Lab Amilase, Lipase: Klinik, Lab Amilase, Lipase: Klinik, Lab Amilase, Lipase

Pemeriksaan Penunjang : Pemeriksaan Penunjang : Pemeriksaan Penunjang : Pemeriksaan Penunjang : USGUSGUSGUSG

CT SCANCT SCANCT SCANCT SCAN

ERCPERCPERCPERCP

Lab.Lab.Lab.Lab. :::: LeLeLeLeuuuukositosis,kositosis,kositosis,kositosis, kkkkadar gula darah adar gula darah adar gula darah adar gula darah & crp (& crp (& crp (& crp ( >>>> 100100100100����

insufisiensi pankreas) albumininsufisiensi pankreas) albumininsufisiensi pankreas) albumininsufisiensi pankreas) albumin ↓↓↓↓, creatinin, creatinin, creatinin, creatinin ↑↑↑↑(dehidrasi), amylase (dehidrasi), amylase (dehidrasi), amylase (dehidrasi), amylase serum serum serum serum ↑↑↑↑,,,, lipase lipase lipase lipase ↑↑↑↑

Radiologi :Radiologi :Radiologi :Radiologi : sentinal loop dari usus halus sentinal loop dari usus halus sentinal loop dari usus halus sentinal loop dari usus halus

calcalcalcalsifikasi pankreas + sakit sifikasi pankreas + sakit sifikasi pankreas + sakit sifikasi pankreas + sakit calcalcalcalsifikasi pankreas + sakit sifikasi pankreas + sakit sifikasi pankreas + sakit sifikasi pankreas + sakit

USGUSGUSGUSG :::: oedematous pankreas, perioedematous pankreas, perioedematous pankreas, perioedematous pankreas, peri

pankreatitis, fluid / pseudo kistepankreatitis, fluid / pseudo kistepankreatitis, fluid / pseudo kistepankreatitis, fluid / pseudo kiste

ERCP :ERCP :ERCP :ERCP : banyak gas banyak gas banyak gas banyak gas ���� lebih baik dengan CT SCAN lebih baik dengan CT SCAN lebih baik dengan CT SCAN lebih baik dengan CT SCAN

“ gold standard ““ gold standard ““ gold standard ““ gold standard “ ���� diagnosa terapidiagnosa terapidiagnosa terapidiagnosa terapi

KEPARAHAN/SEVERITY : Kriteria – Ranson (48 jam) 11 pointsGlagow ( segera ) 8 pointsAPACHE system

Ranson Criteria Glosgow criteria

(1 points for each criteria) (1 points for each criteria)

� oedematous� hemoragic� nekrosis� nekrosis

Organ failure: hipotensi BP <90hipoxiensi PaO2 < 8kPa (60 mmHg)Renal failure, creatinin > 200 µmol/l (2mg/dl)GI bleeding > 500 ml / 24 jam

Creactive protein > 100 mg/l � severe pankreatitis prognostik jelek“ sensitive parameter “

Severity Of Pancreatitis

Ranson criteria Glosgow criteria

(1 point for each factor ) (1 point for each factor )

On Admission On Admission

Age > 55 years Age > 55 yearsWBC count > 16,000 / mm3 WBC count > 16,000 / mm3

Glucose > 200 mg/dl Glucose > 200 mg/dlSerum LDH >350 IU/L LDH > 600 IU/LSerum LDH >350 IU/L LDH > 600 IU/LSerum ast >250 U/dl BUN > 45 mg /l

PO2 < 60 mmHgAlbumin < 3.2 gr / dlCalcium < 8 mg / dl

First 48 hoursSerum calcium < 8 mg/dlBase deficit > 4 mEq/LFluid sequestration > 6 LArterial PO2 <60 mm HgBUN rises > 5 mg / dlHaematocrit decreases > 10 %

TERAPI / PENATALAKSANAAN :

���� Ringan : decompresi ( mencegah exocrin )puasaIVFDNGT (aspirasi cairan lambung)Pain killer – pethidin

tramal syringe pumptramal syringe pump

���� Berat : ICU

���� Nutritional support – TPN Mild ���� lapar ���� beri makan

PPI / ARH2 – mencegah tukak stres

Acute Pancreatitis

Mild Pancreatitis Ranson less than 3 at 48 h Glasgow less than 3

Establish Severity Severe Pancreatitis Ranson more than 3 at 48 h Glasgow more than 3

Expected complete recovery in 3-5 days

NPO Analgesia IV Hydration

Patient Worsens

Admit to ICU Invasive monitoring NPO Analgesia Fluid resuscitation Consider antibiotics Treat metabolic complications Nutrional

support

No Improvement

Figure . Treatment Algorithm for acute pancreatitis

Real Time Ultrasonography

Choledocholithiasis

Technical Failure

Contrast Echanced CT

No Improvement after 48-72 h

Pancreatic NecrosisPeripancreatic fluid

collection

Endoscopic papillotomy CT Guided percutaneous aspiration

CT Guided percutaneous aspiration

Infected

Yes

SurgeryFailed

Purcutaneous Drainage

Infected

Yes

Antibiotik :

Broad spectrum – cephalosporin - Imipenem 3x500, - Sulperazone IV / 12 jam

Indikasi severe pankreatitis

necrotizing pankreatitis (dinamik, CT ), cholangitis

Somatostatin : 3 mg / 12 jam drip

Sandostatin : 12 amp / 24 jam Sandostatin : 12 amp / 24 jam

Komplikasi :Sistemik - Paru- GI bleeding - Obtruksi

Lokal - Pancreatiuc necrosis- Pseudo kiste – spleen - Fistula

Complication of Acute PancreatitisComplication of Acute Pancreatitis

LocalLocal SystemicSystemic

PancreaticPancreatic

Pseudocyst/fluid collection Phlegmon/sterile Pseudocyst/fluid collection Phlegmon/sterile necrosis Infected pancreatic necrosis necrosis Infected pancreatic necrosis Pancreatic abscessPancreatic abscess

NonpancreaticNonpancreatic

Pancreatic ascites Sympathetic effusion Pancreatic ascites Sympathetic effusion Gastrointestinal perforations Mesenteric, Gastrointestinal perforations Mesenteric,

CardiovascularCardiovascular

Hypotension and shock Pericardial effusion and Hypotension and shock Pericardial effusion and tamponade Electrocardiogram Changestamponade Electrocardiogram Changes

ResporatoryResporatoryHypoxaemiaHypoxaemiaPleural effusionPleural effusionAtelectasisAtelectasisPulmonary infiltrationPulmonary infiltrationAdult respiratory distress syndromeAdult respiratory distress syndromeRespiratory failureRespiratory failureGastrointestinal perforations Mesenteric, Gastrointestinal perforations Mesenteric,

splenic, portal vein thrombosissplenic, portal vein thrombosis

Respiratory failureRespiratory failure

MetabolicMetabolicHypocalcaemiaHypocalcaemiaHyperglyceridaemiaHyperglyceridaemiaMetabolic acidosisMetabolic acidosis

RenalRenalOliguriaOliguriaAcute tubular necrosisAcute tubular necrosisRenal artery or vein thrombosisRenal artery or vein thrombosis

HaematologicalHaematologicalVascular thrombosisVascular thrombosisDisseminated intravascular coagulationDisseminated intravascular coagulation

(DIC)(DIC)Gastrointestinal bleedingGastrointestinal bleeding

Complication Of Chronic Pancreatitis

Abdominal Pain

Melabsorption

Diabetes

PseudocystsPseudocysts

Pancreatic Calculi

Biliary Obstruction

Duodenal Obstruction

Splanchnic and mesenteric venous obstruction

PANKREATITIS KRONIK :

Defenisi : - peradangan pankreas yg berlanjut menimbulkan kerusakan struktur dan fungsi yang irreversible.

- timbul fibrosis dan atrofi kelenjar pankreas, dilatasi saluran.

- Keparahan: - keparahan sakit - insufiasiensi pankreas (fat>20gr/hr)

- Rasa sakit : tanda prognosis - Rasa sakit : tanda prognosis pankreatitis kronis, radiasi ke punggung,hyperamykase

- CT Scan : pseudo kisteStop alkohol, pain killer : pethidin, NSAID, Opiad, enzym pankreas 3x11 antara makan, ARH2/PPIERCP drainage :

Mengurangi sakit kurangi : - lemak+ ARH2 / PPI- MCT

TUMOR PANKREAS : Jinak & Ganas ( Carcinoma )

Carcinoma : terlambat diagnosis � radical operasi

Keluhan : tergantung bagian yang terkena kaput � painless joundice

Obesy & tail – sakit + BB ↓

Papilla Vateri – prognosa baikPapilla Vateri – prognosa baik

Ikterus – operasi pankreato duonectomy�survival 3 thn� 50% � kaput � 10 %

GAMBARAN KLINIK :

Jaundice, bekas garukan, convoisier sign � pulpable GB

Diagnosa : klinis – ikterus, sakit, BB ↓

USG, CT Scan / MRI � biopsi aspirasi

ERCP – diagnostik + terapi

sitologi / PA

Terapi : - Operasi- Radiasi � 16 minggu survival- Chemoterapi 5 FU

Chemo + radiasi 40 minggu survival

KOMPLIKASI :

���� Lokal : nekrosis pankreatik (20%)infeksi� Cephalosporin / imipenem↑ tenderness,demam tinggi,lekositosis,bakteremia � sepsis

Aspirasi biopsi, CT guided � gram stein / kultur GR (-)

Aspirasi biopsi, CT guided gram stein / kultur � GR (-)

Terapi : infected necrosis � surgical emergency “ debridemant” � mortilitas 10 %-15 %Steril nekrosis � konservatif � 10 %� sistemic komplikasi � agresif medical atau surgical debri demant

���� Pseudokiste :

fluid collection (30-50%) dgn pankreatitis berat.

Fluid collection : > 4 minggu 10 %

Uncomplicated pseudokiste >6 cm/ > 6 minggu � terapi.

Asimtomatik psk < 6 cm� resolve spontaneus

Terapi PSK : Terapi PSK :

- ERCP� insertion stent pankreatitisCept gastrostomy, cept duodenectomy

- percutaneus drainage

- Operasi: cept gastrostomy

cept jejenectomy, cept duodenectomy

���� Fistula : - asites, pleura efusicutaneus, bowel,

- amylase / protein- drainage of fluid collection by thoracosentesis

atau parasentesis.

ERCP : stent pancreaticinfeksi dengan somatostain 600 µgr/hari Pankreatic reseksi

���� Sistemik :

Pulmonary : - drainage pleura efusi- pankreatic - ARDS – respiratory support with positif

end expirety

GI hemorahagic � angiografi and emboli

Obstruksi � spasme & odem + reseksi

BATU EMPEDU = KOLELITIASIS

Sering dijumpai pada Praktek sehari-hari

Banyak pasien batu empedu = asimtomatik

Manifestasi klinik :- nyeri episodik

- Kolesistitis akut - Kolesistitis akut

- Ikterus obstruktif, Kolangitis, Pankreatitis bila batu migrasi ke duktus koledokus.

Banyak ditemukan pada wanita, makin bertambah dgn meningkatnya usia.

FAKTOR RESIKO UNTUK BATU EMPEDU :

- Bertambahnya usia

- Gender wanita

- Kehamilan

- Estrogen

- Obesitas

- Etnik (penduduk Asli Amerika)

- Sirosis

- Anemia hemolitik

- Nutrisi Parenteral Total

Manifestasi Klinik Batu Empedu tergantung Lokasi di sal. Empedu :

1. Batu empedu asimtomatik

2. Kolik bilier / kolesistitis akut

3. Sindroma Mirizzi : - nyeri

- ggn tes fungsi hati (Bil�, FA/GGT �, SGOT/PT �, USG sal empedu melebar)SGOT/PT �, USG sal empedu melebar)

4. Kolangitis

5. Pankreatitis akut bilier : amilase / lipase ��, fungsi hati �

6. Batu Intra hepatik