Dyspepsia Dr Maduseno Sp Pd

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CURRICULUMVITAE Nama : Dr.SutantoMaduseno,SpPDKGEH

TempatLahir :Yogyakarta

Agama :Islam

AlamatRumah

:Jl.Tegalsari

No.

6RT

09/RW

30,

Jl.

Palagan

Tentara

Pelajar

Yogyakarta

Alamatkantor :RSUPDr.Sardjito

PendidikanTerakhir :Sp2KonsultanGastroenterohepatologi

Status :Menikah

PENDIDIKAN

SDJetis Harjo 1 Yogyakatta

SMPNV Yogyakarta

SMAIII Yogyakarta

FKUGM Yogyakarta

Spesialis Penyakit Dalam FKUGM

Sp2KonsultanFKUI

RIWAYATJABATAN

Kepala Poliklinik Penyakit Dalam RSUPDr.Sardjito Yogyakarta,tahun 2002 2009 Wakil Kepala Instalasi Rawat Jalan RSUPDrSardjito Yogyakarta.Tahun 20032004.

KepalaInstalasiRawatJalanRSUPDr.SardjitoYogyakarta,tahun2004 2009

KetuatimpengujikesehatanuntukwilayahPropinsiDaerahIstimewaYogyakartatahun20062009

DirekturMedikdanKeperawatanRSUPDrSardjito,tahun2009sekarang

ORGANISASIPROFESI(CabangYogyakartadanNasional)

AnggotaIkatanDokterIndonesia(IDI) PengurusPerhimpunanSpesialisPenyakitDalam(PAPDI)cabangYogyakarta

SeksiPenelitianPengurusBesarPGIJakarta

SeksiHumasPengurusBesarPPHIJakarta

PengurusIkatanRematologiIndonesiacabangYogyakarta

AnggotaPengurusCabangPPHIPGIPEGIYogyakarta

ORGANISASISOSIAL

DAN

PENGHARGAAN

AnggotadonordarahtetapPMIcabangKotaYogyakartasejaktahun1979,dansaatinitelahmenyumbangdarahsebanyak95 kali

MendapatpenghargaansebagaidokterpuskesmasTeladanKabupatenMadiundanPropisiJawaTimurpadatahun1987


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By

Sutanto

MadusenoDivofGastrohepatology,DepartofInternalMedicines,FacultyofMedicine,GadjahMada

University/SardjitoGeneralHospital

Yogyakarta


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DYSPEPSIADEFINITION:

Symptomslikepainornauseainepigastrium

accompaniedby

disgust,

vomit,

bloat,

easy

to

full,

fullnessornitre,whichissuspectedcomefromtheabnormalityof uppergastrointestinaltractus(SCBA)


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Dysmotility

H.pyloriinfection/

inflammation

Psychosocialfactors

Alteredgastricacidsecretion

Guthypersensitivity

Mechanismsof

dyspepsia

Witteman&Tytgat,NetherlandsJMed1995;46:20511.Talleyetal.,BMJ2001;323:12947.

Tacketal.,CurrGastroenterolRep2001;3:5038.

Dyspepsia:pathogenicmechanisms


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Natureofsymptoms

Patientsdegreeofdistress

Severityofsymptoms

Alarmfeatures

Assessment

ofsymptoms

CharacterRadiationTiming,durationandfrequency

Modifyingfactors

Par,CanJGastroenterol1999;13:64754.

Dyspepsia:symptomassessment


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Ethiology

Organic

Dyspepsia

: Thereisanorganabnormalityasulcergastroduodenal,

gastroesofageal refluxs andgastriccarcinoma(Talley,

1998)


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WhatisFunctionalDyspepsia?Persitentorrecurrentpainordiscomfortcenteredin

theupperabdomen 12weekswithinprevious12months

Noevidenceoforganicdiesease

Norelationbetweendyspepticsymptomsandbowelmovements(IBS).

Exclusionofpatientswithdominantheartburn

symptomsofdyspepsiavs.diagnosisoffunctionaldyspepsia


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FunctionalDyspepsia Acommontermwhichisgiventothepatientas:

abdominalpainornauseaontheupperofstomachwhich

isrepeatedlyhappenmorethanthreemonths,andatleast

alongofthattime25%symptomsofdyspepsiaappearand

noevidenceorganicdiseasewhichisresponsibletothat

symptomsclinically,biochemistrically,endoscopyand

ultrasonografy(Talleyetal,1991).But,patientwithgastritisandduodenitisnonerosifisincludedinthisterm

(Hu&Kren,1998)


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DyspepsiaSubgroupsDysmotilitylike

Ulcerlike

Unspecified


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RomeIII

Diagnostic

Criteria

for

Functional

Dyspepsia

Functional Dyspepsia

At least 3 months, with onset at least 6 months previously,

of 1 or more of the following:

Bothersome postprandial fullness Early satiation

Epigastric pain

Epigastric burningAnd

No evidence of structural disease (including at upper

endoscopy) that is likely to explain the symptoms


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RomeIII

Diagnostic

Criteria

for

Epigastric

PainSyndromeEpigastric Pain Syndrome

At least 3 months, with onset at least 6 months previously, with ALL of

the following:

Pain and burning that is:

intermittent

localized to the epigastrium of at least moderate severity, at least once

per week,

and NOT:generalized or localized to other abdominal or chest regions

2. relieved by defecation or flatulence

3. fulfilling criteria for gallbladder or sphincter of Oddi disorders


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RomeIII

Diagnostic

Criteria

for

PostprandialDistressSyndromePostprandial Distress SyndromeAt least 3 months, with onset at least 6 months

previously, of 1 or more of the following:

Bothersome postprandial fullness

1. occurring after ordinary-sized meals

2. at least several times a week Early satiation

1. that prevents finishing a regular meal

2. and occurs at least several times a week


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Clasificationacutedyspepsia (newonsetdyspepsia)

SuddenlySighwiththequalityofsighwhichisusuallymoretremendouswithalongerresponsetothemedication.

chronicdyspepsia Sighwhichissometimesdissappear,sometimesappear,

more

than

two

weeks.

The

sigh

is

not

as

tremendous

as

acutedyspepsiawithaquickresponsetothemedication.


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AgresifFactor GastricAcid Pepsin Refluxsbile

Nicotin Alcohol Antiinflamationnonsteroid

medicine Cortikosteroid

Helicobacterpylori Freeradical

Agresif Factor Defensif Factor

DefensifFactorMucosabloodcurrent(microsirculation)

Superficial

epithel

cellProstaglandinFosfolipid/SurfactansMusinBikarbonat

Motilitas

Diagramoftheequlibriumtheoryofintegrationgastrointestinal

tractus

mucosa

especially

gastric

&

duodenum


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Proton pump

Inhibitor

Gastrin Acetylcholine Histamine

AntagonistH2

H+K+ATPase

H+ Cl-

Cl-

(-)

(-)K+

Parietal cell

Parietal Cell and proton pump (H+, K+-ATPase)

(Robinson, 1999)


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Gastritis; Should we follow symptoms orsigns?

Symptom complex

Endoscopic findings

Microscopic inflammations


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Clinicallyappearance

ofChronicgastritisDyspesia

Painpattern

:pain

food

pain

not

always

happen,ifhappen patognomonis.

Painfoodrelief duodeniulcers.

TrueDiagnosis:endoscopy biopsy PAalgoritmadyspesia


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Presenceof

symptoms

in

patients

with

functionaldyspepsia

TackJ,etal. Gastroenterology2001;121:52635


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Gastritis


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Endoscopy(ExaminationIndication)1. AnegativeresultoradoubtresultofRadiology

Examination:

toosmall&toosuperficial

2. Indication

operation

of

Gastric

ulcer

or

put

aside

thevicious

3. Lookagainifthemedicalmedicationisnot

successed

4. DeterminethesourceofHemorrhage


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MechanismofAcidSecretion

CephalicphaseGastricphaseNervus Vagus

Asetilcholine

ECLcell

Histamine

FoodinGaster

Gcell

Gastrin

ParietalCell


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Nervus Vagus

ECLcell

Gcell

Gastrin H+

K+

Cl

H+

H+

HCl


CephalicphaseGastricphase

Asetilcholine

Histamine

FoodinGaster ParietalCell


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CephalicphaseGastricphaseNervus Vagus

Asetilcholine

ECLcell

Histamine

FoodinGaster

Gcell

Gastrin

ParietalCell


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Nervus Vagus

ECLcell

Gcell

Gastrin H+

K+

Cl

H+

H+

HCl


CephalicphaseGastricphase

Asetilcholine

Histamine

FoodinGaster ParietalCell


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Algoritmofdyspepsiamanagementinthepublic

DYSPEPSIA

AGE < 45 YEARSWITHOUT NATURAL SIGNS

AGE > 45 Years with Natural signs :- vomiting - fever

- hematemesis - ictherus

- Loose of body Weight

The history of using chronic OAINS

The hystory og gastric cancer in the family

pasient is too worry with his disease

Empiric Therapy for 2 weeks with :

- antacid cured

- H2 antagonist/PPI

- Prokinetic therapy is stopped

fail or exacerbation exacerbation

serology Test of H.pyloriReferral centre : gastroenterologist

/ internist/ pediatrics with

Endoscopy facility

result (-) result (+) referral

exacerbation more than 3 times


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1.GoalofPharmacotherapyindyspepsia

Controlsymptoms

Promote

healing Preventcomplications

Improvehealthrelatedqualityoflife

AvoidAdverseeffectsoftreatment


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Pharmacotherapy

Antacids

Acid

Suppression

drugProkineticagent

Surfaceagent

DYSPEPSIA


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Dyspepsia Treatment1. Antacida

Can be Tab/gel. The best is gel.

Dossage : (15-30) cc 3-4 times a day, an hour after

eat.

(cheap, low complience)


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2. The partition of H2-Receptora. Cimetidin

dossage 2x (200-400) mg every morning and night

or 800 mg at nightb. Ranitidin

dossage 2x (150-300) mg every morning and night

or (300-600) mg at nightc. Famotidin

dossage 200 mg everyday

3. Motilitas Group Donperidon 3x1

Cisapride 3x (5-10) mg/day


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4. Prostaglandin E Group Misoprostol

emprostil

5. Sitoprotectif :

Sukralfat, setraksat, Teprenon

6. Others Medicine : Anti anxiety

Anti depresi

Anti Convulsant7. If needed :

Surgical therapy : vagotomi


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MedicinetoControlGastricAcidAntacida

(cheap,low

compilance,

inefective

for

gastric

ulcers,notconsistenceinmaintaningpHIntragastric,interactionwithothersdrugs,canbeusedinesofagitisrefluxslightly/moderate)

AntagonistreseptorH2(Cimetidine,ranitidine,famotidine)

(consistenceinmaintainingpHIntragastric48

hours,less

efective

at

meal

stimulated

and

day

time

acidsecretion,easytotakhifilaksis,inefectivetoprotectgastriculcersfortheOAINSusers,canbeusedinesofagitisrefluxslightly/moderate)


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Table8.ThePossibilityof theSideeffectthatcanappearafterusingmedicinewhichcontrolgastricacid

Drugs to control

gastric acidThe possibili ty Side effect

Antagonist histamin2Hreceptor:

Proton Pomp barrier :

Sitoprotektif drugs :

headache, dizziness, nausea, mialgia, skinrash, and itchy

Nausea, diarrhea, can be abdominal cholic.

headache, dizziness, and somnolen seldom tosee the light rising of transaminase serum

Sukralfat seldom give Side effect, if happen :

constipated or dryness on mouth, sometimes

abdominal discomfort. No serious side effectcaused by teprenone except the rise of

aminotransferase serum.

(Shirakabe, 1995; Brunton, 1996)

d d


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Acidsupressiondrugs:

H2RA(H2ReceptorAntagonist)

PPI(ProtonPumpInhibitor)

Cimetidine

RanitidineFamotidine

Nizatidine

Omeprazole

LansoprazolePantoprazole

Rabeprazole

Esomeprazole


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TrendsinPrescribingofProtonPumpInhibitorsinGeneralPracticeinEngland

Newer PPIs offer no advantage in terms of

clinical efficacy over established PPIs, are

usually more expensive and have lessevidence for long-term safety.

MeReC Bulletin 2006;16:9-12


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TotalExpenditureofOTCAntisecretoryTherapy,USA,20032006


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Bioavailability(%)

Tolmanetal,JClin Gastroenterol1997;24:6570.Fitton &

Wiseman,

Drugs1996;

51:

46082.HassanAlinetal,Gastroenterology 2000;118:A16.

Swanetal.,AlimentPharmacol Ther1999;13(Suppl 3):117.Howden,Clin Pharmacokinet1991;20:3849.

PPIbioavailabilityafterthefirstdose

8090

80

70

60

50

4030

20

10

0

Lansoprazole Pantoprazole Esomeprazole Rabeprazole Omeprazole

77

64

52

40


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Matur

Nuwun

Dyspepsia Dr Maduseno Sp Pd

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