GROUP 7

Dr. Wiyarni Pambudi Sp.A

Name NIMSTEPHANIE WIBISONO 405070001 MEMBERLISA WIBOWO 405070004 MEMBERANDI SURYA JAYA 405070010 MEMBERCLAUDIO UDJAJA 405070011 LEADERFAJAR PERMATA SARI 405070032 SCRIBERJACKY TANZIL 405070061 MEMBERCHASTINE FAUSTINA 405070070 MEMBERDIAN WIJAYANTI 405070076 MEMBERELLEN ARISTIKA G. 405070083 MEMBERRITCHIE SANTOSO 405070115 MEMBERFERDY SANJAYA 405070118 MEMBERHARI DARMAWAN LEE 405070155 SECRETARY

Learning Objective

• Knowing the process of normal swallow• Knowing the problem of swallow• Knowing the process of digestion and

absorption• Knowing the process of hungry and and

satisfied• Knowing the nutrition for child

CASE 3B Jacko, a one-month-old male baby is brought to your private practice by his parents with a chief complain of constant irritability and regurgitation. The 2.8 kg newborn baby of an uneventful full term pregnancy and delivery, was discharged on the second day of life. He always seems to be hungry, and since his mother is certain that she does not produce enough breast milk, she gives milk formula after she breastfed him. That has already happened for two weeks. Jacko currently breastfeeds for 10 minutes, then consumes another 60 ml by bottle. When left with grandparents, he will finish an entire 120 ml bottle in 5-10 minutes and they reported that he will cry if they try to cut it off at the recommended 60 ml. Vomiting generally occurs immediately after feedings. It is not forceful, nor it is blood or biletinged. He fills 10 diapers with urine daily, and lately he has had watery stools, which have further worried his grandparents. Despite all this, he weighed 3.5 kg at the two week checkup and he now weighs 4.3 kg. Exam: VS are unremarkable. His physical examination is notable only for fussiness when laid supine on the table, with resolution when held upright or in the prone position. You witness effortless regurgitation of 2-5 ml of curdled formula every few minutes during examination since his parents “topped him off” with milk formula in your waiting room before the appointment.

Process Of Swallowing

Picture : process of swallowing

Swallowing

• The movement swallowed was followed with the rise posterior the tongue in a sudden push food/liquid to posterior pharynx

• superior&anterior larynx move, epiglotis position courage larynx airway, nasofarynx closed by palatum molle and uvula

• The posterior esophagus sphincter relaxation with constrictor farynx muscle, push the food into esophagus first peristaltic wave

• Second peristaltic wavelocal distention that played a role in the evacuation esofagus from leftovers/the contents of gasterwave this emptied esofagus with movement efforts encouraged

Nervus

• Nervus trigeminus• Nervus glosofaringeal• Nervus vagus

Regurgitation

• Definition

Regurgitation was the rise in food from throat or the side without being accompanied by the feeling of nausea and the contraction of the very strong stomach muscle.

Etiology

• Regurgitasi often as a result of by acid that rose from the side (refluk acid).

• Regurgitasi could be also caused by the constriction (striktur) or the throat obstruction.

Symptom

• Acid that came from the side caused regurgitasi from materials that were felt acid or bitter. The constriction or the throat obstruction caused regurgitation the liquid had phlegm that did not feel or food that was not yet digested.

Diagnosis

• The diagnosis refluks acid was maintained was based on results of the inspection x-rayed, the grating of the pressure and the throat acidity and the other inspection. The diagnosis from the constriction or the throat obstruction was maintained was based on results of the inspection x-rayed or endoscopy

GER

• Gastroesophageal Reflux (GER) or Reflux is the medical term used to describe a condition in which stomach contents - food and gastric acid - frequently flow back up out of the stomach into the esophagus

GERD

• GERD stands for gastroesophageal reflux disease or acid reflux disease. The problem occurs when acid and other contents of the stomach repeatedly flow back up into the esophagus. This happens because the lower esophageal sphincter (LES) either relaxes at the wrong time, or it is weak, so it allows acid and other stomach contents to flow back up into the esophagus.

Etiology• The position sfingter in abdomen • the Corner insertio esofagus inside gaster• Pressure sfingter • The pressure sfingter spontan mechanism

main refluks • Refluks through sfingter that was weak

chronic often happen in esofagitis • Refluks with the pressure normal,terjadi if the

stomach pressure me↑ (cough, cry, defecation)

Etiology Other lifestyle contributors to GERD may include the following :• being overweight• overeating• consuming certain foods, such as citrus, peppermint, chocolate, fatty,

and spicy foods• caffeine• alcohol• smoking• use of nonsteroidal anti-inflammatory (NSAIDs) drugs such as aspirin

and ibuprofen

Other medical causes of heartburn may include the following:• gastritis - an inflammation of the stomach lining.• ulcer disease

Symptoms of GERD :

• Vomit and slow gaster emptiness• Pneumonia aspiration• Chronic cough• Mengi• Relaps Pneumonia • Rumination• Failure to thrive

Symptoms of GERD :

• Heartburn• Regurgitation• Difficulty swallowing• Water brash

Diagnosis• The mild case clinical value & response against therapy

• Severe case – did esofagografi barium with the guidance fluoroscopy– Scintiscans show the aspirations of the contents of

gaster and show the refluks – Esofagoskopi evaluating reflux & severe strictur– Biopsy esofagus prove the existence reflux

Diagnosis• Roentgentgrafi with coventional Barium

- Exhibited the existence of the period that disturbing in the lumen/exhibited reflux gastroseofagus

• Picture and video of esofagram– Knew the change in the pattern swallowing &

esofagus peristaltic movement

• Manometri Esophagus– Evaluated the wave of the pressure in esophageal &

change in the pressure on low esophageal sphincter

• Scan radionuklid– Evaluated peristaltic efficiency in cleaned esofagus &

tested the existence refluks and aspirastion

• pH in distal esophagus– Sensitive for the gaster acid refluks

• Endoskopi fiberoptic– Carried out the biopsy and visualisation esofagus

without general anaesthesia , examination this to detect and take the foreign object

Complications

• include esophageal cancer, erosive esophagitis, and Barrett's esophagus. GERD also aggravates asthma and sleep apnea

Theraphy• Metoklopramid• Domperidone• Cisapride• Antasida• Anatgonis reseptor H2• PPI (Omeprazol)

Atresia esofagus (AE)

• Esophageal atresia is a disorder of the digestive system in which the esophagus does not develop properly.

Variasi Atresia Esofagus Gross of Boston :

Tipe A – atresia esofagus without fistula or pure atresia esofagus (10%) Tipe B – atresia esofagus withTEF proksimal (<1%) Tipe C – atresia esofagus with TEF distal (85%) Tipe D – atresia esofagus with TEF proksimal and distal (<1%) Tipe E – TEF withoutatresia esofagus or fistula tipe H (4%) Tipe F – stenosis esofagus kongenital (<1%)

Causes

• the upper esophagus ends blindly and does not connect with the lower esophagus and stomach

Diagnosed

• blood tests • chest x-rays and other x-rays • a special chest x-ray that is done after a

nasogastric tube is put through the nose into the esophagus to the point where the esophagus stops

• cinefluorography, a moving X-ray scan to observe the function of the esophagus

ACHALASIA

• The disturbance motility that was rare where the relative obstruction in continuation gastroesofagus to more badly,because the nonexistence of the peristaltic wave in esophageal

Symptomps

• dysphagia• Regurgitation• cough• Failure to thrive• Retention in esophagusesophagitis

Diagnosis

Manometri esofagus find imperfect and the nonexistence relaxation of lower esophagus sphincter at the time of swallowing, don’t existence of the peristaltic wave at the time of swallowing, no existence of the peristaltic wave of the primary promoter / sekunder, increase lower sphincter esophagus

Therapy

• Nifedipin (channel of calsium duct)• Botulisme intrasfingter injection • Operation a gap of muscle fiber in

gastroesofagus be connected.• Balloon cateter and fluoroscopy

Hungry process

• Nucleus lateral hypotalamus, as a center of hungry

• Nucleus ventromedial hypotalamus as a center of satisfied

• And sinergy with nucleus paraventrikular, dorsomedial, dan arkuata

The Standard nutrition For Child

• Kalori : 100 -120 / kg BB. Example child with 8 kg : 8 x 100 /120 = 800/960 kkal

• Protein : 1,5 - 2 g / kg BB Example child with 8 kg : 8 x 1,5/2 = 12/16 : 4 = 3/4 gram

• Karbohidrat : 50-60 % from the total calory

• Lemak: 20 % from the total calory

CONCLUSIONS

Jacko maybe suffered GER (gastroesophageal reflux) caused by overeating.

Watery stools occurs because of too much consume milk so the digestion and absorbtion is uncompletely

Suggestion

• Give nutrition appropriate with the need and age.

References• Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL,

Jameson JL, et all, editors. Harrison’s principle of internal medicine. 17th ed. USA: Mc Graw Hill medical, 2008.

• Wyllie R. The digestive system. In Kliengman RM, berhman RE, Jenson HB, stanton BF. Nelson’s textbook of pediatrics. 18th ed. Philadelphia: WB saunders Co, 2007: 1521-645

• Sondheimer JM, Sundaram S. Gastrointestinal tract. In Hay WW, Levin MJ, Sondheimer JM, Deterding RR. Current diagnosis & treatmentpediarics. 19th ed. New york: the Mcgraw-Hill Co, 2009:557-608

• Departemen Farmakologi dan Terapi. Farmakologi dan Terapi. Edisi 5 Jakarta: Balai penerbit FKUI, 2007.

• Sherwood L, Human phisiology. 5th ed. Belmont: Thomson learning 2004.