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Plenary (Tue, 6 Sept 2016) : Problem 3-Gastrointestinal System
Plenary (Tue, 6 Sept 2016) : Problem 3-Gastrointestinal System
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STEP 1. UNFAMILIAR TERMS
1. Lethargic = keadaan yang capek, lesu
2. Coated tounge= lidah berselaput
3. Distended abdomen = buncit
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STEP 2. FORMULATE PROBLEMS
a) Anak perempuan: diare berlendir & berdarah
kram abdomen, mual, muntah, demam, penurunan nafsu makan (2
hari yang lalu)
pemeriksaan disik= letargi, febris, HR= 100 bpm (N), coated
tounge, distended abdomen
b) Anak laki-laki: diare cair, tanpa muntah & demam setelah minum
susu formula (1 bulan yang lalu)
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STEP 2. FORMULATE PROBLEMS
1. Apa hubungan makan telur setengah matang dan jajan sembarangan
dengan keluhan anak tersebut?
2. Apa yang menyebabkan lidah berselaput?
3. Apa hubungan pipa yang sedang direnovasi dengan gejala anak
tersebut?
4. Apa yang menyebabkan diare berlendir dan berdarah?
5. Apa yang menyebabkan distensi abdomen pada hasil pemeriksaan?
6. Kenapa diare disertai demam dan muntah?
7. Apa perbedaan diare berlendir dan berdarah dengan diare cair?
8. Apa bahaya diare cair dan diare berlendir berdarah bila dibiarkan?
9. Apa hubungan susu formula dengan diare cair?
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STEP 3. BRAINSTORMING
1. Jajan sembarangan kurang higienitas, telur setengah matang bakterinya tidak mati.
2. Terjadinya kolonisasi bakteri & jamur.
3. Kurangnya higienitas dan kualitas air karena terkontaminasi: bakteri ( E.coli 0157:H7, Shigella);
parasit lain (amoeba, STH: Ascaris lumbricoides, Trichuris trichiura, Strongyloides stercoralis, Oxyuris
vermicularis, Ancylostoma duodenale, Necator americanus).
4. Diare berdarah adanya luka terbuka; diare berlendir mukosa usus terkikis sel goblet
rusak=> etiologi :Shigella, Amoeba; diare cair air tidak terabsorpsi, tubuh mendeteksi ancaman
infeksi sehingga berupaya mengeluarkan cairan.
5. Perforasi akibat infeksi abdomen dikarenakan luka terbuka pada mukosa dibiarkan sehingga usus
menipis permukaannya distensi abdomen.
6. TNF-α hipotalamus (pusat pengatur suhu tubuh) demam (akibat inflamasi yang disebabkan
infeksi parasit, virus, bakteri, dan jamur)
7. sama dengan no. 4.
8. Diare cair jika dibiarkan dapat menyebabkan cairan tubuh yang dikeluarkan dehidrasi; diare
berlendir dan berdarah bila dibiarkan anemia.
9. Intoleransi laktosa, infeksi V.cholerae, infeksi Rotavirus
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STEP 4. MIND-MAPPING
Pencegahan + KIE
Klasifikasi patofisiologi
Mekanisme
defekasi
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STEP 5. LEARNING OBJECTIVES
1. Explain Anatomy of Lower GIT
2. Explain Histology of Lower GIT
3. Explain Biochemistry of Lower GIT
4. Explain Physiology of Lower GIT
5. Explain the definition and classification of diarrhea
6. Explain the etiology of diarrhea
7. Explain the pathophysiology of diarrhea
8. Explain the sign and symptoms of diarrhea
9. Explain the physical and supporting examination for diarrhea
10.Explain the pharmacological and non-pharmacological treatment for diarrhea
(+ PRESCRIPTION)
11.Explain the prevention and education for diarrhea
12.Explain the complication and prognosis of diarrhea
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LO 1. ANATOMY OF LOWER GIT
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Source: Moore KL. Clinically oriented anatomy. 5th Ed. 2005. pg 386-399
SMALL INTESTINE
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Source: Moore KL. Clinically oriented anatomy. 5th Ed. 2005. pg 386-399
ARTERIAL SUPPLY AND MESENTERIES OF INTESTINES
Source: Moore KL. Clinically oriented anatomy. 5th Ed. 2005. pg 386-399
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LARGE INTESTINE
Source: Moore KL. Clinically oriented anatomy. 5th Ed. 2005. pg 386-399 13
CECUM & APPENDIX
Cecum
-. Has no mesentery
-. Lies in the iliac fossa inferior
-. If distended with feces or gas palpable
-. Ileocolic artery
Appendix
-. Position: retrocecal
-. Has short triangular mesentery
mesoappendix
-. Appendicular artery
Source: Moore KL. Clinically oriented anatomy. 5th Ed. 2005. pg 386-399
ARTERIAL SUPPLY TO THE INTESTINES
Source: Moore KL. Clinically oriented anatomy. 5th Ed. 2005. pg 386-399 15
LO 2. HISTOLOGY OF LOWER GIT
ABSORPTIVE SURFACE OF SMALL INTESTINE
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Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
PANETH CELL
• located in the basal portion of the • produce two chemicals that thwart bacteria:
intestinal crypts below the stem cells 1. lysozyme, the bacterial-lysing enzyme
• are exocrine cells with large, also found in saliva; and
eosinophilic secretory granules in their 2. defensins, small proteins with
apical cytoplasm antimicrobial powers
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Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
GOBLET CELLS
• produce glycoprotein mucins that are
hydrated and cross-linked to form mucus,
whose main function is to protect and
lubricate the lining of the intestine.
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Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
Jejunum
Jejunum •This is very similar to the duodenum
except Brunner’s glands are absent
•Extensive villi are present as are
the crypts of crypts of Lieberkuhn
•The pilcae cicularis are permanent
folds in the intestinal mucosa
•There are 2 layers of smooth
muscle: longitudinal and circular
•Mucosa consists of simple columnar
epithelium with goblet cells.
Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
Ileum
Ileum
•This is very similar to the duodenum except Brunner’s glands are absent
•The villi are present as are the crypts of Lieberkuhn
•The 2 layers of smooth muscle (TM) and the submocusa (SM)
•Contains lymphatic nodules called Peyer’s patches that are found in the
mucosa
Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
WALL OF THE LARGE INTESTINE
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Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
Colon
Colon
Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
Appendix
Appendix
Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
The distal end of the GI tract is the anal canal, 3-4 cm long.
At the rectoanal junction the simple columnar mucosal lining of the
rectum is replaced by stratified squamous epithelium
37
Source: Sherwood L. Human physiology: From cells to systems. 8th Ed. 2013: pg.581-606
SPHINCTER
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Source: Sherwood L. Human physiology: From cells to systems. 8th Ed. 2013: pg.581-606
Absorption
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Source: Sherwood L. Human physiology: From cells to systems. 8th Ed. 2013: pg.581-606
LARGE INTESTINE: COLON
• Receives ± 500 ml of chyme from
the small intestine each day.
• feces
• Haustral contractions slowly
shuffle the contents in a back-and-
forth mixing movement largely
controlled by locally mediated
reflexes involving the intrinsic
plexuses.
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Source: Sherwood L. Human physiology: From cells to systems. 8th Ed. 2013: pg.581-606
DEFECATION REFLEX
• The gastroileal reflex moves the remaining
smallintestine contents into the large intestine,
• the gastrocolic reflex pushes the colonic contents
into the rectum, triggering the defecation reflex.
• Feces are eleminated by the defecation reflex.
* Criterion fulfilled for the last 3 months with symptom onset at least
6 months prior to diagnosis
TTP&HUS
Decreased of
Theraphy Begin to multipication Toxin production
floranormal
3. NEUROTOXIN
Pathogen Pathogenesis Found in Result
Staph. aureus Most common food borne, Meat or diary product Vomitting and diarrhea
grow in warm condition,
onset 2-6 hr
Baillus aureus Produce 2 type of toxin Cooked meat, poultry, Vomitting and diarrhea
vegetables, and dessert
Clostridium Perfringens Usually mild, self limiting Meats and gravies Diarrhea
after 24 hrs of diarrhea
NORWALK-VIRUS
Usually cause epidemics in school-aged children or
adults.
Infection usually comes from contaminated wateror food.
Clinical manifestations: (usually last several days)
Cramping abdominal pain
vomiting,and low-grade fever
Diagnosed by: stool viral culture.
VIRAL INFECTION
ROTAVIRUS
Most common cause of viral gastroenteritis.
Usually occurs between 3 months and 3yrs of age. Although most
common during wintermonths, it may occur year round.
Clinical manifestations:
Diarrhea
Fever and vomiting.
Blood is not usually found in stools
Usually lasts for few days and up to 1 wk.
SOURCE: MAYOCLINIC.ORG 79
Typhoid Fever
Definition and epidemiology etiology
• Typhoid fever is a life-threatening illness caused • Salmonella is part of the family of
by the bacteriumSalmonella Typhi. Enterobacteriaceae
• In the United States, it is estimated that
approximately 5,700 cases occur annually. Most • It comprises two species, Salmonella
cases (up to 75%) are acquired while traveling bongori and Salmonella enterica,
internationally. Typhoid fever is still common in • Common :Salmonella Typhi lives only in
the developing world, where it affects about
humans
21.5 million persons each year.
• Typhoid carriers
• Fecal-oral transmission route
http://www.cdc.gov/nczved/divisions/dfbmd/diseases/typhoid_fever/
Pathophysiology Typhoid Fever
enteric fever/typhoid fever occurs by ingestion multiply in the lumen small intestine
penetrate the small intestine mucosa From the submucosa, invading bacteria are taken
up by macrophages,and the organisms travel to mesenteric lymph nodes bloodstream via
the thoracic duct (primary bacteraemia) liver – gallbladder(cholecystitis) & spleen
(secondary bacteraemia)
http://www.nejm.org/doi/full/10.1056/NEJMra020201
http://www.mayoclinic.org/diseases-conditions/typhoid-fever/basics/definition/con-20028553
Typhoid Fever
• Prevention
– Vaccines
– Wash your hands
– Avoid drinking untreated water.
– Avoid raw fruits and vegetables.
– Choose hot foods.
• Prevent infecting others
– Avoid handling food.
– Wash your hands often.
– Take your antibiotics
http://idai.or.id/public-articles/klinik/imunisasi/melengkapi-
mengejar-imunisasi-bagian-i.html
http://www.mayoclinic.org/diseases-conditions/typhoid-fever/basics/definition/con-20028553
Typhoid Fever
Prognosis
• Early antibiotic therapy has transformed
a previously lifethreatening illness of
several weeks’ duration with a mortality
rate approaching 20% into a short-
lasting febrile illness with negligible
mortality.
• The high mortality rates which continue
to be reported from some endemic
countries are undoubtedly related to
delayed diagnosis and/or inappropriate
treatment.
http://www.aafp.org/afp/2009/1001/p692.html
CHARACTERISTIC OF STOOL EXAMINATION
Source: Eckstein L, Adams K, eds. Pocket Resource for Nutrition Assessment. Chicago, IL: Dietetics in Health Care Communities Dietetic Practice 105
Group, Academy of Nutrition and Dietetics; 2013.
NON- PHARMACOLOGIC TREATMENT
Oral Rehydration
Administration of 1-2 L dextrose 5% in 0.5 isotonic
sodium chloride solution with 50 mEq NaHCO3 and
10-20 mEq KCl over 30-45 minutes may be necessary
in patients who are severely dehydrated.
Rehydrate patients until mental status and signs of
perfusion and pulse are normal
For pediatric patients, administer 20 mL/kg of
isotonic sodium chloride solution initially for
resuscitation; Repeat as necessary and add KCl as
indicated
PAY ATTENTION TO SOME NUTRITION THAT CAUSES DIARRHEA
LO 11. PREVENTION FOR DIARRHEA
Preventing viral diarrhea
Wash frequently.
Use hand sanitizer when washing isn't possible.
http://www.mayoclinic.org/diseases-conditions/typhoid-fever/basics/prevention/con-20028553
LO 12. COMPLICATIONS FOR DIARRHEA
Loss of water and electrolytes Dehydration, hypokalemia,
metabolic acidosis, seizures, metabolic alkalosis
Impaired blood circulation hypovolemic shock
Hypoglycemia Disturbance nutrition, protein energy
malnutrition
Weight loss
Disturbance of renal function worsened diarrhea lead to
kidney failure
Death
LO 12. PROGNOSIS FOR DIARRHEA
CONCLUSION
We assume that the first patient (12-year-old girl) may have gastroenteritis as the main
reason of the symptoms acquired, such as abdominal cramp, nausea, vomiting, fever, feeling
irritable, and decrease in appetite for the past two days, also with one-day history of bloody,
mucousy diarrhea five times a day; while her brother ( 7-month-old boy), may have
intolerance to lactosa due to the change consumption type of milk that causes the osmotic
pathogenic mechanism resulted in the watery diarrhea.
MEDICAL PRESCRIPTION
R/ Ciprofloxacin 500 mg tab No. XIV
∫ 2 dd 1 p.c.
_______________________________§
R/ Paracetamol 500 mg tab No. XXI
∫ 3 dd 1 p.r.n. Panas >38⁰C
_______________________________§
Name : Patient X
Age : Adult (>18 y.o)
Diagnosis : Typhoid Fever
For children:
Contraindication to < 18 y.o.
PCT dosage=10 mg/kgBW/x
REFERENCES
Moore KL. Clinically oriented anatomy. 5th Ed. 2005. pg 386-399
Netter FH. Atlas of human anatomy. 6th ed. Philadelphia: Saunders Elsevier; 2014.
Eroschenko VP. Atlas histologi diFiore: dengan korelasi fungsional. Ed 11. Jakarta: EGC; 2008.
Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
Sherwood L. Human physiology: From cells to systems. 8th Ed. 2013: pg.581-606
Ahmed N.Clinical Biochemistry.2011: pg.481-491
Bates’ Guide to Physical examination and history taking
Harrison’s principles of internal medicine. 19th ed. Pg.1052
Jana B. Essentials of practice of medicine. New Delhi: B. Jain Publishers (P) Ltd.; 2002.
Wyllie R. The digestive system. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF. Nelson’s textbook of pediatrics. 18th ed. Philadelphia:
WB Saunders Co; 2007: 1521-645.
Managing acute gastroenteritis among children. CDC Morbidity and Mortality Weekly Report; 2003.
Manson's Tropical Infectious Diseases 23rd Ed
Pearson Education. 2013
http://www.mayoclinic.org/diseases-conditions/typhoid-fever/basics/prevention/con-20028553