GASTROENTEROHEPATOLOGI IMODUL TUTOR 2 PROGRAM STUDI PENDIDIKAN DOKTER FAKULTAS KEDOKTERAN UNIVERSITAS ISLAM MALANG SEMESTER GENAP TA. 2012/2013 |GEH1 ...........7 Minggu Kedua Jadwal Minggu Kedua ......5 7 jump Minggu Pertama ..................................................................................................18 2|GEH1 ......17 7 jump Minggu Kedua ................................DAFTAR ISI Kata Pengantar ....................1 Daftar Isi ...........................................................................................................................................................2 Minggu Pertama Jadwal Minggu Pertama ................................................................................................................................................................. rencana pemeriksaan penunjang) disfagia : Case Mapping Alur diagnosis disfagia : anamnesis.30 -12.00 SDL SDL SDL 16.20 -16.10 14. rencana pemeriksaan penunjang) benda asing esofagus : Case Mapping penatalaksanaan (sesuai kompetensi) benda asing esofagus 3|GEH1 . diagnosis banding. pemeriksaan fisik.50 -11.40 09. diagnosis banding.40 -09. pemeriksaan fisik.00 Sholat Ashar Berjamaah di Masjid Ainul Yaqin Pembagian Presentasi Pleno Pertama Kedua Ketiga Keempat Kelima Keenam : Anatomi dan Histologi Esofagus : Fisiologi pergerakan makanan dalam saluran cerna : Concept Mapping Jenis-jenis penyebab disfagia : Concept Mapping Alur diagnosis disfagia : anamnesis.10 -14.00 -09.20 MKDU Senin 25 Maret 2013 SDL Selasa 26 Maret 2013 Pleno Skenario 1 Rabu 27 Maret 2013 Tutorial I Kamis 28 Maret 2013 SDL Cadangan Kuliah Pakar Tutorial II Jumat 29 Maret 2013 Sabtu 30 Maret 2013 Istirahat Pleno Skenario 1 Histologi Traktus Digestivus YHA Sholat Dhuhur Berjamaah di Masjid Ainul Yaqin Praktikum Histologi Traktus Digestivus YHA Istirahat & Mikrobiologi Sist. Pencernaan YAM Kegiatan Mahasiswa Fisiologi Sistem Pencernaan DSD LIBUR KENAIKAN ISA AL MASIH Pembimbingan Akademik MKDU SDL 14.50 09. Esophagus Hari / Jam Tgl 08.30 11.JADWAL BLOK GASTROENTEROHEPATOLOGI 1 TH.30 12. AJARAN 2011-2012 Minggu II.30 -14. pemeriksaan penunjang yang diperlukan. diagnosis banding. Bagaimana pencegahan yang harus dilakukan pada keadaan tersebut? 3 jump : Brain Storming Mahasiswa mencari informasi tentang corpus alienum sistem pencernaan terutama pada anakanak baik diagnosis. Apa penatalaksanaan pasien pada kasus tersebut? 5. 2 tahun dibawa ke UGD RS karena tidak sengaja menelan uang koin yang dipegang. 1st jump : Identifikasi Kata Kunci Tertelan uang koin sehingga mulut ngiler karena tidak bisa menelan ludah gangguan menelandisfagia Dysphagia (dis-FAY-jee-ah) is difficulty in swallowing. diagnosis banding. Y. rencana pemeriksaan penunjang) disfagia : Case Mapping Alur diagnosis: anamnesis. Mengapa setelah tertelan. 4|GEH1 rd . menolak bila didekati pemeriksa.CUPLIKAN SKENARIO MINGGUAN KASUS MINGGU KEDUA UANG TERTELAN An. Y rewel. penatalaksanaan baik farmakologi maupun non farmakologi. pemeriksaan fisik. Pemeriksaan penunjang apa yang perlu direncanakan untuk menegakkan diagnosis? 4. Khususnya di esofagus Mahasiswa mencari informasi tentang Pertama Kedua Ketiga Keempat Kelima : Anatomi dan Histologi Esofagus : Fisiologi pergerakan makanan dalam saluran cerna : Concept Mapping Jenis-jenis penyebab disfagia : Concept Mapping Alur diagnosis disfagia : anamnesis. sesekali cegukan. 2008) 2 nd jump : Problem List 1. Apa langkah anda selanjutnya dalam penatalaksanaan anak tersebut? X rays tampak sebagai berikut. commonly associated with obstructive or motor disorders of the esophagus. pemeriksaan fisik. Orangtuanya panik karena anaknya tertelan uang koin. Pada pemeriksaan fisik tampak an. Mulut ngiler karena tidak bisa menelan ludah. diagnosis banding.(Jones. Dokter segera melakukan tindakan gawat darurat pada anak tersebut. Apa kemungkinan yang terjadi bila uang koin tertelan sebagaimana ilustrasi kasus tersebut? 2. an Y mengalami ngiler? 3. rencana pemeriksaan penunjang) benda asing esofagus Keenam th : Case Mapping penatalaksanaan (sesuai kompetensi) benda asing esofagus 4 jump : Mapping (case & concept) Case Mapping Concept Mapping : Jenis-jenis Penyebab dysphagia 5|GEH1 . Concept Mapping Alur diagnosis Dysphagia : anamnesis. pemeriksaan fisik. diagnosis banding. rencana pemeriksaan penunjang 6|GEH1 . Management of esophageal foreign body impaction 7|GEH1 . 8|GEH1 . Dapat menyusun rencana penatalaksanaan (sesuai kompetensi) kasus gangguan fungsi esofagus (menelan). 6 jump.5th jump. Mengetahui anatomi histologi esofagus. 5. 4. Learning Objectives 1. Reporting th 9|GEH1 . Self Directed Learning Lihat 7th jump. Dapat menyusun alur diagnosis gangguan fungsi esofagus (menelan). Dapat menjelaskan patofisiologi kasus gangguan fungsi esofagus (menelan). 2. 3. Mengetahui fisiologi fungsi esofagus (menelan). Dormier baskets. 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 Food bolus impactionmeat or other foodglucagon1.wheezing. vomiting. are likely to have difficulty passing the duodenum and should be removed Sharp-pointed objectsChicken and fish bones.An Y. Disk batteries Magnets coins 10 | G E H 1 . or respiratory distress Ingested Foreign bodies Oropharyngeal or proximal esophageal perforation can cause neck swelling. shape. tidak bisa menelan ludah Spontaneously unwitnessed Frequently. straightened paperclips. rat-tooth or alligator). refusal to eat. erythema. 2 tahun Peak inc 6 bln-3 thn Tidak sengaja tertelan uang koin Ngiler.0 mg intravenous to induce relaxation of the distal esophagus. needles. or retrieval net Long objectsObjects longer than 6 cm. symptoms occur well after the patient ingests the foreign body. tenderness. polyp graspers. thereby allowing spontaneous bolus passage while endoscopic therapy is coordinated True foreign bodies Short-blunt objects. snare. size. magnetic probes. toothpicks. and dental bridgework ingestions have been associated with complications. polypectomy snares. bread bag clips. blood-stained saliva. 2011) Equipment Endoscopes Retrieval devices::rat-tooth and alligator forceps. and number of ingested foreign bodies and help exclude aspirated objects 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. young childrenpresent with choking. retrieval nets.or crepitus CT scan if necessary Metal detector X rays+ oesophageal foreign bodies Biplane radiographscan confirm the location.-->coins can be removed with a foreign body forceps (eg. such as toothbrushes and eating utensils. drooling. Reporting LO 1.7th jump. Anatomi Histologi Esofagus 11 | G E H 1 . 12 | G E H 1 . ) long. the lower portion of the inferior constrictor muscle is contracted. situated chiefly on the middle constrictor muscle. The pharynx is divided into three regions: the nasopharynx. the oropharynx. ESOPHAGUS The esophagus is that portion of the GI tract that connects the pharynx to the stomach (see figs.13). compresses the lumen of the pharynx involuntarily during swallowing. 17. which arise from the thyrocervical trunk. together with a deep sympathetic branch from the superior cervical ganglion. It is formed by the pharyngeal branches of the glossopharyngeal and vagus nerves.3). at the level of the larynx (see fig. The middle constrictor muscle arises from the hyoid bone and stylohyoid ligament and encircles the middle portion of the pharynx. posterior to the nasal cavity. preventing air from entering the esophagus. The inferior constrictor muscle arises from the cartilages of the larynx and encircles the lower portion of the pharynx. approximately 25 cm (10 in. called constrictors (fig. 18. which branch from the external carotid arteries. The pharynx is also served by small branches from the inferior thyroid arteries. The pharynx has both digestive and respiratory functions. During breathing.15). from the gastrointestinal tract PHARYNX The funnel-shaped pharynx (far'ingks) is a muscular organ that contains a passageway approximately 13 cm (5 in. 18. originating at the larynx and lying posterior to the trachea. The supporting walls of the pharynx are composed of skeletal muscle. 13 | G E H 1 wavelike intestinal contractions that move food through the . called feces. and the lumen is lined with a mucous membrane containing stratified squamous epithelium. gastrointestinal tract Defecation—the discharge of indigestible wastes. This involves the following functional activities: Ingestion—the taking of food into the mouth Mastication—chewing movements to pulverize food and mix it with saliva Deglutition—the swallowing of food to move it from the mouth to the pharynx and into the esophagus Digestion—the mechanical and chemical breakdown of food material to prepare it for absorption Absorption—the passage of molecules of food through the mucous membrane of the small intestine and into the blood or lymph for distribution to cells Peristalsis—rhythmic.1 and 18. The superior constrictor muscle attaches to bony processes of the skull and mandible and encircles the upper portion of the pharynx. The pharynx is served principally by ascending pharyngeal arteries.LO 2. Venous return is via the internal jugular veins.) long connecting the oral and nasal cavities to the esophagus and larynx. It is a collapsible tubular organ. posterior to the oral cavity. The motor and most of the sensory innervation to the pharynx is via the pharyngeal plexus. and the laryngopharynx. Fisiologi fungsi esofagus (menelan) The principal function of the digestive system is to prepare food for cellular utilization. The external circular layer of pharyngeal muscles. The mucus secreted by the compound glands in the upper esophagus prevents mucosal excoriation by newly entering food. After food or fluid pass into the stomach. which is why poison grains are effective in killing mice and rats. Despite this protection.14). the lower esophageal sphincter may function erratically. The main body of the esophagus is lined with many simple mucous glands. although the heart is not involved. its walls contain either skeletal or smooth muscle. Sequential 14 | G E H 1 . is the complex mechanical and physiological act of moving food or fluid from the oral cavity to the stomach. depending on the location. At the gastric end and to a lesser extent in the initial portion of the esophagus. and forces the bolus into the oropharynx. creates a pressure. The upper third of the esophagus contains skeletal muscle. The lower esophageal (gastroesophageal) sphincter is a slight thickening of the circular muscle fibers at the junction of the esophagus and the stomach. The events of this stage are involuntary and are elicited by stimulation of sensory receptors located at the opening of the oropharynx. causing them to ―spit up‖ following meals. 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. 18. this sphincter constricts to prevent the stomach contents from regurgitating into the esophagus. deglutition is divided into three stages. The second stage of deglutition is the passage of the bolus through the pharynx. the middle third. In infants under a year of age. there are also many compound mucous glands. and the terminal portion. The first deglutitory stage is voluntary and follows mastication. Elevation of the larynx against the epiglottis seals the glottis so that food or fluid is less likely to enter the trachea. The hyoid bone and the larynx are also elevated. a peptic ulcer at times can still occur at the gastric end of the esophagus. This can create a burning sensation commonly called heartburn. the mouth is closed and breathing is temporarily interrupted. During this stage. Pressure of the tongue against the transverse palatine folds seals off the nasopharynx from the oral cavity. A bolus is formed as the tongue is elevated against the transverse palatine folds (palatal rugae) of the hard palate (see fig.The esophagus is located within the mediastinum of the thorax and passes through the diaphragm just above the opening into the stomach. 18. a combination of skeletal and smooth muscle. Swallowing Mechanisms Swallowing. such as rodents. 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. smooth muscle only. and it does at times permit the acidic contents of the stomach to enter the esophagus.5) through contraction of the mylohyoid and styloglossus muscles and the intrinsic muscles of the tongue. if food is involved. have a true lower esophageal sphincter and cannot regurgitate. or deglutition (de''gloo-tish'un). The esophageal secretions are entirely mucous in character and principally provide lubrication for swallowing. For descriptive purposes. The soft palate and pendulant palatine uvula are elevated to close the nasopharynx as the bolus passes. Certain mammals. The lower esophageal sphincter is not a well-defined sphincter muscle comparable to others located elsewhere along the GI tract. whereas the compound glands located near the esophagogastric junction protect the esophageal wall from digestion by acidic gastric juices that often reflux from the stomach back into the lower esophagus. and many other smooth muscle tubes of the body. the entry and passage of food through the esophagus. which keep the intestinal contents thoroughly mixed at all times. Peristalsis is an inherent property of many syncytial smooth muscle tubes. This stage is completed in just a second or less. the entire process of deglutition takes place in slightly more than a second. 18. for a typical bolus. The basic propulsive movement of the gastrointestinaltract is peristalsis. the time frame is 5 to 8 seconds. this is analogous to putting one’s fingers around a thin distended tube. In the case of fluids. 15 | G E H 1 . (Peristalsis also occurs in the bile ducts. Functional Types of Movements in the Gastrointestinal Tract Two types of movements occur in the gastrointestinal tract: (1) propulsive movements. then constricting the fingers and sliding them forward along the tube.contraction of the constrictor muscles of the pharynx moves the bolus through the pharynx to the esophagus.15). Propulsive Movements—Peristalsis. ureters. which is illustrated in Figure 62–5. and (2) mixing movements. The bolus is moved through the esophagus by peristalsis (fig. That is. Other stimuli that can initiate peristalsis include chemical or physical irritation of the epithelial lining 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 this ring then spreads along the gut tube. if a large amount of food collects at any point in the gut. strong parasympathetic nervous signals to the gut will elicit strong peristalsis.Also. glandular ducts. The third stage.) The usual stimulus for intestinal peristalsis is distention of the gut. is also involuntary. which cause food to move forward along the tract at an appropriate rate to accommodate digestion and absorption. and a contractile ring appears that initiates a peristaltic movement. A contractile ring appears around the gut and then moves forward. Any material in front of the contractile ring is moved forward. stimulation at any point in the gut can cause a contractile ring to appear in the circular muscle. the complex is called the myenteric reflex or the peristaltic reflex. Esophageal varices. are of major importance. spicy meal. Therefore. Directional Movement of Peristaltic Waves Toward the Anus . but it normally dies out rapidly in the orad direction while continuing for a considerable distance toward the anus. dysphagia.The exact cause of this directional transmission of peristalsis has never been ascertained. Therefore. can occur in either direction from a stimulated point. At the same time. and/or hematemesis. pushing the intestinal contents in the anal direction for 5 to 10 centimeters before dying out. namely heartburn. Peristalsis.Function of the Myenteric Plexus in Peristalsis . Esophagitis and hiatal hernias are far more frequent and rarely threaten life. effectual peristalsis requires an active myenteric plexus. Distressing to the physician is that all disorders of the esophagus tend to produce similar symptoms. 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. the result of cirrhosis and portal hypertension. 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. Peristalsis occurs only weakly or not at all in any portion of the gastrointestinal tract that has congenital absence of the myenteric plexus.‖ 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. which is called ―receptive relaxation.T he peristaltic reflex plus the anal direction of movement of the peristalsis is called the ―law of the gut. 16 | G E H 1 . Peristaltic Reflex and the “Law of the Gut. This complex pattern does not occur in the absence of the myenteric plexus. theoretically. since their rupture is frequently followed by massive hematemesis (vomiting of blood) and even death by exsanguination.‖ thus allowing the food to be propelled more easily anally than orad.” When a segment of the intestinal tract is excited by distention and thereby initiates peristalsis. pain. the contractile ring causing the peristalsis normally begins on the orad side of the distended segment and moves toward the distended segment. the gut sometimes relaxes several centimeters downstream toward the anus. Also. Diagnostic evaluation of dysphagia. Third Edition. Wray Rural Training Tract Family Medicine Residency Program.72:287-91. Colorado Foreign Body Ingestion In Children. 292. 2008. American Society for Gastrointestinal Endoscopy. Betty Davis. Dysphagia (difficulty in swallowing) is encountered both with deranged esophageal motor function and with diseases that narrow or obstruct the lumen.. 2008. LO 4. Wray. 2005 American Academy of Family Physicians Jones. USA 17 | G E H 1 . Uyemura. LO 3. particularly by those lesions associated with inflammation or ulceration of the esophageal mucosa. Rencana penatalaksanaan (sesuai kompetensi) kasus gangguan fungsi esofagus (menelan) Cook IJ. The clinical diagnosis of esophageal disorders often requires specialized procedures such as esophagoscopy. LO 5.D. Nat Clin P Gastroenterol.Heartburn (retrosternal burning pain) usually reflects regurgitation of gastric contents into the lower esophagus. Am Fam Physician 2005. World Gastroenterology Organisation Practice Guidelines : Dysphagia.5(7):393-403. M. radiographic barium studies.. and manometry. Alur diagnosis kasus gangguan fungsi esofagus (menelan). Management of ingested foreign bodies and food impactions. Patofisiologi kasus gangguan fungsi esofagus (menelan). Thomson Corporation. Comprehensive Medical Terminology. 2011 Monte C. 2007. Pain and hematemesis are sometimes evoked by esophageal disease.