GASTROENTEROHEPATOLOGI I

MODUL TUTOR 2

PROGRAM STUDI PENDIDIKAN DOKTER FAKULTAS KEDOKTERAN UNIVERSITAS ISLAM MALANG SEMESTER GENAP TA. 2012/2013

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DAFTAR ISI

Kata Pengantar .............................................................................................1 Daftar Isi .......................................................................................................2 Minggu Pertama Jadwal Minggu Pertama ........................................................................5 7 jump Minggu Pertama .......................................................................7

Minggu Kedua Jadwal Minggu Kedua ...........................................................................17 7 jump Minggu Kedua ..........................................................................18

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JADWAL BLOK GASTROENTEROHEPATOLOGI 1 TH. AJARAN 2011-2012

Minggu II. Esophagus
Hari / Jam Tgl 08.00 -09.40 09.40 -09.50 09.50 -11.30 11.30 -12.30 12.30 -14.10 14.10 -14.20 MKDU Senin 25 Maret 2013 SDL Selasa 26 Maret 2013 Pleno Skenario 1 Rabu 27 Maret 2013 Tutorial I Kamis 28 Maret 2013 SDL Cadangan Kuliah Pakar Tutorial II Jumat 29 Maret 2013 Sabtu 30 Maret 2013

Istirahat Pleno Skenario 1 Histologi Traktus Digestivus YHA

Sholat Dhuhur Berjamaah di Masjid Ainul Yaqin Praktikum Histologi Traktus Digestivus YHA Istirahat & Mikrobiologi Sist. Pencernaan YAM Kegiatan Mahasiswa Fisiologi Sistem Pencernaan DSD LIBUR KENAIKAN ISA AL MASIH Pembimbingan Akademik

MKDU

SDL

14.20 -16.00

SDL

SDL

SDL

16.00

Sholat Ashar Berjamaah di Masjid Ainul Yaqin

Pembagian Presentasi Pleno Pertama Kedua Ketiga Keempat Kelima Keenam : Anatomi dan Histologi Esofagus : Fisiologi pergerakan makanan dalam saluran cerna : Concept Mapping Jenis-jenis penyebab disfagia : Concept Mapping Alur diagnosis disfagia : anamnesis, pemeriksaan fisik, diagnosis banding, rencana pemeriksaan penunjang) disfagia : Case Mapping Alur diagnosis disfagia : anamnesis, pemeriksaan fisik, diagnosis banding, rencana pemeriksaan penunjang) benda asing esofagus : Case Mapping penatalaksanaan (sesuai kompetensi) benda asing esofagus

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CUPLIKAN SKENARIO MINGGUAN

KASUS MINGGU KEDUA UANG TERTELAN
An. Y, 2 tahun dibawa ke UGD RS karena tidak sengaja menelan uang koin yang dipegang. Orangtuanya panik karena anaknya tertelan uang koin. Pada pemeriksaan fisik tampak an. Y rewel, menolak bila didekati pemeriksa. Mulut ngiler karena tidak bisa menelan ludah, sesekali cegukan. Dokter segera melakukan tindakan gawat darurat pada anak tersebut. Apa langkah anda selanjutnya dalam penatalaksanaan anak tersebut? X rays tampak sebagai berikut.

1st jump : Identifikasi Kata Kunci Tertelan uang koin sehingga mulut ngiler karena tidak bisa menelan ludah gangguan menelandisfagia Dysphagia (dis-FAY-jee-ah) is difficulty in swallowing, commonly associated with obstructive or motor disorders of the esophagus.(Jones, 2008) 2
nd

jump : Problem List 1. Apa kemungkinan yang terjadi bila uang koin tertelan sebagaimana ilustrasi kasus tersebut? 2. Mengapa setelah tertelan, an Y mengalami ngiler? 3. Pemeriksaan penunjang apa yang perlu direncanakan untuk menegakkan diagnosis? 4. Apa penatalaksanaan pasien pada kasus tersebut? 5. Bagaimana pencegahan yang harus dilakukan pada keadaan tersebut?

3 jump : Brain Storming Mahasiswa mencari informasi tentang corpus alienum sistem pencernaan terutama pada anakanak baik diagnosis, diagnosis banding, pemeriksaan penunjang yang diperlukan, penatalaksanaan baik farmakologi maupun non farmakologi. Khususnya di esofagus Mahasiswa mencari informasi tentang Pertama Kedua Ketiga Keempat Kelima : Anatomi dan Histologi Esofagus : Fisiologi pergerakan makanan dalam saluran cerna : Concept Mapping Jenis-jenis penyebab disfagia : Concept Mapping Alur diagnosis disfagia : anamnesis, pemeriksaan fisik, diagnosis banding, rencana pemeriksaan penunjang) disfagia : Case Mapping Alur diagnosis: anamnesis, pemeriksaan fisik, diagnosis banding, 4|GEH1

rd

rencana pemeriksaan penunjang) benda asing esofagus Keenam

th

: Case Mapping penatalaksanaan (sesuai kompetensi) benda asing esofagus

4 jump : Mapping (case & concept) Case Mapping Concept Mapping : Jenis-jenis Penyebab dysphagia

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Concept Mapping Alur diagnosis Dysphagia : anamnesis, pemeriksaan fisik, diagnosis banding, rencana pemeriksaan penunjang

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Management of esophageal foreign body impaction

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5th jump. Learning Objectives 1. Mengetahui anatomi histologi esofagus. 2. Mengetahui fisiologi fungsi esofagus (menelan). 3. Dapat menyusun alur diagnosis gangguan fungsi esofagus (menelan). 4. Dapat menjelaskan patofisiologi kasus gangguan fungsi esofagus (menelan). 5. Dapat menyusun rencana penatalaksanaan (sesuai kompetensi) kasus gangguan fungsi esofagus (menelan). 6 jump. Self Directed Learning Lihat 7th jump. Reporting
th

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An Y, 2 tahun

Peak inc 6 bln-3 thn

Tidak sengaja tertelan uang koin Ngiler, tidak bisa menelan ludah

Spontaneously unwitnessed
Frequently, symptoms occur well after the patient ingests the foreign body, young childrenpresent with choking, refusal to eat, vomiting, drooling,wheezing, blood-stained saliva, or respiratory distress

Ingested Foreign bodies

Oropharyngeal or proximal esophageal perforation can cause neck swelling, erythema, tenderness,or crepitus CT scan if necessary Metal detector X rays+ oesophageal foreign bodies Biplane radiographscan confirm the location, size, shape, and number of ingested foreign bodies and help exclude aspirated objects

Management Airway
Ventilatory status and an airway evaluation

Timing
The need for and timing depend on the patient age and clinical condition (Tabel 2)(ASGE, 2011)

Equipment
Endoscopes Retrieval devices::rat-tooth and alligator forceps, polypectomy snares, polyp graspers, Dormier baskets, retrieval nets, magnetic probes, and friction-fit adaptors or banding caps Overtubes protects the airway and facilitates passage of the endoscope during removal of multiple objects or during piecemeal clearance of a food impaction Food bolus impactionmeat or other foodglucagon1.0 mg intravenous to induce relaxation of the distal esophagus, thereby allowing spontaneous bolus passage while endoscopic therapy is coordinated True foreign bodies Short-blunt objects.-->coins can be removed with a foreign body forceps (eg, rat-tooth or alligator), snare, or retrieval net Long objectsObjects longer than 6 cm, such as toothbrushes and eating utensils, are likely to have difficulty passing the duodenum and should be removed Sharp-pointed objectsChicken and fish bones, straightened paperclips, toothpicks, needles, bread bag clips, and dental bridgework ingestions have been associated with complications. Disk batteries Magnets coins

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7th jump. Reporting LO 1. Anatomi Histologi Esofagus

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LO 2. Fisiologi fungsi esofagus (menelan) The principal function of the digestive system is to prepare food for cellular utilization. This involves the following functional activities: Ingestionthe taking of food into the mouth Masticationchewing movements to pulverize food and mix it with saliva Deglutitionthe swallowing of food to move it from the mouth to the pharynx and into the esophagus Digestionthe mechanical and chemical breakdown of food material to prepare it for absorption Absorptionthe passage of molecules of food through the mucous membrane of the small intestine and into the blood or lymph for distribution to cells Peristalsisrhythmic, gastrointestinal tract Defecationthe discharge of indigestible wastes, called feces, from the gastrointestinal tract PHARYNX The funnel-shaped pharynx (far'ingks) is a muscular organ that contains a passageway approximately 13 cm (5 in.) long connecting the oral and nasal cavities to the esophagus and larynx. The pharynx has both digestive and respiratory functions. The supporting walls of the pharynx are composed of skeletal muscle, and the lumen is lined with a mucous membrane containing stratified squamous epithelium. The pharynx is divided into three regions: the nasopharynx, posterior to the nasal cavity; the oropharynx, posterior to the oral cavity; and the laryngopharynx, at the level of the larynx (see fig. 17.3). The external circular layer of pharyngeal muscles, called constrictors (fig. 18.13), compresses the lumen of the pharynx involuntarily during swallowing. The superior constrictor muscle attaches to bony processes of the skull and mandible and encircles the upper portion of the pharynx. The middle constrictor muscle arises from the hyoid bone and stylohyoid ligament and encircles the middle portion of the pharynx. The inferior constrictor muscle arises from the cartilages of the larynx and encircles the lower portion of the pharynx. During breathing, the lower portion of the inferior constrictor muscle is contracted, preventing air from entering the esophagus. The motor and most of the sensory innervation to the pharynx is via the pharyngeal plexus, situated chiefly on the middle constrictor muscle. It is formed by the pharyngeal branches of the glossopharyngeal and vagus nerves, together with a deep sympathetic branch from the superior cervical ganglion. The pharynx is served principally by ascending pharyngeal arteries, which branch from the external carotid arteries. The pharynx is also served by small branches from the inferior thyroid arteries, which arise from the thyrocervical trunk. Venous return is via the internal jugular veins. ESOPHAGUS The esophagus is that portion of the GI tract that connects the pharynx to the stomach (see figs. 18.1 and 18.15). It is a collapsible tubular organ, approximately 25 cm (10 in.) long, originating at the larynx and lying posterior to the trachea. 13 | G E H 1 wavelike intestinal contractions that move food through the

The esophagus is located within the mediastinum of the thorax and passes through the diaphragm just above the opening into the stomach. The opening through the diaphragm is called the esophageal hiatus (e -sof''a -je'al hi-a'tus) The esophagus is lined with a nonkeratinized stratified squamous epithelium (fig. 18.14); its walls contain either skeletal or smooth muscle, depending on the location. The upper third of the esophagus contains skeletal muscle; the middle third, a combination of skeletal and smooth muscle; and the terminal portion, smooth muscle only. The esophageal secretions are entirely mucous in character and principally provide lubrication for swallowing. The main body of the esophagus is lined with many simple mucous glands. At the gastric end and to a lesser extent in the initial portion of the esophagus, there are also many compound mucous glands. The mucus secreted by the compound glands in the upper esophagus prevents mucosal excoriation by newly entering food, whereas the compound glands located near the esophagogastric junction protect the esophageal wall from digestion by acidic gastric juices that often reux from the stomach back into the lower esophagus. Despite this protection, a peptic ulcer at times can still occur at the gastric end of the esophagus. The lower esophageal (gastroesophageal) sphincter is a slight thickening of the circular muscle fibers at the junction of the esophagus and the stomach. After food or fluid pass into the stomach, this sphincter constricts to prevent the stomach contents from regurgitating into the esophagus. There is a normal tendency for this to occur because the thoracic pressure is lower than the abdominal pressure as a result of the air-filled lungs. The lower esophageal sphincter is not a well-defined sphincter muscle comparable to others located elsewhere along the GI tract, and it does at times permit the acidic contents of the stomach to enter the esophagus. This can create a burning sensation commonly called heartburn, although the heart is not involved. In infants under a year of age, the lower esophageal sphincter may function erratically, causing them to spit up following meals. Certain mammals, such as rodents, have a true lower esophageal sphincter and cannot regurgitate, which is why poison grains are effective in killing mice and rats. Swallowing Mechanisms Swallowing, or deglutition (de''gloo-tish'un), is the complex mechanical and physiological act of moving food or fluid from the oral cavity to the stomach. For descriptive purposes, deglutition is divided into three stages. The first deglutitory stage is voluntary and follows mastication, if food is involved. During this stage, the mouth is closed and breathing is temporarily interrupted. A bolus is formed as the tongue is elevated against the transverse palatine folds (palatal rugae) of the hard palate (see fig. 18.5) through contraction of the mylohyoid and styloglossus muscles and the intrinsic muscles of the tongue. The second stage of deglutition is the passage of the bolus through the pharynx. The events of this stage are involuntary and are elicited by stimulation of sensory receptors located at the opening of the oropharynx. Pressure of the tongue against the transverse palatine folds seals off the nasopharynx from the oral cavity, creates a pressure, and forces the bolus into the oropharynx. The soft palate and pendulant palatine uvula are elevated to close the nasopharynx as the bolus passes. The hyoid bone and the larynx are also elevated. Elevation of the larynx against the epiglottis seals the glottis so that food or fluid is less likely to enter the trachea. Sequential 14 | G E H 1

contraction of the constrictor muscles of the pharynx moves the bolus through the pharynx to the esophagus. This stage is completed in just a second or less.

The third stage, the entry and passage of food through the esophagus, is also involuntary. The bolus is moved through the esophagus by peristalsis (fig. 18.15). In the case of fluids, the entire process of deglutition takes place in slightly more than a second; for a typical bolus, the time frame is 5 to 8 seconds. Functional Types of Movements in the Gastrointestinal Tract Two types of movements occur in the gastrointestinal tract: (1) propulsive movements, which cause food to move forward along the tract at an appropriate rate to accommodate digestion and absorption, and (2) mixing movements, which keep the intestinal contents thoroughly mixed at all times. Propulsive MovementsPeristalsis. The basic propulsive movement of the gastrointestinaltract is peristalsis, which is illustrated in Figure 625. A contractile ring appears around the gut and then moves forward; this is analogous to putting ones ngers around a thin distended tube, then constricting the ngers and sliding them forward along the tube. Any material in front of the contractile ring is moved forward. Peristalsis is an inherent property of many syncytial smooth muscle tubes; stimulation at any point in the gut can cause a contractile ring to appear in the circular muscle, and this ring then spreads along the gut tube. (Peristalsis also occurs in the bile ducts, glandular ducts, ureters, and many other smooth muscle tubes of the body.) The usual stimulus for intestinal peristalsis is distention of the gut. That is, if a large amount of food collects at any point in the gut, the stretching of the gut wall stimulates the enteric nervous system to contract the gut wall 2 to 3 centimeters behind this point, and a contractile ring appears that initiates a peristaltic movement. Other stimuli that can initiate peristalsis include chemical or physical irritation of the epithelial lining in the gut.Also, strong parasympathetic nervous signals to the gut will elicit strong peristalsis.

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Function of the Myenteric Plexus in Peristalsis . Peristalsis occurs only weakly or not at all in any portion of the gastrointestinal tract that has congenital absence of the myenteric plexus. Also, it is greatly depressed or completely blocked in the entire gut when a person is treated with atropine to paralyze the cholinergic nerve endings of the myenteric plexus. Therefore, effectual peristalsis requires an active myenteric plexus.

Directional Movement of Peristaltic Waves Toward the Anus . Peristalsis, theoretically, can occur in either direction from a stimulated point, but it normally dies out rapidly in the orad direction while continuing for a considerable distance toward the anus.The exact cause of this directional transmission of peristalsis has never been ascertained, although it probably results mainly from the fact that the myenteric plexus itself is polarized in the anal direction, which can be explained as follows. Peristaltic Reex and the Law of the Gut. When a segment of the intestinal tract is excited by distention and thereby initiates peristalsis, the contractile ring causing the peristalsis normally begins on the orad side of the distended segment and moves toward the distended segment, pushing the intestinal contents in the anal direction for 5 to 10 centimeters before dying out. At the same time, the gut sometimes relaxes several centimeters downstream toward the anus, which is called receptive relaxation, thus allowing the food to be propelled more easily anally than orad. This complex pattern does not occur in the absence of the myenteric plexus. Therefore, the complex is called the myenteric reex or the peristaltic reex.T he peristaltic reex plus the anal direction of movement of the peristalsis is called the law of the gut. Lesions of the esophagus run the gamut from highly lethal cancers to the merely annoying "heartburn" that has affected many a partaker of a large, spicy meal. Esophageal varices, the result of cirrhosis and portal hypertension, are of major importance, since their rupture is frequently followed by massive hematemesis (vomiting of blood) and even death by exsanguination. Esophagitis and hiatal hernias are far more frequent and rarely threaten life. Distressing to the physician is that all disorders of the esophagus tend to produce similar symptoms, namely heartburn, dysphagia, pain, and/or hematemesis.

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Heartburn (retrosternal burning pain) usually reflects regurgitation of gastric contents into the lower esophagus. Dysphagia (difficulty in swallowing) is encountered both with deranged esophageal motor function and with diseases that narrow or obstruct the lumen. Pain and hematemesis are sometimes evoked by esophageal disease, particularly by those lesions associated with inflammation or ulceration of the esophageal mucosa. The clinical diagnosis of esophageal disorders often requires specialized procedures such as esophagoscopy, radiographic barium studies, and manometry. LO 3. Alur diagnosis kasus gangguan fungsi esofagus (menelan). LO 4. Patofisiologi kasus gangguan fungsi esofagus (menelan). LO 5. Rencana penatalaksanaan (sesuai kompetensi) kasus gangguan fungsi esofagus (menelan) Cook IJ. Diagnostic evaluation of dysphagia. Nat Clin P Gastroenterol. 2008;5(7):393-403. World Gastroenterology Organisation Practice Guidelines : Dysphagia. 2007. American Society for Gastrointestinal Endoscopy, Management of ingested foreign bodies and food impactions, 2011 Monte C. Uyemura, M.D., Wray Rural Training Tract Family Medicine Residency Program, Wray, Colorado Foreign Body Ingestion In Children. Am Fam Physician 2005;72:287-91, 292.. 2005 American Academy of Family Physicians Jones, Betty Davis. Comprehensive Medical Terminology, Third Edition. Thomson Corporation. 2008. USA

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