Ger Blok Gastro May 2011

8/17/2019 Ger Blok Gastro May 2011

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Dyspepsia &Gastroesophageal

Refux (GER)

Wan NedraBagian Anak FK. Univ YARSI

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1.Peptic ulcer disease

2.GER 3.Helicobacter pylory

infection

ACID – REA!ED DI"#RDER"

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Berupa kumpulan gejala yang nonspesi!k

ber"ubungan dengan saluran pencernaanbagian atas

yang terjadi berulang selama minimal 2

bulan

#"elimsky dan #$inn% 2&&1

$ANI%E"!A"I IINI

'D D*"'E'"IA

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'ayor(

)yeri perut di daera" epigastrium

'unta" berulang * minimal 3+,bulan-

'inor(

Gejala yg ber"ubungan dg makan *noreksia% BB menurun-

)yeri perut yg dirasa pd malam "ari

Heartburn

Oral Regurgitasi

)eusia kronik

/enda0a berulang

)yeri perut disekitar umbilikal

da ri0ayat keluarga P. yspepsia

RI!ERIA DIAGN#"!I D*"'E'"IA

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Ealuas

i( 2

mayoratau

1mayor

4 2minor

5minor


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Gejala( )yeri perut di epigastrium% pada malam "ari%regurgitasi% "earburn% BB menurun% "ematemesis danmelena

Ri0ayan 'akan(

'akanan berlemak% makanan pedas% ca6ein% laktose

Penggunaan 7batobatan(8ortikosteroid% )/9

lko"ol% tembakau *rokok-

7bat2 yang meransang pengeluaran asam lambung

ANA$NE"I"

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Pemeriksaan a0al(

Hematologi dg di6erential count

:;


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H2 reseptor antagonis(

=#imetidine 2& > 5& mg, kg, "ari 2 kali , "ari maks( 5&&mb

=Ranitidine 2 5 mg, kg, "ari% 2 kali se"ari *mak( 1?& mg-

Proton Pump 9n"ibitor

=:ansopra$ol &%@ mg,kg,"ari

=7mepra$ol &%@ mg, kg, "ari

#ytoprotectie gents(

/ukralfat 5&@& mg, kg, "ari% 5 kali se"ari * mak 1 g-

'ENG#+A!AN

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• forceful expulsion of gastrointestinal contents into the

oesophagus

DE%INI"I


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Vomiting

Regurgitation

Gastroesophageal reflux


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;orceful e+pulsion of gastrointestinalcontents t"roug" t"e mout"

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Vomiting


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/.motorik somatik

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S.motorik somatik

Saraf otonom

S. Simpatis

S. Parasimpatis

Saraf enterikN. Vagus

asetil kolinpleksus mienterikus

motilitas sal!erna

pl. mienterikuspl. sumukosa


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"mpuls

Chemo-receptor

Trigger Zone

!astrointestinal tract" #

Vomiting !enter

en$ogen exogen

"mpuls

#omiting

afferen N. Vagus


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Vomiting centre

Chemo-receptor Trigger Zone

Blood Brain Barrier

esophagus


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%&S

'un$us

(orpus

)onus $ecrease

*ntrum Peristaltic $ecrease

P+lorus

,uo$enum

)onus increase


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'ost common in c"ildren *A infant-

#onfusing t"e parents

:ifet"reatening causes of omiting


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= Age neonates, in-ant, .hild

=Gastrointestinal tra.to/stru.tion & non o/stru.tion

• Extra0gastrointestinal tra.t

A''R#AC

1

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Neonates

tresia esop"agus% pylorus stenosis% spitting up

GER% )E#% c"alasia% 9nfection *


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/canning gambar HP/

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2 etiology

treat a.id and /ase in/alan.edDrugs

Do3peridone

$eto.lopra3ide

Cisapride

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$herap%


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Gastroesop"ageal reu+

Cust spitting up% or

somet"ing more serious D

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456 general in-ant population

5& of c"ildren consulting a pediatrician

F& of all 5 mont"s old infants

•regurgitate at least 1 +,day

•2? is considered by t"e parents as a problem

RGE

@ abnormal pH esop"agus monitoring

1,3&& > 1,1&&& seere

*#"ouc"ou% I2J )elson et al% 1IIF-

REGRGI!A!I#N

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'hysiologi. refux

occurs mainly after meal

does not normally cause symptoms

s"ort duration of reu+ episodes

'athologi. refux

freLuent reu+ episodes of longer duration

reu+ episodes occuring during t"e day,nig"tmay produce symptoms M inamation,mucosal injury

GER

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$EC1ANI"$" #% GER

attenuate' s(allo(s)'%sfun!tional peristalsis

*ength of *&+)

,aturation of *&+$*&+ relaxation

"na'e-uate

gra#itation

'ela%e' gastri!empt%ing)

'istension

.efi!ient or 'ela%e'esophageala!i' !learan!e

"n!ompetent

*&+

'ela%e' gastri! empt%ing

'istention

"*&+/ *o(er essophagealsphinter


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RGE

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Acid,Regional blood flow,

tissue prostaglandin E2

permeability to acid

susceptibility to inflamation

Impairment of LES

$+smotilit+

esophagitis

inflamation

$+sfunction

-agal ner-e

aci$/ile

e$ema

firosis

p+lorospasm


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=9ncreased abdominal pressure*oer0eig"t% constipation-

=9ncreased respiratory e6ort related toe+ercise

*food- allergy% crying% cigarette smoking

=Hereditary predisposed

!RIGGER %AC!#R"

%A7#RING GER

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Emesis M regurgitation are t"e most common

‘primary’ GER disease

secondary GER disease

infection% metabolic disorders% M food allergystimulation omiting center in t"e dorsolateral

reticular formation by e6erent M a6erent impuls

CINICA $ANI%E"!A!I#NGER

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sual 3ani-estations

/peci!c manifestation

regurgitation% nausea% omiting

Possibly related to complications

N anaemia *iron de!ency anaemia-

"aematemesis M melena

dysp"agia% 0eig"t loss% irritable infants

ect N adult

"*$'!#$" #%GER

(0 DI"EA"E)

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nusual presentations

N c"ronic respiratory disease

apnea% apparent life t"reatening% /9/

2 to .ongenital and8or CN"a/nor3alities

cerebral palsy% psyc"omotory retardation

careful "istory% obseration of feeding% Mp"ysical e+amination are mandatory

"*$'!#$" #% GER

(0 DI"EA"E)

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1. a. Parental reassurance b. 'ilkt"ickening agents *D-

2. Prokinetics

3. Positional adjuant t"erapy5. a. H2 receptor antagonist

b. Proton pump in"ibitors

?. /urgery

!REA!$EN!

REC#$$ENDA!I#N"

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%re9uent s3all -eeding

ecrease t"e number of transient :E/ rela+ations

Reduced olume cause of distress to infants

Restriction olume in clearly oerfed babies

!hi.:ening in-ants -or3ula

ecrease t"e freLuency M olume of regurgitation

time crying↓% improes sleep% caloric retention ↑%

coug"ing *after feeding- ↓

*Kandenplas% 1II5% Borelli% 1IIF-

REGRGI!A!I#N AND

%EEDING

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Gastrokinetic action indirect release of acetylc"olinein t"e myentericus ple+us

Reduces regurgitation


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/leeping and crying decrease GER

#rying increases abdominal pressure% but also

increases :E/P

3&& prone antitrendelenburg position

/9/ D

Beyond t"e age of /9/ * A 12 mont"s-

*7renstein% 1II&J 7renstein% 1IIFJ


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GER 0 A"!1$A

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Vagal stimulation lea'ing to

ron!hospasm

*ar%ngeal irritation

% refluxate

ulmonar% aspiration

of refluxate


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Recent studies report t"at 5?F? of c"ildren0it" uncontrolled ast"ma su6er G7R

Prokinetic

↓ GER N coug" episodes at nig"t in ?& c"ildren

remission of resp. symptoms or less antiast"mamedication

*'cKeag"% 1I@FJ 7renstein% 1I@@J


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n!ompli!ate' G&Rn!ompli!ate' G&R

NoNo in-estigationsNoNo in-estigations

Phase 1Phase 1 11eeks2eeks2

Phase 1Phase 1 11eeks2eeks2

Phase Phase 1313

eeks2eeks2

Phase Phase 1313

eeks2eeks2 reconsi$er $iagnosis of !& reconsi$er $iagnosis of !&

pp monitoringpp monitoring

NormalNormalNormalNormal *normal *normal *normal *normal

! ! 7!8S 7!8S &n$oscop+ &n$oscop+

li t ' G&R h iti


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ompli!ate' G&R / esophagitis ompli!ate' G&R / esophagitis

&n'os!op%&n'os!op%

&so 9 !ra$e 3&so 9 !ra$e 3

&+ &+

phase 1 : phase 1 :

* 'ormula * 'ormula(isapri$e 13(isapri$e 13

momo

phase 1 : phase 1 :

* 'ormula * 'ormula

(isapri$e 13(isapri$e 13

momo

phase 1 : : 3 : 4phase 1 : : 3 : 4: Positional treatment": Positional treatment"

; / mepra


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!1AN *#

Ger Blok Gastro May 2011

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