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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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2
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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
$ANI%E"!A"I IINI
'D D*"'E'"IA
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'ayor(
)yeri perut di daera" epigastrium
'unta" berulang * minimal 3+,bulan-
'inor(
Gejala yg ber"ubungan dg makan *noreksia% BB menurun-
)yeri perut yg dirasa pd malam "ari
Heartburn
Oral Regurgitasi
)eusia kronik
/enda0a berulang
)yeri perut disekitar umbilikal
da ri0ayat keluarga P. yspepsia
RI!ERIA DIAGN#"!I D*"'E'"IA
14/05/16
4
Ealuas
i( 2
mayoratau
1mayor
4 2minor
5minor
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Gejala( )yeri perut di epigastrium% pada malam "ari%regurgitasi% "earburn% BB menurun% "ematemesis danmelena
Ri0ayan 'akan(
'akanan berlemak% makanan pedas% ca6ein% laktose
Penggunaan 7batobatan(8ortikosteroid% )/9
lko"ol% tembakau *rokok-
7bat2 yang meransang pengeluaran asam lambung
ANA$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 *#