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Get That Cow Milk Away
From Me, Please…!!August 28th, 2009
Group 0 Tutor "r# $ %iwi&g
Fa'ulty Me"i'i&e o( Taruma&agara
)&i*ersity
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M+M+-.Name NIM
/*o Aria&"i 010001
Fio&a 010003
A&"i 0100022
4o*i Ayu&ita .a&toso 010000
oyke .itompul 0100010
5o*i&a 010001
Miske Marsogi 0100011
Algri %i6aya 010008
Meilie Aria&ie 0100
Merli& 7o"ir 0100
-ika .te(a&i T 01009
A&&e 0100
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.C+4A-/• :ou re'ei*e a 'all (rom Mrs# Melati, mother o(
-osa, a
pre*iously healthy 2;mo&th ol" girl# For the past owe*er,
her temperature has&?ti&'rease", &o a=" 'rampi&g or
'oli', =ut to"ay sheseems a =it pale a&" more irrita=le#
• )&(ortu&ately Mrs# Melati "i"&?t =reast(ee"
-osaa=out a week ago, a&" gi*e her regular 'ow milk(ormula#
%hile you are "is'ussi&g her (amily history,Mrs Melati reports
that -osa?s =rother a&" sister areha*i&g (oo" allergy, her
3 year ol" =rother isasthmati' as well as his (ather# The mother
assume"that he has the same "airy pro"u't allergy like his <year
ol" sister#
• :ou tell her to =ri&g him (or (urther
"iag&osti'i&*estigatio& a&" 'all the la'tatio&
'li&i' (or a'ou&seli&g appoi&tme&t i& or"er
to retur& to
e@'lusi*e =reast(ee"i&g#
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5ear&i&g =6e'ti*e
• A&atomy o( "igesti*e tra't• Physiology o( "igesti*e
tra't
• Pathophysiology
– +mesis – ''ult =lee"i&g mu'ous i& the
stool
• Biere&tial "iag&osis (rom
– +mesis
– ''ult =lee"i&g mu'ous i& the stool
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DIFFICULT WORDS
• emesis DemEeEsisD emH;sisI *omiti&g#• occult
bleeding es'ape o( =loo" i& su'h small Kua&tity
that it 'a& =e "ete'te" o&ly =y 'hemi'al test or
=ymi'ros'opi' or spe'tros'opi' e@ami&atio
• irritable DirEriEtaE=leD irL;tah;=lI
1. 'apa=le o( rea'ti&g to a stimulus#
. a=&ormally se&siti*e to stimuli#
!. pro&e to e@'essi*e a&ger, a&&oya&'e, or
impatie&'e#
• colic D'olEi'D kolikI
1. a'ute paro@ysmal a="omi&al pai. pertai&i&g to the
'olo
Borla&"s Me"i'al Bi'tio&ary (or >ealth Co&sumers#
N 200 =y.au&"ers, a& impri&t o( +lse*ier, /&'# All
rights reser*e"#I
http://medical-dictionary.thefreedictionary.com/vomitinghttp://medical-dictionary.thefreedictionary.com/vomiting
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A4ATM: F B/G+.T/$+
T-ACT
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P>:./5G: F
B/G+.T/$+ T-ACT
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M)T>.ali*a;Gla&"s paroti", su=li&gual
su=ma&"i=ular;Mi&or gla&" u''al;99#1O >2, 0#1O
protei&amylase, mu'us, lysoyme,
ele'trolyteI
Fu&'tio&s;Amylasepolisa''hari"e "issa'hari"e;Mu'us
lu=ri'atio&, (oo";
'o&"e&si&g; as a sol*e&t stimulate
"taste=u"; arti'ulatio&;>ygie&e;>C
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ther i&put ta&pa ra&gsa&ga& oral, 'th
=erpikir, melihat, mem=aui,me&"e&gar
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PAT>P>:./5G:
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Pathophysiology o( .tool with loo"
Mu'ous
Mu'ose =arrier weake&e" "ue toi&(e'tio&
+@u"ate (ormatio& =loo"*essel i& lami&a propria
loo" mu'ous i& stool
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Pathophysiology o(+mesis
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-+G)-G/TAT/4
• BeR&itio& – eortless mo*eme&t o( stoma'h
'o&te&ts /&to the
esophagus a&" mouth# /t is &ot asso'iate" with
"istress,a&" i&(a&ts with regurgitatio& are
o(te& hu&gry
imme"iately a(ter a& episo"e• -egurgitatio& is a result
o( G+- gastroesophageal
reSu@I through a& i&'ompete&t, or i&
i&(a&ts,immature lower esophageal sphi&'ter
• This is o(te& a "e*elopme&tal pro'ess
a&"regurgitatio& or spitti&gU resol*es with
maturity – )sually re*ol*es i& 80O i&(a&ts =y 3mo,
90O =y 2mo
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-+G)-G/TAT/4
Sign 7 S!mpt#ms8
• 9eig+t
"#ss• Ha"it#sis• Indigesti#n• 3+r#nica""! ra: and
c+apped "ips
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G+-B
• Gastroesophageal reSu@ G+-I is a 'ommo&, sel(;limite"
pro'ess i& i&(a&ts that usually resol*es =ysi@ to 2
mo&ths o( age# The pre*ale&'e o( G+-peaks =etwee& V mo
o( age
– /( 'ompli'atio&s "e*elop or regurgitatio&
persists, G+- is'o&si"ere" pathologi' 'o&si"ere" as
gastroesophagealreSu@ "isease, G+-BI rather tha& merely
"e*elopme&tal "eser*es (urther e*aluatio& treatme&t
• G+-B or a'i" reSu@, is a 'o&"itio& i& whi'h
theliKui" 'o&te&t o( the stoma'h regurgitates =a'ksup or
reSu@esI i&to the esophagus
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Classi(yi&g G+-B
Gastroesophageal-eSu@
Physiologi'alGastroesophageal -eSu@ ;G+-
Gastroesophageal -eSu@Bisease W G+-B.ymptomati'I
Primary G+-BMotility pro=lemAe'ti&g lower+sophageal
sphi&'ter
.e'o&"ary G+-B+@ter&al (a'tor
'ausi>ra&sie&t rela@atio&s o(lower +sophageal
sphi&'ter
eg# Foo" allergyI
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Pathophysiology
• G+- o''urs whe& the lower esophageal sphi&'ter 5+.I
ope&sspo&ta&eously, (or *aryi&g perio"s o( time, or
"oes &ot 'loseproperly a&" stoma'h 'o&te&ts rise up
i&to the esophagus# G+-is also 'alle" a'i" reSu@ or a'i"
regurgitatio&, =e'ause "igesti*e 6ui'esX'alle" a'i"sXrise
up with the (oo"# The esophagus is thetu=e that 'arries (oo" (rom
the mouth to the stoma'h# The 5+.
is a ri&g o( mus'le at the =ottom o( the esophagus that a'ts
likea *al*e =etwee& the esophagus a&" stoma'h#
• %he& a'i" reSu@ o''urs, (oo" or Sui" 'a& =e taste"
i& the =a'ko( the mouth# %he& reSu@e" stoma'h a'i" tou'hes
the li&i&g o(the esophagus it may 'ause a =ur&i&g
se&satio& i& the 'hest or
throat 'alle" heart=ur& or a'i" i&"igestio ''asio&al
G+- is'ommo& a&" "oes &ot &e'essarily mea&
o&e has G+-B#Persiste&t reSu@ that o''urs more tha&
twi'e a week is'o&si"ere" G+-B, a&" it 'a&
e*e&tually lea" to more serioushealth pro=lems# People o( all
ages 'a& ha*e G+-B#
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.ymptoms
• G+- is 'ommo& i& healthy i&(a&ts# More t(an
(al) o) all babiese*+erience re,u* in t(e -rst ! mont(s o(
li(e, =ut most sto+s+itting u+ beteen t(e ages o) 1 to / mont(s#
&ly asmall &um=er o( i&(a&ts ha*e se*ere
symptoms#
• "n in)ant it( #&R ma0 e*+erience – s+itting
u+
– 2omiting – coug(ing – irritabilit0 – +oor
)eeding – blood in t(e stools
• /& a small &um=er o( =a=ies, G+- results i&
symptoms that 'ause'o&'er These symptoms i&'lu"e
– poor growth "ue to a& i&a=ility to hol" "ow&
e&ough (oo" – irrita=ility or re(usi&g to (ee" "ue to
pai& – =loo" loss (rom a'i" =ur&i&g the
esophagus – =reathi&g pro=lems
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+@ami&atio&
• &ndosco+0
• $io+sies
• 34ra0s
• &*amination o) t(e t(roat and lar0n*
• &so+(ageal acid testing
• "cid +er)usion test
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Treatme&tTreatment
5i(e stylemo"iR'atio&
+le*atio& o( the upper =o"y at &ight ge&erally is
re'omme&"e" (or allpatie&ts with G+-B
G+-B Biet Y These (oo"s shoul" =e a*oi"e" a&"
i&'lu"e Cho'olate, peppermi&t, al'ohol 'aei&ate"
"ri&ksY Fatty (oo"s whi'h shoul" =e "e'rease"I a&"
smoki&g whi'h shoul"=e stoppe"I also re"u'e the pressure i&
the sphi&'ter a&" promote
reSu@Y Chewi&g gum stimulates the pro"u'tio& o( more
=i'ar=o&ate;'o&tai&i&g sali*a a&" i&'reases
the rate o( swallowi&g#
A&ta'i"s A&ta'i"s &eutralie the a'i" i& the
stoma'h so that there is &o a'i" toreSu@they "o so (or o&ly
a short perio" o( time
The =est way to take a&ta'i"s, there(ore, is
appro@imately o&e hour
a(ter meals or 6ust =e(ore the symptoms o( reSu@ =egi& a(ter
a meal#.i&'e the (oo" (rom meals slows the emptyi&g (rom
the stoma'h, a&a&ta'i" take& a(ter a meal stays i&
the stoma'h lo&ger a&" isee'ti*e lo&ger
>istami&A&tago&ist
The Rrst me"i'atio& "e*elope" (or more ee'ti*e a&"
'o&*e&ie&ttreatme&t o( a'i";relate" "iseases,
i&'lu"i&g G+-B, was a histami&ea&tago&ist,
spe'iR'ally 'imeti"i&e TagametI
>istami&e is a& importa&t 'hemi'al =e'ause it
stimulates a'i"pro"u'tio& =y the stoma'h
T
http://www.medicinenet.com/script/main/art.asp?articlekey=839http://www.medicinenet.com/script/main/art.asp?articlekey=839
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Treatment
Protei& Pump/&hi=itor
The se'o&" type o( "rug "e*elope" spe'iR'ally (or
a'i";relate""iseases, su'h as G+-B, was a proto& pump
i&hi=itor PP/I,spe'iR'ally, omepraole Prilose'I
The a"*a&tage o( a PP/ o*er a& >2
a&tago&ist is that the PP/shuts o a'i" pro"u'tio& more
'ompletely a&" (or a lo&ger perio"o( timeFi*e "iere&t
PP/s are appro*e" (or the treatme&t o( G+-B,i&'lu"i&g
omepraole Prilose'I, la&sopraole Pre*a'i"I,ra=epraole
A'iphe@I, pa&topraole Proto&i@I, a&"
esomepraole4e@iumI# A R(th PP/ pro"u't 'o&sists o( a
'om=i&atio& o(omepraole a&" so"ium =i'ar=o&ate
Zegeri"I# PP/s e@'ept (orZegari"I are =est take& a& hour
=e(ore meals
Pro Motility Brug Pro;motility "rugs work =y stimulati&g the
mus'les o( thegastroi&testi&al tra't, i&'lu"i&g the
esophagus, stoma'h, smalli&testi&e, a&"Dor 'olo &e
pro;motility "rug, meto'loprami"e-egla&IPro;motility "rugs
i&'rease the pressure i& the lower esophagealsphi&'ter
a&" stre>he& the 'o&tra'tio&s peristalsisI o(
theesophagus
Foam arriers Foam =arriers are ta=lets that are 'ompose" o(
a& a&ta'i" a&" a(oami&g age&t#
There is o&ly o&e (oam =arrier, whi'h is a
'om=i&atio& o(alumi&um hy"ro@i"e gel, mag&esium
trisili'ate, a&" algi&ateGa*is'o&I#
.urgery The surgi'al pro'e"ure that is "o&e to
pre*e&t
reSu@ is te'h&i'ally k&ow& as (u&"opli'atio&
a&" is'alle" reSu@ surgery or a&ti;reSu@ surgery
http://www.medicinenet.com/script/main/art.asp?articlekey=813http://www.medicinenet.com/script/main/art.asp?articlekey=813http://www.medicinenet.com/script/main/art.asp?articlekey=812http://www.medicinenet.com/script/main/art.asp?articlekey=812http://www.medicinenet.com/script/main/art.asp?articlekey=813http://www.medicinenet.com/script/main/art.asp?articlekey=813
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/4F+CT/4
• PA-A./T+.
• ACT+-/A
• $/-).+.
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OCCULT $L&&DIN#IN STOOL
&M&SIS
$acteria
.almo&ella Q QQ
Campylo=a'ter Q QQ
.higella QQ QQQ
+#Coli QQQ QQ
$i=rio QQ QQ
%arasites
+&tamoe=a histolyti'a QQ Q
Crytospori"ium ; QQ
Cy'lospora ; QQ
Giar"ia ; QQ5iruses
4oro*irus ; QQQ
-ota*irus ; QQQ
4 "isappear 6 sel"om 66 'ommo&
666o)ten
Gi "i 5 =li
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Giar"ia 5am=liaPAT>G+4+./.I
•Patologi "a& ge6ala –Biare, "isertaisteatore
kaere&aga&ggua& a=sorpsilemak#
–Ga&ggua& a=sorpsikarote&, (olat, "a&*it#
2#
–Pro"uksi e&immukosa 6uga=erkura&g
–.i&"rommala=sorpsi
–Pe&yerapa& =iliru=i&shg
me&gham=atakti*itas lipase
pa&kreatik
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FB A55+-G:
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FB A55+-G:
• Foo" allergy is a group o( "isor"ers i& whi'hsymptoms
result (rom immu&ologi' respo&ses tospe'iR' (oo"
a&tige&s
• +pi"emiology
–Males [ (emales\ more i& i&(a&ts wD history
o(atopy
– 3O o( 'hil"re& "uri&g st
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FB A55+-G:
• /& i&(a&'y hyperse&siti*ity is most o(te&
asso'iate"with i&gestio& o( 'ows milk or soy protei
• Although &ursi&g 'a& pre*e&t the
"e*elopme&t o((oo" illergy, ma&i(esiatio&s o( (oo"
allergy,
espe'ially pro'to'olitis, 'a& o''ur with
&ursi&g#Cows milk i& the mothers "iet is the most
'ommo&i"e&tiRa=le 'ause o( (oo";allergi' rea'tio&s
i&&ursi&g i&(a&ts\ rea'tio& to pea&ut,
soy, or egg i&the mothers "iet o''urs less o(te
• Amo&g i&(a&ts a&" 'hil"re& with (oo"
allergy, 90Oo( rea'tio&s are to egg, milk, pea&ut, soy, or
wheat#.e*e&ty;R*e per 'e&t o( 'hil"re& with pro*e&
(oo"allergy rea't o&ly to a si&gle (oo"#
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Ma6or Foo" Allerge&s
Class 1Food %rotein "llergen Name
Cow?s milk ];5a'toglo=uli&Casei&
os ";8os ";1
egg *omu'oi" Gal "
Pea&ut $i'ili&Co&gluti&
Ara h Ara h 2
Fish Paral=umi& Ga" '
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FB A55+-G:
• /g+ me"iate"
– ral allergy sy&"rome
– G/ a&aphyla@is
– thers• 4o& /g+ me"iate"
– Allergi' proto'olitis
– Foo" i&"u'e" e&tero'olitis
– Celia' "isease
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Foo" Allergy W /g+ Me"iate"
Food "llerg0 7Ig& Mediated
ral Allergy.y&"rome
• Allerge& 'o&ta't to orophary&@
it'hi&gor ti&gli&g a&" a&gioe"ema o( the
lips,to&gue, palate, a&" throat• These symptoms may
pre'e"e other /g+;me"iate" ma&i(estatio&s o( (oo"
allergy#Allergy to polle& hay (e*erI is also 'ommo&/&
these patie&ts#• Fa'ial erythema (rom 'o&ta't with
'itrus
a&" tomato pro"u'ts is &ot 'o&si"ere"&immu&e
respo&se#
G/ A&aphyla@is • -api" o&set o( &ausea,
'rampi&ga="omi&al pai&, *omiti&g, or "iarrhea or
a'om=i&atio& o( these 'o&"itio&s o''urs
a(ter i&gestio& o( a& allerge
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Allergi' Pro'to'olitis
• "ay V < mo age prese&ts wD spots or streaks o(=loo"
a&" mu'us i& stool o''asio&al mil" "iarrhea
• /&'rease" &um=ers o( white =loo" 'ells i& stool
a&"peripheral eosi&ophilia may =e prese&t\
&o"ular
lymphoi" hyperplasia o''urs i& V 21 Oo( 'ase• Most
o(te&, 'ause" =y hyperse&siti*ity to 'ow?smilk\ soy
se&siti*ity ^ 'ommo&
• This "isor"er also o''urs i& e@'lusi*ely
=reast;(e"patie&ts a&" o''asio&ally a=ates with
mater&al "ietmo"iR'atio& with elimi&atio& o( milk
pro"u'ts#
• 4o&;=reast;(e" i&(a&ts 'a& =e treate" with
protei&hy"rolysate (ormulas# ''asio&ally, a& ami&o
a'i";=ase" (ormula may =e reKuire"#
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Foo" /&"u'e" +&tero'olitis
• Protra'te" *omiti&g a&" "iarrhea =egi&=etwee&
wk a&" < mo o( age# 5ess se*ererea'tio&s 'a&
o''ur i& ol"er 'hil"re& a&"a"ults
• .tools 'o&tai& o''ult =loo", &eutrophils,
a&"eosi&ophils# e6u&al =iopsy
"emo&stratesSatte&e" *illi, e"ema, a&" i&Sammatory
'ells
• .ymptoms resol*e withi& 2 hr o( remo*al o(the
oe&"i&g (oo" a&" re'ur withi& ;3 hr
o(rei&tro"u'tio&
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Biag&osis
• Foo" allergy is suspe'te" whe& typi'alsymptoms o''ur with
the i&tro"u'tio& o(spe'iR' (oo"
– ther &o& allergi' me'ha&isms o(
(oo"i&tolera&'e shoul" =e rulle" out e@'ompromise"
"igesti*e or a=sorpti*epro'ess, 'o&tami&atio&
wDmi'ro=es to@i&s,or pharma'ologi' a'ti*ity o( (oo"sI
• +limi&atio& "iet a&" su=seKue&t
"ou=le;=li&",pla'e=o 'o&trolle" (oo" 'halle&ge BPCFCI
gol" sta&"art (or "iag&osis (oo" allergy
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Treatme&t Prog&osis• +limi&atio& o( "iet#
Most ma&i(estatio&s resol*e" withi&
se*eral "ays, some may take weeks – /&(a&ts at high
risk (or "e*elopi&g (oo" allergy may =e&eRt(rom
=reast;(ee"i&g a&" the elimi&atio& o( soli"s
a&"'ows milk protei& (rom their "iet (or the st 3 mo o(
li(e
• Chil" wD se*ere li(e threate&i&g /g+ me"iate"
rea'tio&s
shoul" ha*e a''ess to i&6e'ta=le a&tihistami&e
epi&ephri&e
• >y"rolysate (ormula, ami&o a'i" =ase" (ormula
• -emo*al o( 'ow?s milk (rom mother?s "iet
• 81O i&(a&ts wD &o& /g+ me"iate" (oo"
hyperse&siti*ity to
milk protei&s &o lo&ger ha*e symtomps o& (oo"
'halle&ge=y < yr o( age
• -esolutio& o( symptoms (rom 'ows milk or soy
protei&hyperse&siti*ity is 'ommo& =y yr o( age
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INTUSSUSC&%TION
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/4T)..).C+PT/4• /&tussus'eptio& is the most (reKue&t
'ause o(
i&testi&al o=stru'tio& i& the Rrst 2 years o(
li(e#• Male [ (emales#• The pre"isposi&g (a'tors are
– Polyps
– Me'kel "i*erti'ulum – mphalomese&teri'
rem&a&ts – Bupli'atio&s – >e&o'h
.'h_&lei& purpura – 5ymphoma – 5ipoma –
Parasites – Foreig& =o"ies – $iral e&teritis with
hypertrophy o( Peyer pat'hes#
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/4T)..).C+PT/4
Cli&i'al Fi&"i&gs• Chara'teristi'ally, a
thri*i&g i&(a&t =etwee& the
ages o( < a&" 2 mo&ths "e*elops
re'urri&gparo@ysms o( a="omi&al pai& with s'reami&g
a&"
"rawi&g up o( the k&ees#• $omiti&g a&" "iarrhea
o''ur soo& a(terwar" 90O
o( 'asesI, a&" =loo"y =owel mo*eme&ts withmu'us appear
withi& the &e@t 2 hours 10OI#
Biag&osis
• history, @;ray, =arium e&ema
Treatme&t
• arium e&ema, surgery
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5ACT.A /4T5+-A4C+
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5a'tose /&tolera&'e
• BeR&itio&• 5a'tose i&tolera&'e, also 'alle"
la'tase "eR'ie&'y,
mea&s you are&t a=le to (ully "igest the milk
sugarla'toseI i& "airy pro"u'ts#
• .ymptoms – egi&
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5a'tose /&tolera&'e
Types• 4ormal result o( agi&g (or some people
primary la'tose i&tolera&'eI
• -esult o( ill&ess or i&6ury se'o&"ary la'tose
i&tolera&'eI – small i&testi&e "e'reases
la'tase pro"u'tio&
a(ter a& ill&ess, surgery or i&6ury to yoursmall
i&testi&e#
– /t 'a& o''ur as a result o( i&testi&al
"iseases• Co&"itio& youre =or& with 'o&ge&ital
la'tose
i&tolera&'eI
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Test Treatme&t
• Tests a&" "iag&osis – 5a'tose tolera&'e
test#
– >y"roge& =reath test
– .tool a'i"ity test
• Treatme&t – )se la'tase e&yme ta=lets#
– Take a 'al'ium suppleme&t
– Try pro=ioti's
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Co&'lusio&
• i& this 'ase we stu"ie" a=out – A&atomy o(
"igesti*e tra't
– Physiology o( "igesti*e tra't
– Pathophysiology• +mesis
• ''ult =lee"i&g mu'ous i& the stool
– Biere&tial "iag&osis (rom
• +mesis
• ''ult =lee"i&g mu'ous i& the stool
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.uggestio&
• %e re'omme&"e" -osa?s mother to 6oi& with
la'tatio& 'li&i'
• Follow the "o'tor?s i&stru'tio&
• %e suggest -osa?s mother to gi*ee@'lusi*e =reast (ee"
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-e(ere&'es
• Curre&t# Biag&osis Treatme&t i&
Pe"iatri's#200# ).A M' Graw;>ill 'ompa&ies
• .u"oyo, Aru %# uku A6ar /lmu Pe&yakitBalam# 2003# akarta
F7)/
• 7liegma& -M, erhma& -+, e&so&
>,.ta&to& F# 4elso&?s Te@t=ook o(
Pe"iatri's#8th e"# Phila"elphia % .au&"ers Co, 200#
• www# +me"i'i&e#'om• www# Me"i'i&e&et#'om
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Tha&k you
