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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

Senin Selasa Rabu Kamis Jumat Sabtu

Tgl 25 Maret 2013 26 Maret 2013 27 Maret 2013 28 Maret 2013 29 Maret 2013 30 Maret 2013

08.00 -09.40

SDL Pleno Skenario

1 Tutorial I SDL

LIBUR KENAIKAN

ISA AL MASIH

Cadangan Kuliah Pakar

09.40 -09.50

Istirahat

09.50 -11.30

MKDU Pleno Skenario

1

Histologi Traktus

Digestivus YHA

Tutorial II

11.30 -12.30

Sholat Dhuhur Berjamaah di Masjid Ainul Yaqin

12.30 -14.10

MKDU SDL

Praktikum Histologi Traktus

Digestivus YHA

Fisiologi Sistem Pencernaan

DSD Pembimbingan

Akademik

&

Kegiatan Mahasiswa

14.10 -14.20

Istirahat

14.20 -16.00

SDL SDL SDL Mikrobiologi Sist.

Pencernaan YAM

16.00 Sholat Ashar Berjamaah di Masjid Ainul Yaqin

Pembagian Presentasi Pleno

Pertama : Anatomi dan Histologi Esofagus

Kedua : Fisiologi pergerakan makanan dalam saluran cerna

Ketiga : Concept Mapping Jenis-jenis penyebab disfagia

Keempat

: Concept Mapping Alur diagnosis disfagia : anamnesis, pemeriksaan fisik,

diagnosis banding, rencana pemeriksaan penunjang) disfagia

Kelima : Case Mapping Alur diagnosis disfagia : anamnesis, pemeriksaan fisik, diagnosis

banding, rencana pemeriksaan penunjang) benda asing esofagus

Keenam : Case Mapping penatalaksanaan (sesuai kompetensi) benda asing esofagus

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CUPLIKAN SKENARIO MINGGUAN

1st

jump : Identifikasi Kata Kunci

Tertelan uang koin sehingga mulut ngiler karena tidak bisa menelan ludahgangguan

menelandisfagia

Dysphagia (dis-FAY-jee-ah) is difficulty in swallowing, commonly associated with

obstructive or motor disorders of the esophagus.(Jones, 2008)

2nd

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?

3rd

jump : Brain Storming

Mahasiswa mencari informasi tentang corpus alienum sistem pencernaan terutama pada anak-

anak baik diagnosis, diagnosis banding, pemeriksaan penunjang yang diperlukan,

penatalaksanaan baik farmakologi maupun non farmakologi. Khususnya di esofagus

Mahasiswa mencari informasi tentang

Pertama : Anatomi dan Histologi Esofagus

Kedua : Fisiologi pergerakan makanan dalam saluran cerna

Ketiga : Concept Mapping Jenis-jenis penyebab disfagia

Keempat

: Concept Mapping Alur diagnosis disfagia : anamnesis, pemeriksaan fisik,

diagnosis banding, rencana pemeriksaan penunjang) disfagia

Kelima : Case Mapping Alur diagnosis: anamnesis, pemeriksaan fisik, diagnosis banding,

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.

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rencana pemeriksaan penunjang) benda asing esofagus

Keenam : Case Mapping penatalaksanaan (sesuai kompetensi) benda asing esofagus

4th

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).

6th

jump. Self Directed Learning

Lihat 7th jump. Reporting

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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

An Y, 2 tahun Peak inc 6 bln-3 thn

Tidak sengaja tertelan uang koin Spontaneously unwitnessed

Ngiler, tidak bisa menelan ludah

Ingested Foreign bodies

X rays+ oesophageal foreign bodies

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

Oropharyngeal or proximal esophageal perforation can cause neck swelling, erythema, tenderness,or crepitus

Biplane radiographscan confirm the location, size, shape, and number of

ingested foreign bodies and help

exclude aspirated objects

CT scan if

necessary

Metal detector

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, wavelike intestinal contractions that move food through the

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.

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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

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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 en-

tire 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.The 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 (me-

nelan)

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