obat anti ulcus-21

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FARMAKOTERAPI GANGGUAN / FARMAKOTERAPI GANGGUAN / PENYAKIT PENYAKIT GASTROINTESTINAL GASTROINTESTINAL : : OBAT ANTI ULCUS OBAT ANTI ULCUS Oleh Oleh Wiwik Kusumawati Wiwik Kusumawati

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Page 1: Obat Anti Ulcus-21

FARMAKOTERAPI GANGGUAN FARMAKOTERAPI GANGGUAN / PENYAKIT / PENYAKIT GASTROINTESTINALGASTROINTESTINAL: : OBAT ANTI ULCUSOBAT ANTI ULCUS

OlehOleh

Wiwik KusumawatiWiwik Kusumawati

Page 2: Obat Anti Ulcus-21

Apakah penyakit atau gangguan Apakah penyakit atau gangguan pada saluran cerna ?pada saluran cerna ?

Apa obatnya (farmakoterapi) untuk Apa obatnya (farmakoterapi) untuk penyakit atau gangguan tersebut ?penyakit atau gangguan tersebut ?

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TujuanTujuanPada akhir pembelajaran mahasiswa Pada akhir pembelajaran mahasiswa

akan dapatakan dapat : :

1.1. MenjelaskanMenjelaskan prinsip farmakoterapi prinsip farmakoterapi penyakit ulkus peptik penyakit ulkus peptik

2.2. MenyebutkanMenyebutkan penggolongan penggolongan obat obat antiulkus antiulkus

3.3. Menjelaskan Menjelaskan mekanisme aksimekanisme aksi obat obat antiulkus antiulkus

4.4. MenjelaskanMenjelaskan efek samping efek samping obat antiulkus obat antiulkus

5.5. MenentukanMenentukan pemilihan obat pemilihan obat anti ulkus anti ulkus yang tepat pada px dg ulkus peptikum yang tepat pada px dg ulkus peptikum

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CASECASE

A 62 years old man who present to the A 62 years old man who present to the emergency department on Sunday evening emergency department on Sunday evening complaining of intermittent burning epigastric complaining of intermittent burning epigastric pain for more than 2 months. His pain is not pain for more than 2 months. His pain is not radiating and occurs to the right of his radiating and occurs to the right of his epigastrium. This pain change in intensity and is epigastrium. This pain change in intensity and is worse with meals. He also has noticed worse with meals. He also has noticed intermittent belching, being bloated, being weak intermittent belching, being bloated, being weak when walking, and complains of nausea after when walking, and complains of nausea after eating. Since last Friday, he has been having eating. Since last Friday, he has been having black, tarry bowel movements. He does not black, tarry bowel movements. He does not have any history of PUD or GI bleeding and has have any history of PUD or GI bleeding and has not experienced anorexia or vomiting.not experienced anorexia or vomiting.

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PendahuluanPendahuluan

Pemberian obat Per Oral (PO)Pemberian obat Per Oral (PO) Efek samping obat PO :Efek samping obat PO :

• Erosi lambung/gastriris (40-50 %)Erosi lambung/gastriris (40-50 %)• Ulkus (10-25 %)Ulkus (10-25 %)• DiareDiare

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Ulkus peptikumUlkus peptikum

Penyakit dengan dampak Penyakit dengan dampak kerusakan pada mukosa sampai kerusakan pada mukosa sampai tunika muskularis saluran cernatunika muskularis saluran cerna

Ulkus duodenum (duodenal ulcer)Ulkus duodenum (duodenal ulcer) Ulkus lambung (gastric ulcer)Ulkus lambung (gastric ulcer)

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Etiologi ulkus peptikumEtiologi ulkus peptikum

Infeksi helicobacter pylori (80 % - Infeksi helicobacter pylori (80 % - 95 %)95 %)

Ketidakseimbangan faktor agresif Ketidakseimbangan faktor agresif (ulserogenik) dan faktor defensif (ulserogenik) dan faktor defensif (protektif)(protektif)

Efek samping NSAIDsEfek samping NSAIDs

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Al-Baqarqh (168) & Al-Al-Baqarqh (168) & Al-A`Raf (160)A`Raf (160)

Hai manusia makanlah apa-apa Hai manusia makanlah apa-apa yang ada di bumi yang halal lagi yang ada di bumi yang halal lagi baik.baik.

…………………………..makanlah yang baik-..makanlah yang baik-baik, di antara rizki yang Kami baik, di antara rizki yang Kami anugerahkan kapadamu.anugerahkan kapadamu.

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Obat anti ulkusObat anti ulkus

Antacid dan antisekretoriAntacid dan antisekretori Obat sitoprotektifObat sitoprotektif KombinasiKombinasi

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AntacidAntacid

Bufer mukosaBufer mukosa Menurunkan PH lambung dengan Menurunkan PH lambung dengan

menetralisir asam lambungmenetralisir asam lambung Efek samping diareEfek samping diare Aluminium hidroksida dan Aluminium hidroksida dan

magnesium karbonat (efektif untuk magnesium karbonat (efektif untuk ulkus duodenum)ulkus duodenum)

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AntisekretoriAntisekretori

Antagonis reseptor H2 (cimetidin, Antagonis reseptor H2 (cimetidin, ranitidin, famotidin, dll)ranitidin, famotidin, dll)

Antagonis reseptor muskarinik/M1 Antagonis reseptor muskarinik/M1 (piranzepin)(piranzepin)

Inhibitor pompa proton Inhibitor pompa proton (omeprazole)(omeprazole)

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Antagonis reseptor H2Antagonis reseptor H2

Efektif menghambat sekresi asam Efektif menghambat sekresi asam lambung karena histamin, lambung karena histamin, makanan, pentagastrin, insulin, dllmakanan, pentagastrin, insulin, dll

Efektif untuk ulkus lambung Efektif untuk ulkus lambung maupun duodenum (ranitidin)maupun duodenum (ranitidin)

PO atau IVPO atau IV Ikatan dengan sitokrom P450Ikatan dengan sitokrom P450

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CIMETIDINCIMETIDIN efektif untuk efektif untuk

terapi ulkus terapi ulkus lambung dan lambung dan duodenumduodenum

efek samping: efek samping: pusing, mual, pusing, mual, muntah, muntah, kemerahan.kemerahan.

Impotensi, Impotensi, gynecomasti gynecomasti

RANITIDINRANITIDIN inhibitor poten inhibitor poten

sekresi asam sekresi asam lambunglambung

lebih aktif 5-8xlebih aktif 5-8x durasi lebih lamadurasi lebih lama ikatan sitokromP450 ikatan sitokromP450

kurangkurang reseptor androgenik reseptor androgenik

kurangkurang efektif profilaksis efektif profilaksis

u.duodenum u.duodenum (NSAIDs)(NSAIDs)

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Dosis :Dosis :• Cimetidin 400 mg 2x/hari atau 800 Cimetidin 400 mg 2x/hari atau 800

mg/malammg/malam• Ranitidin 150 mg 2x/hari atau 300 Ranitidin 150 mg 2x/hari atau 300

mg/malammg/malam Lama terapi 4-8 mingguLama terapi 4-8 minggu

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PiranzepinPiranzepin

Antagonis reseptor M1 (efek Antagonis reseptor M1 (efek samping)samping)

Efektif untuk terapi dan preventif Efektif untuk terapi dan preventif ulkus duodenum rekurenulkus duodenum rekuren

Kurang dapat diterima Kurang dapat diterima dibandingkan H2 antagonisdibandingkan H2 antagonis

Dosis 50 mg 2x/hari atau 100 Dosis 50 mg 2x/hari atau 100 mg /malam (4-6 minggu)mg /malam (4-6 minggu)

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OmeprazoleOmeprazole

Inhibitor pompa protonInhibitor pompa proton Menghambat enzim H+/ K+ ATPaseMenghambat enzim H+/ K+ ATPase Potensi lebih besar dibandingkan Potensi lebih besar dibandingkan

H2 antagonis (respon 2 minggu = 4 H2 antagonis (respon 2 minggu = 4 minggu H2 antagonis)minggu H2 antagonis)

Penyembuhan ulkus duodenum Penyembuhan ulkus duodenum lebih cepatlebih cepat

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Monoterapi dapat menekan H pyloriMonoterapi dapat menekan H pylori Kombinasi dengan antibiotik dapat Kombinasi dengan antibiotik dapat

untuk eradikasi H pyloriuntuk eradikasi H pylori Efek samping diare, headache, Efek samping diare, headache,

nausea, dllnausea, dll Dosis 20-40 mg / pagi (2-8 minggu)Dosis 20-40 mg / pagi (2-8 minggu)

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Obat sitoprotektifObat sitoprotektif

Prostaglandin analog Prostaglandin analog (misoprostole)(misoprostole)

SukralfatSukralfat Senyawa bismuthSenyawa bismuth

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MisoprostoleMisoprostole

Analog prostaglandinAnalog prostaglandin Efektivitas sebanding dengan H2 Efektivitas sebanding dengan H2

antagonisantagonis Efek sitoprotektif pada dosis rendahEfek sitoprotektif pada dosis rendah Efek samping kolik, nausea, diare, Efek samping kolik, nausea, diare,

dispepsia, headache, perdarahan uterusdispepsia, headache, perdarahan uterus Kontra indikasi ibu hamilKontra indikasi ibu hamil Dosis 200 mikrogram 4x/hari (4-8 Dosis 200 mikrogram 4x/hari (4-8

minggu)minggu)

Page 20: Obat Anti Ulcus-21

Parietal cell

H+

Lumen stomach

HistamineParacrine cell

G-cells

Vagus

K+

H+

K+

Mucus

M1

G

H2

cAMP

ATP

Cl- Cl-

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Eradikasi Infeksi H pyloriEradikasi Infeksi H pylori

* Bismuth * Bismuth chelatechelate

* Amoxycillin* Amoxycillin•MetronidazoleMetronidazole•70-80 %70-80 %•2 minggu2 minggu

OmeprazoleOmeprazole ClarithromycinClarithromycin MetronidazoleMetronidazole 95-100 %95-100 % 1 minggu1 minggu

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Eradikasi Infeksi H pylori Eradikasi Infeksi H pylori (revisi, Neal, 2005)(revisi, Neal, 2005)

OmeprazoleOmeprazole ClarithromycinClarithromycin Amoxicillin Amoxicillin Kesembuhan pd 90 % pxKesembuhan pd 90 % px 1 minggu1 minggu

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An Aspirin Tablet and a Gastric An Aspirin Tablet and a Gastric Ulcer, 2000Ulcer, 2000

A 76-year-old woman had iron-deficiency anemia, a A 76-year-old woman had iron-deficiency anemia, a hematocrit of 24 percent, and a positive test for hematocrit of 24 percent, and a positive test for occult blood in stool. For several years, she had been occult blood in stool. For several years, she had been taking 400 mg of etodolac twice a day for rheumatoid taking 400 mg of etodolac twice a day for rheumatoid arthritis; one tablet of enteric-coated, regular-arthritis; one tablet of enteric-coated, regular-strength aspirin a day; and 1 mg of warfarin sodium a strength aspirin a day; and 1 mg of warfarin sodium a day for severe peripheral vascular disease. Her day for severe peripheral vascular disease. Her international normalized ratio was 1.15. After international normalized ratio was 1.15. After receiving a transfusion, she underwent upper receiving a transfusion, she underwent upper gastrointestinal endoscopy, which revealed an gastrointestinal endoscopy, which revealed an aspirin tablet, with the enteric coating still intact, aspirin tablet, with the enteric coating still intact, within an ulcer of the gastric antrum. The tablet was within an ulcer of the gastric antrum. The tablet was removed with a forceps. Treatment with etodolac and removed with a forceps. Treatment with etodolac and aspirin was stopped, and the patient was given 30 mg aspirin was stopped, and the patient was given 30 mg of lansoprazole twice a day. Two months later, a of lansoprazole twice a day. Two months later, a second endoscopic examination showed complete second endoscopic examination showed complete healing of the ulcer. healing of the ulcer.

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A Comparison of Omeprazole with A Comparison of Omeprazole with Ranitidine for Ranitidine for UlcerUlcers Associated with s Associated with Nonsteroidal Antiinflammatory Drugs,1998Nonsteroidal Antiinflammatory Drugs,1998 BackgroundBackground Suppressing acid secretion is thought to reduce Suppressing acid secretion is thought to reduce

thethe risk of risk of ulcerulcers associated with regular use of nonsteroidal s associated with regular use of nonsteroidal antiinflammatoryantiinflammatory drugs (NSAIDs), but the best means of drugs (NSAIDs), but the best means of accomplishing this isaccomplishing this is uncertain.uncertain.

MethodsMethods We studied 541 patients who required continuous We studied 541 patients who required continuous treatmenttreatment with NSAIDs and who had with NSAIDs and who had ulcerulcers or more than 10 s or more than 10 erosions in eithererosions in either the stomach or duodenum. Patients were the stomach or duodenum. Patients were randomly assigned torandomly assigned to double-blind treatment with double-blind treatment with omeprazole, 20 mg or 40 mg orallyomeprazole, 20 mg or 40 mg orally per day, or ranitidine, per day, or ranitidine, 150 mg orally twice a day, for four150 mg orally twice a day, for four or eight weeks, depending or eight weeks, depending on when treatment was successful (definedon when treatment was successful (defined as the resolution as the resolution of of ulcerulcer and the presence of fewer than five and the presence of fewer than five erosions in the erosions in the stomach and fewer than five erosions in thestomach and fewer than five erosions in the duodenum, and duodenum, and not more than mild dyspepsia). We randomly assignednot more than mild dyspepsia). We randomly assigned 432 432 patients in whom treatment was successful to maintenancepatients in whom treatment was successful to maintenance

treatment with either 20 mg of omeprazole per day or 150 treatment with either 20 mg of omeprazole per day or 150 mgmg of ranitidine twice a day for six months.of ranitidine twice a day for six months.

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A Comparison of Omeprazole with A Comparison of Omeprazole with Ranitidine for Ranitidine for UlcerUlcers Associated with s Associated with Nonsteroidal Antiinflammatory DrugsNonsteroidal Antiinflammatory Drugs ResultsResults At eight weeks, treatment was successful in 80 At eight weeks, treatment was successful in 80

percentpercent (140 of 174) of the patients in the group given 20 (140 of 174) of the patients in the group given 20 mg of omeprazolemg of omeprazole per day, 79 percent (148 of 187) of per day, 79 percent (148 of 187) of those given 40 mg of omeprazolethose given 40 mg of omeprazole per day, and 63 percent per day, and 63 percent (110 of 174) of those given ranitidine(110 of 174) of those given ranitidine (P<0.001 for the (P<0.001 for the comparison with 20 mg of omeprazole andcomparison with 20 mg of omeprazole and P = 0.001 for P = 0.001 for the comparison with 40 mg of omeprazole). Thethe comparison with 40 mg of omeprazole). The rates of rates of healing of all types of lesions were higher with healing of all types of lesions were higher with omeprazoleomeprazole than with ranitidine. During maintenance than with ranitidine. During maintenance therapy, the estimatedtherapy, the estimated proportion of patients in remission proportion of patients in remission at the end of six monthsat the end of six months was 72 percent in the was 72 percent in the omeprazole group and 59 percent in theomeprazole group and 59 percent in the ranitidine group. ranitidine group. The rates of adverse events were similar betweenThe rates of adverse events were similar between groups groups during both phases. Both medications were well tolerated.during both phases. Both medications were well tolerated.

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A Comparison of Omeprazole with A Comparison of Omeprazole with Ranitidine for Ranitidine for UlcerUlcers Associated with s Associated with Nonsteroidal Antiinflammatory DrugsNonsteroidal Antiinflammatory Drugs

ConclusionsConclusions In patients who use NSAIDs In patients who use NSAIDs regularly, omeprazoleregularly, omeprazole healed and prevented healed and prevented ulcerulcers more effectively than did ranitidine.s more effectively than did ranitidine.

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Preventing Recurrent Upper Gastrointestinal Preventing Recurrent Upper Gastrointestinal Bleeding in Patients with Bleeding in Patients with Helicobacter pyloriHelicobacter pylori Infection Who Are Taking Low-Dose Aspirin Infection Who Are Taking Low-Dose Aspirin or Naproxen,2001or Naproxen,2001

BackgroundBackground Many patients who have Many patients who have had upper gastrointestinalhad upper gastrointestinal bleeding bleeding continue to take low-dose aspirin for continue to take low-dose aspirin for cardiovascularcardiovascular prophylaxis or other prophylaxis or other nonsteroidal antiinflammatory drugs nonsteroidal antiinflammatory drugs (NSAIDs)(NSAIDs) for musculoskeletal pain. It is for musculoskeletal pain. It is uncertain whether infectionuncertain whether infection with with Helicobacter pyloriHelicobacter pylori is a risk factor for is a risk factor for bleeding in suchbleeding in such patients.patients.

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Preventing Recurrent Upper Gastrointestinal Preventing Recurrent Upper Gastrointestinal Bleeding in Patients with Bleeding in Patients with Helicobacter pyloriHelicobacter pylori Infection Who Are Taking Low-Dose Aspirin Infection Who Are Taking Low-Dose Aspirin or Naproxen,2001or Naproxen,2001

MethodsMethods We studied patients with a history of upper gastrointestinal We studied patients with a history of upper gastrointestinal

bleeding who were infected with bleeding who were infected with H. pylori H. pylori and who were takingand who were taking low-low-dose aspirin or other NSAIDs. We evaluated whether eradicationdose aspirin or other NSAIDs. We evaluated whether eradication of of the infection or omeprazole treatment was more effectivethe infection or omeprazole treatment was more effective in in preventing recurrent bleeding. We recruited patients whopreventing recurrent bleeding. We recruited patients who presented presented with upper gastrointestinal bleeding that was confirmedwith upper gastrointestinal bleeding that was confirmed by by endoscopy. Their ulcers were healed by daily treatment withendoscopy. Their ulcers were healed by daily treatment with 20 mg 20 mg of omeprazole for eight weeks or longer. Then, those whoof omeprazole for eight weeks or longer. Then, those who had been had been taking aspirin were given 80 mg of aspirin daily, andtaking aspirin were given 80 mg of aspirin daily, and those who had those who had been taking other NSAIDs were given 500 mg ofbeen taking other NSAIDs were given 500 mg of naproxen twice naproxen twice daily for six months. The patients in each groupdaily for six months. The patients in each group were then randomly were then randomly assigned separately to receive 20 mg of omeprazoleassigned separately to receive 20 mg of omeprazole daily for six daily for six months or one week of eradication therapy, consistingmonths or one week of eradication therapy, consisting of 120 mg of of 120 mg of bismuth subcitrate, 500 mg of tetracycline, andbismuth subcitrate, 500 mg of tetracycline, and 400 mg of 400 mg of metronidazole, all given four times daily, followedmetronidazole, all given four times daily, followed by placebo for six by placebo for six months.months.

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Preventing Recurrent Upper Gastrointestinal Preventing Recurrent Upper Gastrointestinal Bleeding in Patients with Bleeding in Patients with Helicobacter pyloriHelicobacter pylori Infection Who Are Taking Low-Dose Aspirin Infection Who Are Taking Low-Dose Aspirin or Naproxen, 2001or Naproxen, 2001

ResultsResults We enrolled 400 patients (250 of whom were We enrolled 400 patients (250 of whom were taking aspirintaking aspirin and 150 of whom were taking other and 150 of whom were taking other NSAIDs). Among those takingNSAIDs). Among those taking aspirin, the probability of aspirin, the probability of recurrent bleeding during the six-monthrecurrent bleeding during the six-month period was 1.9 period was 1.9 percent for patients who received eradicationpercent for patients who received eradication therapy and therapy and 0.9 percent for patients who received omeprazole0.9 percent for patients who received omeprazole

(absolute difference, 1.0 percent; 95 percent confidence (absolute difference, 1.0 percent; 95 percent confidence intervalinterval for the difference, –1.9 to 3.9 percent). Among for the difference, –1.9 to 3.9 percent). Among usersusers of other NSAIDs, the probability of recurrent of other NSAIDs, the probability of recurrent bleeding was 18.8bleeding was 18.8 percent for patients receiving percent for patients receiving eradication therapy and 4.4 percenteradication therapy and 4.4 percent for those treated with for those treated with omeprazole (absolute difference, 14.4omeprazole (absolute difference, 14.4 percent; 95 percent; 95 percent confidence interval for the difference,percent confidence interval for the difference, 4.4 to 24.4 4.4 to 24.4 percent; P=0.005).percent; P=0.005).

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Preventing Recurrent Upper Gastrointestinal Preventing Recurrent Upper Gastrointestinal Bleeding in Patients with Bleeding in Patients with Helicobacter pyloriHelicobacter pylori Infection Who Are Taking Low-Dose Aspirin Infection Who Are Taking Low-Dose Aspirin or Naproxen, 2001or Naproxen, 2001

ConclusionsConclusions Among patients with Among patients with H. pyloriH. pylori infection and a historyinfection and a history of upper gastrointestinal of upper gastrointestinal bleeding who are taking low-dose aspirin,bleeding who are taking low-dose aspirin, the the eradication of eradication of H. pyloriH. pylori is equivalent to treatment is equivalent to treatment withwith omeprazole in preventing recurrent bleeding. omeprazole in preventing recurrent bleeding. Omeprazole is superiorOmeprazole is superior to the eradication of to the eradication of H. H. pyloripylori in preventing recurrent bleeding in preventing recurrent bleeding in patients in patients who are taking other NSAIDs, such as naproxen.who are taking other NSAIDs, such as naproxen.

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Helicobacter pyloriHelicobacter pylori Infection and the Infection and the Development of Development of GastricGastric Cancer, 2001 Cancer, 2001

Conclusions Conclusions GastricGastric cancer develops in persons cancer develops in persons infected withinfected with H. pyloriH. pylori but not in uninfected but not in uninfected persons. Those with histologicpersons. Those with histologic findings of severe findings of severe gastricgastric atrophy, corpus-predominant gastritis, atrophy, corpus-predominant gastritis, or or intestinal metaplasia are at increased risk. intestinal metaplasia are at increased risk. Persons withPersons with H. pyloriH. pylori infection and non infection and nonulcerulcer dyspepsia, dyspepsia, gastricgastric ulcerulcers,s, or or gastricgastric hyperplastic polyps are also at risk, but those hyperplastic polyps are also at risk, but those withwith duodenal duodenal ulcerulcers are not.s are not.

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Helicobacter pyloriHelicobacter pylori Infection and the Infection and the Development of Gastric Cancer, 2002Development of Gastric Cancer, 2002

The authors enrolled 1526 patients, of whomThe authors enrolled 1526 patients, of whom 1246 had 1246 had H. pyloriH. pylori infection. Of the infection. Of the H. pyloriH. pylori–positive–positive patients, 297 patients, 297 had gastric ulcers and 275 had duodenal ulcers.had gastric ulcers and 275 had duodenal ulcers. Hence, Hence, 572 patients had a condition for which treatment to 572 patients had a condition for which treatment to eradicateeradicate the the H. pyloriH. pylori infection is indicated. The infection is indicated. The remaining remaining H. pyloriH. pylori–positive–positive patients had gastric polyps patients had gastric polyps and nonulcer dyspepsia, conditionsand nonulcer dyspepsia, conditions for which eradication for which eradication treatment is not currently indicated.treatment is not currently indicated.

Eradication treatment was administered to 253 patients, Eradication treatment was administered to 253 patients, butbut the authors do not specify whether these patients the authors do not specify whether these patients were amongwere among the 572 who had gastric ulcers or duodenal the 572 who had gastric ulcers or duodenal ulcers. Assumingulcers. Assuming that they were, there remained at least that they were, there remained at least 319 patients who had319 patients who had a clinical indication for eradication a clinical indication for eradication therapy yet did not receivetherapy yet did not receive this treatment. More this treatment. More important, it appears that these remainingimportant, it appears that these remaining patients were patients were not offered this therapy.not offered this therapy.

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Helicobacter pyloriHelicobacter pylori Infection and the Infection and the Development of Gastric Cancer, 2002Development of Gastric Cancer, 2002

No gastric cancer developed after the No gastric cancer developed after the eradication of eradication of H. pyloriH. pylori in the 253 infected in the 253 infected patients who received this treatment. patients who received this treatment. Therefore,Therefore, at least 319 patients were exposed at least 319 patients were exposed to an increased risk of gastricto an increased risk of gastric cancer even cancer even though they had an indication for eradication though they had an indication for eradication therapytherapy that, if successful, would have that, if successful, would have eliminated the risk.eliminated the risk.

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KomplikasiKomplikasi

Faktor hostFaktor host Lokasi ulkusLokasi ulkus KomplikasiKomplikasi

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Tx KomplikasiTx Komplikasi

U duodenumU duodenum OmeprazoleOmeprazole SucralfatSucralfat

U lambungU lambung Tx obat gagal, Tx obat gagal,

operasi/reseksioperasi/reseksi

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ProfilaksisProfilaksis

Antagonis H-2 1/2 dosisAntagonis H-2 1/2 dosis Sucralfat 1 g 2x/hrSucralfat 1 g 2x/hr Indikasi: Indikasi:

• px kumat-kumatan, ada komplikasi px kumat-kumatan, ada komplikasi tidak perlu reseksitidak perlu reseksi

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Asy-Syura (78-80)Asy-Syura (78-80)

Allah yang menciptakan saya dan Allah yang menciptakan saya dan Dia pula yang memberi petunjuk, Dia pula yang memberi petunjuk, memberi makan dan minum dan memberi makan dan minum dan bila saya sakit Dia yang bila saya sakit Dia yang menyembuhkan saya.menyembuhkan saya.

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Wassalamu’alaikum wr.wb.Wassalamu’alaikum wr.wb.