PENYAKIT HATI DAN EMPEDU

PADA KASUS BEDAH

dr. Akhmad Makhmudi, SpB, SpBA

Sub Bagian Bedah Anak SMF Bedah RSUP Dr Sardjito/
Fakultas kedokteran UGM
 PENDAHULUAN

 PADA UMUMNYA KELAINAN – KELAINAN DIBAGI ATAS :

(1) RADANG/ INFEKSI, (2) CACAT BAWAAN / KONGENITAL
(3) NEOPLASMA (4) TRAUMA (5) DEGENERATIF

 PERKEMBANGAN TEKNOLOGI MUTAKHIR :

NUTRISI KLINIK - ENTERAL, PARENTERAL NUTRISI

 HUBUNGAN MORBIDITAS DAN MORTALITAS DENGAN

DIAGNOSIS DINI SERTA PENANGANAN SEGERA SECARA
BENAR DARI DOKTER, FARMASIS, PARAMEDIS, DIETETIS
 ANATOMI
GASTRO INTESTINALIS TRACT

Gastric outlet

Ampulla of Vater

Peyery patchs of lymphoid

GIT System
PRODUK EMPEDU
FUNGSI INTESTINAL
SEKRESI EMPEDU
SEKRESI EMPEDU
 GASTRIN Actions
 in general: stimulates gastric secretion &
motility
1. Stimulates gastric acid secretion
2. Stimulates pepsin&intrinsic factor secretion by the
stomach
3. Stimulates growth of gastric & intestinal mucosa (‘thropic
action’)
4. Increase the tone of musculature of the LOS,stomach &
small intestine
5. Stimulates insulin and glucagon secretion (after a protein
meal)
6. Stimulates calcitonin secretion
CCK-PZ Actions

1. Contraction of gall bladder ( cholecystokinin?)

2. Secretion of pancreatic juice rich in enzyme (
pancreaozymin?)]
3. Augments the actions of secretin in producing an alkaline
pancreatic juice
4. Increases the secretion of enterokinase from intestinal
mucosa
5. Exert trophic effect on the pancreas
6. Inhibit gastric emptying
7. May enhance the motility of the small intestine and colon
8. Along with secretin, it augments the contraction of pyloric
sphincter
9. Together with gastrin, stimulates glucagon secretion
SECRETIN Actions

1. Stimulates bicarbonate rich-watery alkaline

pancreatic juice by increasing bicarbonate secretion
of biliary tract
2. Increases bicarbonate secretion of biliary tract
3. Augments the action of CCK-PZ in producing
pancreatic secretion of digestive enzymes
4. Decreases gastric acid secretion
5. May cause contraction of the pyloric sphincter
6. Increases insulin secretion; but inhibits glucagon
secretion
FUNGSI EMPEDU
 SYMPTOMS AND SIGNS
GASTRO-INTESTINAL TRACT

 ABDOMINAL PAIN: Visceral-Somatic pain

 OBSTIPATIONS - CONSTIPATIONS
 DISTENSIONS
 VOMITING
 ABDOMINALSIGN:inspection, palpations,
auscultations, digital rectal examinations
FUNGSI EMPEDU
ABSORPSI LEMAK
ABSORPSI LEMAK
FUNGSI LEMAK
 PENYAKIT HATI
 KHOLESTASIS
(Obstruksi/ sumbatan saluran empedu)
tanda-tanda: - ikterik /kuning pada kulit/sclera
- feses dempul / putih akholik
(stercobilin negative)
- Urin seperti teh
( uribilinogen negative)
- Bilirubin direk meningkat
 KHOLANGITIS

 Infeksi duktus kholedokhus

karena sumbatan tumor/batu
tanda-tanda:
- Febris/demam
- ikteric/kuning pada kulit dan sclera
- Bilirubin direk meningkat
 KHOLESISITITIS

 Sumbatan dan infeksi pada kandung

empedu (vesiks felea) karena batu tumor
tanda-tanda:
- Febris/demam
- Nyeri tekan perut kanan atas
(Murphy Sign)
- - Bilirubin direk meningkat
BILIARY ATRESIA
 EXTRAHEPATIC BILIARY ATRESIA
: ICTERIC > 2 WEEKS
TIMING OPERATION: 2 MONTH OLD
Tx: KASAI PROCEDURE
( PORTOENTEROSTOMY

KLASIFIKASI ATRESIA BILIARIS

BERDASARKAN VARIASI ANATOMI SISA DUKTUS BILIARIS
EKSTRAHEPATIS (KASAI&PERANCIS):
TIPE 1 (3%): ATRESIA TERBATAS HANYA DI DUKTUS
KHOLEDOKUS
TIPE 2 (6%): TERDAPAT KISTE PADA HILUS HEPAR DAN
BERHUBUNGAN DG PERCABANGAN DUKTUS BILIARIS
INTRAHEPATIS
TIPE 3 (19%): VESIKA FELEA, DUKTUS SISTIKUS DAN DUKTUS
KHOLEDOKUS PATEN/NORMAL
TIPE IV (72%): SELURUH DUKTUS BILIARIS EKSTRAHEPATIS
ATRESIA
ANOREXIA PADA CANCER
CANCER HATI
 Parenteral Nutrition
 Peripheral (PPN)
 Short term parenteral
support (up to 2 weeks)
 Hypertonic solutions (< 900
mOsm/L) may cause phlebitis;
thus must limit PPN solution’s
osmolarity
 Energy and protein provided
by PPN are limited because
dextrose and amino acids
contribute significantly to
osmolarity
 Electrolytes also contribute
to osmolarity
 Central or Total (TPN)
 For long term use,
catheters are surgically
placed
 May have surgically
implanted catheters
which lie beneath the skin
and are accessed by
special needle to
decrease risk of infection
 Can add solution of higher
osmolarity into central
vein (larger lumen)
 When children need tube feeding
& how to choose route of
delivery ?
 Children with acute conditions  Nasogastric (NG) and
and increased requirements. Orogastric (OG) - usually for
E.g. Burns Severe trauma, short term (< 3 months)
Major surgery and Sepsis.
 Gastrostomy (Surgical or
 Children unable to eat due to Percutaneous Endoscopic
mental/physical disability. E.g. Gastrostomy)- for long term
mental retardation, Cerebral
palsy and congenital anomalies.
 Transpyloric Feedings
those who are at high risk for
Children with chronic illnesses


aspiration;
who require long term in pancreatitis patients best
nutritional support. E.g. Cancer, 
to feed nasojejunally beyond
Inflammatory bowel disease, the ligament of Treitz
Cystic fibrosis and congenital
heart disease.
 KOMPLIKASI PARENTERAL
NUTRISI
 HIPERGLIKEMI
 HIPOGLIKEMI
 UREMI PRERENAL
 GANGGUAN FUNGSI HATI
 GANGGUAN CAIRAN&ELECTROLIT
 DEFISIENSI TRACE ELEMEN/VITAMIN
 HIPERCAPNI : CO2 >
 Ileus
illustrations

Vasa:
lymph,venous,artery

Normal
Ileus

Complications:
I.Third space syndrome
(Venous Obstruction)
Dehydrations – mild (5%deficit)
- moderate (10%) Tx/ Fluid resucitations
- severe (15%)
II.Abdomen compartment syndrome Tx/Naso Gastirc Tube(NGT), rectal tube
(distended abdomen- venous return disrturb) Decompressions operative
III.Sepsis
(fecal retentions-bactreial overgrowth-mucous Tx/ Antibiotic Drugs
barrier damage)
Gangguan Cairan, Elektrolit dan
Asam-Basa Perioperatif
 Preoperatif
 Puasa terlalu lama
 Kehilangan cairan/elektrolit
 Asam-basa (Asidosis/alkalosis metabolik)
 Durante operatif
 Kehilangan cairan/elektrolit
 Asam-basa (Respiratorik & Metabolik)
 Postoperatif
 Kehilangan cairan (NGT,drain)
 Iatrogenik
 TIGA STABILITAS :

 CAIRAN DAN ELEKTROLIT

 ASAM – BASA
 SUHU
Dehidrasi
 Kekurangan cairan akibat puasa
 Kebutuhan cairan perjam x lama puasa
 Rehidrasi
 Tanda syok (atasi syok segera)
 Sisa cairan rehidrasi diberikan
 Isotonik : cepat (<8 jam)
 Hipertonik : lambat (48 jam)
 Kalium diberikan bila perfusi ginjal baik
Dehidrasi
 Derajat dehidrasi
 Ringan 5%
 Sedang 10%
 Berat 15%
 Jenis dehidrasi
 Isotonik (Na 130 – 150 mEq/L)
 Hipotonik (Na <130 mEq/L0
 Hipertonik (Na >150mEq/L)
 Tabel : Sign and symptoms of dehydration
Assessment Mild (5%) Moderate (10%) Severe( 15%)
Vital sign
Heart rate Normal Increased Tachycardia>130/min
Respiratory rate Normal Increased tachypnea
Blood pressure Normal Normal Hypotensive systolic <80
Capillary refill Normal 2 – 3 second >3 seconds
Mental Status Alert Irritable Lethargic
Skin
Color Pale Ashen Mottled
Turgor Normal Poor Tenting
Temperature Warm Cool Cool,clammy
Texture Normal Dry Doughy
Fontanelle Flat Depressed Sunken
Mucous membrane Dry Very dry Parched
± tears no tears
Eyes Normal Darkened Sunken
sunken Soft
Thirst Increased Intense Intense if conscious
Urine Output Normal Decreased Minimal
(N:1-2ml/kgbb/jam) concentrated very concentrated
NUTRISI ENTERAL
NUTRISI PARENTERAL
TERAPI NUTRISI PARENTERAL
 EBB PHASE :-HIPOVOLEMIA
- CAIRAN RESUSITASI RL/ ASERING
 FLOW PHASE : NORMOVOLEMIA
CAIRAN NUTRISI:
 KH : D5, D10
 PROTEIN : ASAM AMINO 2,5%, 5%,10%
 LEMAK : LIPID 20%
 ELEKTROLIT: KAEN I B, 3A, 3B
 MINERAL
 DASAR PEMBERIAN NUTRISI
PARENTERAL

 IMBANG PROTEIN POSITIP

 PERHITUNGAN ENERGI:
RUMUS HARRIS BENEDICT: (kcal/hari)
BEE Pria =66,5+13,8xBB(kg)+T(cm)-6,8xU(th)
BEEWanita=65.5+9,5xBB(kg)+1.8xT(cm)-4,7xU(th)
 MALNUTRISI : AEE = 1,2 X BEE
 STRESS FAKTOR : PUASA = 0,85-1.00
AEE = BEE X STRESS FAKTOR X1,25

BEE=Basic Energy Expenditure

AEE=Actual Energy Expenditure
PROGRAM CAIRAN-TERAPI
PARENTERAL
( 6 JAM )

 JUMLAH CAIRAN
 JENIS CAIRAN
 CARA PEMBERIAN CAIRAN
 EVALUASI-MONITORING
 JUMLAH CAIRAN:

1. Defisit cairan / dehidrasi

a. Dehidrasi Ringan : 5% ( 50ml/kgbb x TBW )
b . Dehidrasi Sedang : 10% (100ml/kgbb x TBW )
c. Dehidrasi Berat : 15% (150ml/kbbb x TBW )
* Tonisitas darah:Hipotonis,isotonis,hipertonis
2. Maintenance
Neonatus: 24 jam post operatif dikurangi 30%
3. Perkiraan cairan hilang dalam 24 jam
( on going loss )

2&3 modification to Fluid intake ( see table )

TOTAL BODY WATER ( ASHCRAFT )

UMUR %

Gestasional – 12 minggu 94
12 minggu – 32 minggu 80
Aterm
3-5 hari 78
-3 – 5
Neonatus 75 - 80
Children 65 - 75
Young Man 60
Young Woman 50
Over 60 years man 50
Over 60 years women 45
 MAINTENANCE ( ASHCRAFT )

* Daily Fluid Requirements

Weight Volume

Premature (< 2kg ) 150 ml / kg

Neonatus & infant (2-10 kg ) 100ml/kg for first 10kg
Infant & children (10-20kg ) 1000ml+50ml/kg over 10 kg
Children ( > 20 kg ) 1500ml+20ml/kg over 20 kg
Maintenance therapy
 Jumlah cairan menurut Holliday – Segar
 100/50/20 ml/Kg/hari atau
 4/2/1 ml/kg/jam
 Elektrolit
 Na : 3 – 4 mEq/kg/hari
 K : 2 – 3 mEq/kg/hari
 Cl : 3 – 4 mEq/kg/hari
TABLE : MODIFICATION TO FLUID INTAKE

Decrease Adjustment

Humidified Inspired air X 0.75

Basal state (eg pa ralysed ) X 0.7
High ADH (IPPV,brain injury ) X 0.7
Hypothermia - 12 % per C
High room humidity x 0.7
Renal failure x 0.3 (+urine output )
 Increase
Full activity + oral feeds X 1.5
Fever + 12 % per C
Room temperature > 31 C + 30 % per C
Hyperventilation X 1.2
Neonate - preterm (1-1.5 kg ) X 1.2
- radiant heater X 1.5
- photo terapy X 1.5
Burn - first day + 4% per 1%
area burn
- Subsequently + 2% per 1%
area burn
ADH : antidiuretic hormone
IPPH : intermittent positive pressure ventilation

INSENSIBLE WATER LOSS

Umur Neonatus /kgbb/hr Umr /kgbb/hr

Udara bebas tanpa kelembaban 28 cc Bayi 50-60 cc
Humidified isolette 14 cc Anak 40 cc
Pemanasan 40 - 45 cc Remaja 30 cc
STANDART PAEDIATRIC

MAINTENANCE SOLUTION

UMUR LAR.KRISTALOID
1-2 hari D10% ( tak boleh elektrolit )
3-7 hari D5% NaCl 0,18 % *
< 1 th D5% NaCl 0,225 % *
< 10 th D5% NaCl 0,45 % *
* Tambahkan Maintenance KCl 7,5 %
 KASUS :
 PASIEN ANAK USIA 1 tahun(BB 10 KG) DENGAN ILEUS
DISERTAI DEHIDRASI BERAT DAN FEBRIS SUHU 400C,
ASIDOSIS METABOLIK DAN ANEMIA. HASIL LAB.HB 8G%,
ALBUMIN 2 G/DL, K+ 2 MEQ/L, NA+ 160 MEQ/L,
TROMBOSIT 50000 MM2/DL.( TBW 70%, t normal 36,5C)

TERANGKAN PENATALAKSANAAN LENGKAP dalam 6 jam?

 JUMLAH CAIRAN
1. MAINTENANCE = 1000ML:4= 250ML
2. KOREKSI DEHIDRASI =150X10X70% = 1050 ML
3. KOREKSI SUHU ( SUHU NORMAL 36,5OC)
= 3,5X12%X1000ML = 420 ML
4. TOTAL FLUIDS REQUIREMENT= 1720 ML/6 JAM
= 1720/360 = 4,8 ml/menit
= 96 drops/menit

INFUS MAKRO = 20 drops/cc

INFUS MIKRO = 60 drops/cc