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patofisiologiGIT tractBy okatiranti
What is Liver Cirrhosis?Diffuse fibrosis of the liver with nodule formationAbnormal response of the liver to any chronic injury
Causes of Cirrhosis1. Chronic viral hepatitis2. Metabolic: hemochromatosis, Wilson dis,
alfa-1-antitrypsin, NASH3. Prolonged cholestasis (primary biliary
cirrhosis, primary sclerosing cholangitis)4. Autoimmune diseases (autoimmune
hepatitis)5. Drugs and toxins6. Alcohol
Anatomy of the portal venous system
The Effect of The Liver Nodule
Mechanism of Portal HTN
Cirrhosis
Resistance portal flow
MechanicalNodules
DynamicNitric oxide
Complications of Portal Hypertension
1. Varices
Collaterals
VaricesEsophagusGastricColo-rectalPortal hypertensive gastropathy
Variceal Banding
Types of Shunts
TIPS (Transjugular intrahepatic portosystemic shunt)
Surgical shunt
VaricesPrevention
Treat underlying diseaseEndoscopic banding protocolB-blockersShunt surgery (only if no cirrhosis)Liver transplantation
2. Ascites
Ascites
Definition: fluid in the peritonial cavity
Mechanism of Ascites
Causes of Ascites1. Liver disease: cirrhosis2. Right sided heart failure3. Kidney disease (nephrotic syndrome)4. Low albumin (malnutrition, bowel loss)5. Peritonial infection (TB…)6. Peritonial cancer
PresentationHistory:
Increased abdominal girthIncreased wt
Physical exam:Bulging flanksShifting dullnessFluid wave
DiagnosisPhysical examinationUltrasoundAscitic tap
WBC (>250 PMN: SBP)RBCSAAG (serum albumin to ascitic fluid
albumin gradient)>11 mg/dl : portal hypertension<11 mg/dl : Other
Portal hypertension
or heart failure
Peritonial disease
or kidney disease
Treatment-GeneralTreat the underlying diseaseSalt restriction (<2gm/d)Diuretics
Loop diuretic (Lasix)Aldosterone inhibitor (Spironolactone)
Treatment-ResistantRecurrent tappingPeritoneal-venous shuntTIPS Liver transplantation
Spontaneous Bacterial Peritonitis
Infection of ascitic fluidUsually gram negative (E.Coli)Presentation variableMortality is highDx: ascitic tap = PMN>250Treatment : third generation cephalosporin IV
3. Hepatic Encephalopathy
Hepatic Encephalopathy
Reversible decrease in neurological function secondary to liver diseaseAcute: seen with acute liver failureAcute on chronic: established cirrhosis
Hepatic EncephalopathyMechanism
Hepatic EncephalopathyClinical features
Reversal of sleep patternDisturbed consciousnessPersonality changesIntellectual deteriorationFetor hepaticusAstrexisFluctuating
Flapping Tremor
Drawing Tests
Hepatic EncephalopathyDiagnosis
Clinical (most important)The drawing testsEEG CT/MRI may show cerebral atrophy
Hepatic EncephalopathyExacerbating factors
Hepatic EncephalopathyTreatment
Identify and treat precipitation factorTreat underlying liver diseaseNormal protein dietAntibiotics (Neomycin, metronidazole)LactoloseTransplantation
4. Hepatorenal Syndrome
Hepatorenal SyndromeProgressive renal failureType 1 : rapidly progressive, high mortalityType 2: slower progressionR/O volume depletion secondary to diureticsIV vasoconstrictorsLiver transplantation
Summary1. Mechanical compression of blood flow
plus hemodynamic changes leads to portal hypertension
2. Common complications of portal hypertension are:
Collateral formation (Varices)AscitesHepatic encephalopathy
Summary3. The most important step in variceal bleed
management is resuscitation
4. The most important step in management of hepatic encephalopathy is the identification of the precipitating factor
– Hipokalsemia
PANKREATITIS AKUT
PENDAHULUANThe pancreas is a large gland behind the stomach and close to the duodenum. The duodenum is the upper part of the small intestine. The pancreas secretes digestive enzymes (TRYPSIN, AMYLASE, LIPASE) into the small intestine through a tube called the pancreatic duct. These enzymes help digest fats, proteins, and carbohydrates in food. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones help the body use the glucose it takes from food for energy.
LANJUTAN…
Normally, digestive enzymes do not become active until they reach the small intestine, where they begin digesting food. But if these enzymes become active inside the pancreas, they start "digesting" the pancreas itself.
PANKREATITIS AKUT
Pankreatitis akut adalah reaksiperadangan pankreas yang secara klinisditandai dengan nyeri perut yang akutdisertai kenaikan enzim pankreas dalamdarah dan urinPada pankreatitis akut, didapatiautodigesti dari enzim pankreas terhadapsel pankreas sehingga menimbulkanreaksi inflamasi
LANJUTAN…
Inflamasi dimulai dari perilobuler danjaringan peripankreas dengan manifestasiedema dan nekrosis setempatSetelah itu, mengenai sel asiner perifer, duktus pankreatikus, pembuluh darah, danjaringan sekitarnya
What are the causes of acute pancreatitis?
Acute pancreatitis is usually caused by gallstones or by drinking too much alcohol, but these aren't the only causes. If alcohol use and gallstones are ruled out, other possible causes of pancreatitis should be carefully examined so that appropriate treatment—if available—can begin.
What are the symptoms of acute pancreatitis?
Acute pancreatitis usually begins with pain in the upper abdomen that may last for a few days. The pain may be severe and may become constant—just in the abdomen—or it may reach to the back and other areas Other symptoms may include – swollen and tender abdomen – nausea– vomiting – fever – rapid pulse
How is acute pancreatitis diagnosed?
Besides asking about a person's medical history and doing a physical exam, a doctor will order a blood test to diagnose acute pancreatitis. During acute attacks, the blood contains at least three times more amylase and lipase than usual. Amylase and lipase are digestive enzymes formed in the pancreas. Changes may also occur in blood levels of glucose, calcium, magnesium, sodium, potassium, and bicarbonate. After the pancreas improves, these levels usually return to normal.
LANJUTAN…
A doctor may also order an abdominal ultrasound to look for gallstones and a CAT (computerized axial tomography) scan to look for inflammation or destruction of the pancreas
How is acute pancreatitis treated?
Treatment depends on the severity of the attack. If no kidney or lung complications occur, acute pancreatitis usually improves on its own. Treatment, in general, is designed to support vital bodily functions and prevent complications. A hospital stay will be necessary so that fluids can be replaced intravenously.
LANJUTAN...
If pancreatic pseudocysts occur and are considered large enough to interfere with the pancreas's healing, your doctor may drain or surgically remove them. Unless the pancreatic duct or bile duct is blocked by gallstones, an acute attack usually lasts only a few days. In severe cases, a person may require intravenous feeding for 3 to 6 weeks while the pancreas slowly heals. This process is called total parenteralnutrition
LANJUTAN…Secara klinis, penderita pankreatitis akutdapat beragam, dari yang mudah sembuh(self limiting) sampai yang dapatmenimbulkan gejala-gejala berat dankematian. Untuk itu, diperlukan identifikasipasien yang mempunyai risiko untukkematian berupa penilaian berat atautidaknya penyakit yang diderita
KOMPLIKASI
Komplikasi lokal, berupa: – Pengumpulan cairan yang akut. Hal ini paling
sering terjadi, biasanya terjadi pada awalperjalanan penyakit, dan dapat membaik secaraspontan;
– Nekrosis dari pankreas. Dapat terjadi lokal ataudifus, bisa juga steril dan terinfeksi;
– Abses pankreas. Hal ini merupakan komplikasilokal yang jarang terjadi; serta
– Yang lain, seperti pendarahan, trombosis vena splenikus, nekrosis, dan impaksi batu.
LANJUTAN…
Komplikasi sistemik, berupa: – Syok sirkulasi; – Gagal napas; – Gagal ginjal akut; – Sepsis; – KID (Koagulopati Intravaskular Diseminata); – Hiperglikemia; dan