Dyspepsia in Children-ok

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dispepsia pada anak

Transcript of Dyspepsia in Children-ok

  • Pediatric Dyspepsia & Gastro-esophageal Reflux (GER):Acid Related DisordersDiagnosis and Management

    Wan Nedrawan.nedra@yarsi.ac.idYARSI SCHOOL OF MEDICINE 2015**

  • Peptic ulcer disease (PUD)GER

    OBJECTIVE: **

  • Berupa kumpulan gejala yang non-spesifik berhubungan dengan saluran pencernaan bagian atasyang terjadi berulang selama minimal 2 bulan

    Chelimsky dan Czinn, 2001

    MANIFESTASI KILINIK PUD: DYSPEPSIA **

  • Mayor: Nyeri perut di daerah epigastriumMuntah berulang ( minimal 3x/bulan)

    Minor:Gejala yg berhubungan dg makan (Anoreksia, BB menurun)Nyeri perut yg dirasa pd malam hariHeartburnOral RegurgitasiNeusia kronikSendawa berulangNyeri perut disekitar umbilikalAda riwayat keluarga PUD. Dyspepsia

    KRITERIA DIAGNOSTIK DYSPEPSIA**Evaluasi: - 2 mayor atau -1 mayor + 2 minor

    -4 minor

  • Gejala: Nyeri perut di epigastrium, pada malam hari, regurgitasi, hearburn, BB menurun, hematemesis dan melena

    Riwayan Makan:Makanan berlemak, makanan pedas, caffein, laktose

    Penggunaan Obat-obatan:Kortikosteroid, NSAIDAlkohol, tembakau (rokok)Obat2 yang meransang pengeluaran asam lambungANAMNESIS **

  • Pemeriksaan awal: Hematologi dg differential countLFT, ElektrolitFeses: ParasitUrinalisis

    Pemeriksaan lanjutan:USG hati dan saluran empeduEndoskopiHydrogen breath test

    PEMERIKSAAN LABORATORIUM**

  • H2 reseptor antagonis:Cimetidine 20 40 mg/ kg/ hari 2 kali / hari maks: 400 mbRanitidine 2- 4 mg/ kg/ hari, 2 kali sehari (mak: 150 mg)

    Proton Pump InhibitorLansoprazol 0,8 mg/kg/hariPmeprazol 0,8 mg/ kg/ hari

    Cytoprotective Agents:Sukralfat 40-80 mg/ kg/ hari, 4 kali sehari ( mak 1 g)

    PENGOBATAN**

  • **forceful expulsion of gastrointestinal contents into the oesophagusDEFINISI

  • **

  • S.motorik somatik**S.motorik somatikSaraf otonomS. SimpatisS. ParasimpatisSaraf enterikN. Vagusasetil kolinpleksus mienterikusmotilitas sal.cernapl. mienterikuspl. submukosa

  • **

  • **ImpulsChemo-receptor Trigger ZoneGastrointestinal tract, Vomiting centerendogenexogenImpulsvomitingafferen N. Vagus

  • **Vomiting centreChemo-receptor Trigger ZoneBlood Brain Barrieresophagus

  • **

    LES FundusCorpusTonus decreaseAntrumPeristaltic decrease

    PylorusDuodenumTonus increase

  • Most common in children (> infant)Confusing the parentsLife-threatening causes of vomiting

    Three distinct phases (1) nausea, (2) retching, (3) emesis

    Not preceded in raised intracranial pressure or mechanical obstruction**Vomiting

  • Age: neonates, infant, childGastrointestinal tract: obstruction & non obstructionExtra-gastrointestinal tractAPPROACH**

  • NeonatesAtresia esophagus, pylorus stenosis, spitting upGER, NEC, chalasia, Infection (UTI, OMA, sepsis)Infantspylorus stenosis, intususeption, herniaRGE, gastroenteritis, infection, drugs, aerophagiaChildrenIntusuception, stricture, gastritis, apendisitis Infection, drugs ETIOLOGY**

  • ~ etiologytreat acid and base inbalancedDrugs: DomperidoneMetoclopramideCisapride**Therapy

  • Gastroesophageal reflux

    Just spitting up, or something more serious ?**

  • 20% general infant population40% of children consulting a pediatrician70% of all 4 months old infants regurgitate at least 1 x/day25% is considered by the parents as a problem

    RGE8% abnormal pH esophagus monitoring1/300 1/1000 severe(Chouchou, 92; Nelson et al, 1997)REGURGITATION**

  • The involuntary passage of gastric contents into the esophagus

    saliva, ingested food, drinks, gastric/pancreatic/ biliary secretionsnormal phenomenon, +/- accompanying symptomsphysiologic or pathologic reflux

    (Carre 1983; Vandenplas, 1992; Orenstein, 1994; Vandenplas, 1993)**GER

  • Physiologic refluxoccurs mainly after mealdoes not normally cause symptomsshort duration of reflux episodes

    Pathologic refluxfrequent reflux episodes of longer durationreflux episodes occuring during the day/nightmay produce symptoms & inflamation/mucosal injuryGER**

  • **MECHANISMS OF GER

    attenuated swallows, dysfunctional peristalsisLength of LES, Maturation of LESTLES relaxation Inadequate gravitationdelayed gastric emptying, distension

    Deficient or delayed esophageal acid clearanceIncompetent LES delayed gastric emptyingdistentionILES: Lower essophageal sphinter

  • Increased abdominal pressure (overweight, constipation)

    Increased respiratory effort related to exercise

    (food) allergy, crying, cigarette smoking

    Hereditary predisposedTRIGGER FACTORS FAVORING GER**

  • Emesis & regurgitation are the most common

    primary GER diseasesecondary GER diseaseinfection, metabolic disorders, & food allergystimulation vomiting center in the dorsolateral reticular formation by efferent & afferent impulsCLINICAL MANIFESTATION GER**

  • Usual manifestationsSpecific manifestationregurgitation, nausea, vomitingPossibly related to complications~ anaemia (iron defiency anaemia)haematemesis & melenadysphagia, weight loss, irritable infantsect ~ adultSYMPTOMS OF GER (- DISEASE)**

  • Unusual presentations~ chronic respiratory diseaseapnea, apparent life threatening, SIDS

    ~ to congenital and/or CNS abnormalitiescerebral palsy, psychomotory retardation

    A careful history, observation of feeding, & physical examination are mandatorySYMPTOMS OF GER (- DISEASE)**

  • 1. a. Parental reassurance b. Milk-thickening agents (?)

    2. Prokinetics

    3. Positional adjuvant therapy4. a. H2 receptor antagonist b. Proton pump inhibitors

    5. SurgeryTREATMENT RECOMMENDATIONS**

  • Frequent small feedingDecrease the number of transient LES relaxationsReduced volume cause of distress to infantsRestriction volume in clearly overfed babies

    Thickening infants formulaDecrease the frequency & volume of regurgitationtime crying, improves sleep, caloric retention ,coughing (after feeding) (Vandenplas, 1994, Borelli, 1997)REGURGITATION AND FEEDING**

  • Thickening formula should be considered as the first step

    Can not be given to breastfed infants

    Gastric emptying : Casein > Wheyhydrolysate FORMULA AND MILK-THICKENING**

  • Gastrokinetic action indirect release of acetylcholine in the myentericus plexus

    Reduces regurgitationThe LES pressure and motilityEsophageal peristalsis, gastric emptying

    Increased salivary secretionprotect esophagus via salivary component (bicarbonat buffer)**Prokinetics

  • Sleeping and crying decrease GERCrying increases abdominal pressure, but also increases LES-P

    300 prone anti-trendelenburg positionSIDS ?Beyond the age of SIDS ( > 12 months) (Orenstein, 1990; Orenstein, 1997; Tobin, 1997) POSITION, CRYING, AND REFLUX**

  • **

  • THANK YOU

    **