Ger Blok Gastro May 2012

8/14/2019 Ger Blok Gastro May 2012

1/44

Dyspepsia &

Gastroesophageal Reflux

(GER)

Wan NedraBagian Anak FK. Univ YARSI

0 4 / 1 1 / 2 0 1 3

1


2/44

1.Peptic ulcer disease

2.GER3.Helicobacter pylory infection

ACID RELATED DISORDERS

0 4 / 1 1 / 2 0 1 3

2


3/44

Berupa kumpulan gejala yang non-spesifik

berhubungan dengan saluran pencernaan bagian atas

yang terjadi berulang selama minimal 2 bulan

Chelimsky dan Czinn, 2001

MANIFESTASI KILINIK PUD:

DYSPEPSIA

0 4 / 1 1 / 2 0 1 3

3


4/44

Mayor:

Nyeri perut di daerah epigastrium

Muntah berulang ( minimal 3x/bulan)

Minor:

Gejala yg berhubungan dg makan (Anoreksia, BB menurun)

Nyeri perut yg dirasa pd malam hari

Heartburn

Oral Regurgitasi

Neusia kronik

Sendawa berulang

Nyeri perut disekitar umbilikal

Ada riwayat keluarga PUD. Dyspepsia

KRITERIA DIAGNOSTIK DYSPEPSIA

0 4 / 1 1 / 2 0 1 3

4

Evaluasi:- 2 mayoratau

-1 mayor+ 2 minor

-4 minor


5/44

Gejala: Nyeri perut di epigastrium, pada malam hari, regurgitasi,hearburn, BB menurun, hematemesis dan melena

Riwayan Makan:

Makanan berlemak, makanan pedas, caffein, laktose

Penggunaan Obat-obatan:Kortikosteroid, NSAID

Alkohol, tembakau (rokok)

Obat2 yang meransang pengeluaran asam lambung

ANAMNESIS

0 4 / 1 1 / 2 0 1 3

5


6/44

Pemeriksaan awal:

Hematologi dg differential count

LFT, Elektrolit

Feses: Parasit

Urinalisis

Pemeriksaan lanjutan:

USG hati dan saluran empedu

Endoskopi

Hydrogen breath test

PEMERIKSAAN LABORATORIUM

0 4 / 1 1 / 2 0 1 3

6


7/44

H2 reseptor antagonis:

Cimetidine 2040 mg/ kg/ hari 2 kali / hari maks: 400 mb

Ranitidine 2- 4 mg/ kg/ hari, 2 kali sehari (mak: 150 mg)

Proton Pump Inhibitor

Lansoprazol 0,8 mg/kg/hari

Pmeprazol 0,8 mg/ kg/ hari

Cytoprotective Agents:

Sukralfat 40-80 mg/ kg/ hari, 4 kali sehari ( mak 1 g)

PENGOBATAN

0 4 / 1 1 / 2 0 1 3

7


8/44

Gastroesophageal reflux (GER)

the involuntary passage of gastric contents into theesophagus

Regurgitation:

reflux dribbles effortlessly into or out of the mouth

Vomiting:

0 4 / 1 1 / 2 0 1 3

8

forceful expulsion of gastrointestinal contents into the

oesophagus

DEFINISI


9/44

0 4 / 1 1 / 2 0 1 3

9

Vomiting

Regurgitation

Gastroesophageal reflux


10/44

Forceful expulsion of gastrointestinal contentsthrough the mouth

0 4 / 1 1 / 2 0 1 3

10

Vomiting


11/44

0 4 / 1 1 / 2 0 1 3

11


12/44

S.motorik somatik

0 4 / 1 1 / 2 0 1 3

12

S.motorik somatik

Saraf otonom

S. Simpatis

S. Parasimpatis

Saraf enterikN. Vagus

asetil kolinpleksus mienterikus

motilitas sal.cerna

pl. mienterikuspl. submukosa


13/44

0 4 / 1 1 / 2 0 1 3 13


14/44

0 4 / 1 1 / 2 0 1 3

14

Impuls

Chemo-receptor

Trigger Zone

Gastrointestinal tract,

Vomiting center

endogen exogen

Impuls

vomiting

afferen N. Vagus


15/44

0 4 / 1 1 / 2 0 1 3

15

Vomiting centre

Chemo-receptor Trigger Zone

Blood Brain Barrier

esophagus


16/44

0 4 / 1 1 / 2 0 1 3

16

LES

Fundus

Corpus

Tonus decrease

Antrum Peristaltic decrease

Pylorus

Duodenum

Tonus increase


17/44

Most common in children (> infant)

Confusing the parents

Life-threatening causes of vomiting

Three distinct phases

(1) nausea, (2) retching, (3) emesis

Not preceded in raised intracranial pressure or mechanicalobstruction

0 4 / 1 1 / 2 0 1 3

17

Vomiting


18/44

Age: neonates, infant, child

Gastrointestinal tract: obstruction& non obstruction

Extra-gastrointestinal tract

APPROACH

0 4 / 1 1 / 2 0 1 3

18


19/44

Neonates

Atresia esophagus, pylorus stenosis, spitting up

GER, NEC, chalasia, Infection (UTI, OMA, sepsis)

Infantspylorus stenosis, intususeption, hernia

RGE, gastroenteritis, infection, drugs, aerophagia

Children

Intusuception, stricture, gastritis, apendisitis Infection, drugs

ETIOLOGY0 4 / 1 1 / 2 0 1 3

19


20/44

Scanning gambar HPS

0 4 / 1 1 / 2 0 1 3

20


21/44

~ etiology

treat acid and base inbalanced

Drugs:

Domperidone

Metoclopramide

Cisapride

0 4 / 1 1 / 2 0 1 3

21

Therapy


22/44

Gastroesophageal reflux

Just spitting up, or

something more serious ?

0 4 / 1 1 / 2 0 1 3

22


23/44

20% general infant population

40% of children consulting a pediatrician

70% of all 4 months old infants

regurgitate at least 1 x/day

25% is considered by the parents as a problem

RGE8% abnormal pH esophagus monitoring

1/3001/1000 severe

(Chouchou, 92; Nelson et al, 1997)

REGURGITATION

0 4 / 1 1 / 2 0 1 3

23


24/44

0 4 / 1 1 / 2 0 1 3

24


25/44

0 4 / 1 1 / 2 0 1 3

25


26/44

The involuntary passage of gastric contents into theesophagus

saliva, ingested food, drinks, gastric/pancreatic/ biliary secretions

normal phenomenon, +/- accompanying symptoms

physiologic or pathologic reflux

(Carre 1983; Vandenplas, 1992; Orenstein, 1994; Vandenplas, 1993)

0 4 / 1 1 / 2 0 1 3

26

GER


27/44

Physiologic reflux

occurs mainly after meal

does not normally cause symptoms

short duration of reflux episodes

Pathologic reflux

frequent reflux episodes of longer duration

reflux episodes occuring during the day/night

may produce symptoms & inflamation/mucosal injury

GER

0 4 / 1 1 / 2 0 1 3

27


28/44

0 4 / 1 1 / 2 0 1 3

28

MECHANISMS OF GER

attenuated swallows,dysfunctional peristalsis

Length of LES,

Maturation of LESTLES relaxation

Inadequate

gravitation

delayed gastricemptying,

distension

Deficient or delayedesophageal

acid clearance

Incompetent

LES

delayed gastric emptying

distention

ILES: Lower essophagealsphinter


29/44

RGE

0 4 / 1 1 / 2 0 1 3

29

Acid,Regional blood flow,

tissue prostaglandin E2

permeability to acid

susceptibility to inflamation

Impairment of LES

dysmotility

esophagitis

inflamation

dysfunction

vagal nerve

acid/bile

edema

fibrosis

pylorospasm


30/44


31/44

Emesis & regurgitation are the most common

primary GER disease

secondary GER disease

infection, metabolic disorders, & food allergy

stimulation vomiting center in the dorsolateral reticularformation by efferent & afferent impuls

CLINICAL MANIFESTATION GER

0 4 / 1 1 / 2 0 1 3

31


32/44


33/44

Unusual presentations

~ chronic respiratory disease

apnea, apparent life threatening, SIDS

~ to congenital and/or CNS abnormalities

cerebral palsy, psychomotory retardation

A careful history, observation of feeding, & physicalexamination are mandatory

SYMPTOMS OF GER

(- DISEASE)

0 4 / 1 1 / 2 0 1 3

33


34/44

1. a. Parental reassuranceb. Milk-thickening agents (?)

2. Prokinetics

3. Positional adjuvant therapy4. a. H2receptor antagonist

b. Proton pump inhibitors

5. Surgery

TREATMENT

RECOMMENDATIONS

0 4 / 1 1 / 2 0 1 3

34


35/44

Frequent small feeding

Decrease the number of transient LES relaxations

Reduced volume cause of distress to infants

Restriction volume in clearly overfed babies

Thickening infants formula

Decrease the frequency & volume of regurgitation

time crying, improves sleep, caloric retention ,

coughing (after feeding)

(Vandenplas, 1994, Borelli, 1997)

REGURGITATION AND

FEEDING

0 4 / 1 1 / 2 0 1 3

35


36/44

Thickening formula should be considered as the firststep

Can not be given to breastfed infants

Gastric emptying : Casein > Wheyhydrolysate

FORMULA AND MILK-

THICKENING

0 4 / 1 1 / 2 0 1 3

36


37/44

Gastrokinetic actionindirect release of acetylcholine

in the myentericus plexus

Reduces regurgitation

The LES pressure and motility

Esophageal peristalsis, gastric emptying

Increased salivary secretion

protect esophagus via salivary component (bicarbonat buffer)

0 4 / 1 1 / 2 0 1 3

37

Prokinetics


38/44

Sleeping and crying decrease GER

Crying increases abdominal pressure, but also increases LES-P

300prone anti-trendelenburg position

SIDS ?

Beyond the age of SIDS ( > 12 months)

(Orenstein, 1990; Orenstein, 1997; Tobin, 1997)

POSITION, CRYING,

AND REFLUX

0 4 / 1 1 / 2 0 1 3

38


39/44

0 4 / 1 1 / 2 0 1 3

39


40/44


41/44

Recent studies report that 45-75% of children withuncontrolled asthma suffer GOR

Prokinetic

GER ~ cough episodes at night in 50% children

remission of resp. symptoms or less anti-asthma medication

(McVeagh, 1987; Orenstein, 1988; Tucci F, 93; Pransky SM, 1992)

0 4 / 1 1 / 2 0 1 3

41


42/44

0 4 / 1 1 / 2 0 1 3

42

Uncomplicated GER

No investigations

Phase 1 (1-2weeks)

Phase 2 (1-3

weeks)?? reconsider diagnosis of GER

??

pH monitoring

Normal Abnormal

? GOR ? UGIS ?Endoscopy ?

C li t d GER h iti ?


43/44

0 4 / 1 1 / 2 0 1 3

43

Complicated GER : esophagitis ?

Endoscopy

Eso > Grade 3?

NO

YES

phase 1 + 2A-R Formula

Cisapride 1-3 mo

phase 1 + 2 + 3 + 4(+ Positional treatment,

H2 / Omeprazole)

control endoscopy

stop phase 3

continue phase

2

Eso > Grade 3 ?

UGIS ??

? Surgery

?

NO

YES


44/44

THANK YOU

Ger Blok Gastro May 2012

Documents

Transcript of Ger Blok Gastro May 2012