dyspepsia diagnosis and management · pdf filey alamat rumah : jl.tegalsari no. 6 rt 09/rw 30,...
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CURRICULUM VITAENama : Dr. Sutanto Maduseno, SpPD‐KGEHTempat Lahir : YogyakartaAgama : IslamAlamat Rumah : Jl.Tegalsari No. 6 RT 09/RW 30, Jl. Palagan Tentara Pelajar Yogyakarta Alamat kantor : RSUP Dr. Sardjito Pendidikan Terakhir : Sp2 Konsultan Gastroenterohepatologi Status : Menikah
PENDIDIKANSD Jetis Harjo 1 YogyakattaSMPN V YogyakartaSMA III YogyakartaFK UGM YogyakartaSpesialis Penyakit Dalam FK UGMSp2 Konsultan FK UI
RIWAYAT JABATANKepala Poliklinik Penyakit Dalam RSUP Dr. Sardjito Yogyakarta, tahun 2002 ‐ 2009 Wakil Kepala Instalasi Rawat Jalan RSUP Dr Sardjito Yogyakarta. Tahun 2003‐2004.Kepala Instalasi Rawat Jalan RSUP Dr. Sardjito Yogyakarta, tahun 2004 – 2009Ketua tim penguji kesehatan untuk wilayah Propinsi Daerah Istimewa Yogyakarta tahun 2006‐2009Direktur Medik dan Keperawatan RSUP Dr Sardjito, tahun 2009‐sekarang
ORGANISASI PROFESI (Cabang Yogyakarta dan Nasional)Anggota Ikatan Dokter Indonesia (IDI)Pengurus Perhimpunan Spesialis Penyakit Dalam (PAPDI) cabang YogyakartaSeksi Penelitian Pengurus Besar PGI JakartaSeksi Humas Pengurus Besar PPHI JakartaPengurus Ikatan Rematologi Indonesia cabang YogyakartaAnggota Pengurus Cabang PPHI‐PGI‐PEGI Yogyakarta
ORGANISASI SOSIAL DAN PENGHARGAAN‐ Anggota donor darah tetap PMI cabang Kota Yogyakarta sejak tahun 1979, dan saat ini telah menyumbang darah sebanyak 95 kali‐Mendapat penghargaan sebagai dokter puskesmas Teladan Kabupaten Madiun dan Propisi Jawa Timur pada tahun 1987
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By Sutanto MadusenoDiv of Gastrohepatology,Depart of Internal
Medicines, Faculty of Medicine, Gadjah Mada University/Sardjito General Hospital
Yogyakarta
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DYSPEPSIADEFINITION :
Symptoms like pain or nausea in epigastrium accompanied by disgust, vomit, bloat, easy to full, fullness or nitre, which is suspected come from the abnormality of upper gastro‐intestinal tractus (SCBA)
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Dysmotility
H. pyloriinfection/
inflammation
Psychosocial factors
Altered gastric acid secretion
Gut hypersensitivity
Mechanisms of dyspepsia
Witteman & Tytgat, Netherlands J Med 1995; 46: 205–11.Talley et al., BMJ 2001; 323:1294–7.
Tack et al., Curr Gastroenterol Rep 2001; 3: 503–8.
Dyspepsia: pathogenic mechanisms
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Nature of symptoms
Patient’s degree of distress
Severity of symptoms
Alarm features
Assessment of symptoms
CharacterRadiationTiming, duration and frequencyModifying factors
Paré, Can J Gastroenterol 1999; 13: 647–54.
Dyspepsia: symptom assessment
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EthiologyOrganic Dyspepsia :
There is an organ abnormality as ulcer gastro‐duodenal, gastro esofageal refluxs and gastric carcinoma (Talley, 1998)
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What is Functional Dyspepsia?Persitent or recurrent pain or discomfort centered in the upper abdomen
12 weeks within previous 12 monthsNo evidence of organic dieseaseNo relation between dyspeptic symptoms and bowel movements (IBS).Exclusion of patients with dominant heartburn
symptoms of dyspepsia vs. diagnosis of functional dyspepsia
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Functional Dyspepsia A common term which is given to the patient as : abdominal pain or nausea on the upper of stomach which is repeatedly happen more than three months, and at least a long of that time 25% symptoms of dyspepsia appear and no evidence organic disease which is responsible to that symptoms clinically, biochemistrically, endoscopy and ultrasonografy (Talley et al, 1991). But, patient with gastritis and duodenitis non erosif is included in this term (Hu & Kren, 1998)
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Dyspepsia SubgroupsDysmotility‐likeUlcer‐likeUnspecified
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Rome III Diagnostic Criteria for Functional DyspepsiaFunctional 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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Rome III Diagnostic Criteria for Epigastric Pain SyndromeEpigastric Pain SyndromeAt 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 regions2. relieved by defecation or flatulence3. fulfilling criteria for gallbladder or sphincter of Oddi disorders
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Rome III Diagnostic Criteria for Postprandial Distress SyndromePostprandial Distress SyndromeAt least 3 months, with onset at least 6 months previously, of 1 or more of the following:• Bothersome postprandial fullness1. occurring after ordinary-sized meals2. at least several times a week• Early satiation1. that prevents finishing a regular meal2. and occurs at least several times a week
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Clasificationacute dyspepsia (new onset dyspepsia)
Suddenly Sigh with the quality of sigh which is usually more tremendous with a longer response to the medication.
chronic dyspepsiaSigh which is sometimes dissappear, sometimes appear, more than two weeks. The sigh is not as tremendous as acute dyspepsia with a quick response to the medication.
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• Agresif Factor– Gastric Acid– Pepsin– Refluxs bile – Nicotin– Alcohol– Antiinflamation nonsteroid
medicine– Cortikosteroid– Helicobacter pylori– Free radical
Agresif Factor Defensif Factor
Defensif FactorMucosa blood current (microsirculation)Superficial epithel cellProstaglandinFosfolipid/SurfactansMusinBikarbonatMotilitas
Diagram of the equlibrium theory of integration gastro‐intestinal tractus mucosa especially gastric & duodenum
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Proton pumpInhibitor
Gastrin Acetylcholine Histamine
Antagonist H2
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 or signs?
Symptom complex� Endoscopic findings� Microscopic inflammations
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Clinically appearance of Chronic gastritis
DyspesiaPain pattern : pain‐food‐pain not always happen, if happen patognomonis.Pain‐food‐relief duodeni ulcers.True Diagnosis : endoscopy biopsy PA algoritma dyspesia
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Presence of symptoms in patients with functional dyspepsia
Tack J, et al. Gastroenterology 2001;121:526‐35
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Gastritis
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Endoscopy (Examination Indication)1. A negative result or a doubt result of Radiology
Examination : too small & too superficial
2. Indication operation of Gastric ulcer or put aside the vicious
3. Look again if the medical medication is not successed
4. Determine the source of Hemorrhage
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Mechanism of Acid SecretionCephalic phaseGastric phase
Nervus Vagus
Asetilcholine
ECL‐cell
Histamine
Food in Gaster
G‐cell
Gastrin
Parietal Cell
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Nervus Vagus
ECL‐cell
G‐cell
Gastrin H+
K+
Clˉ
H+
H+
HCl
Mechanism of Acid SecretionCephalic phaseGastric phase
Asetilcholine
Histamine
Food in Gaster Parietal Cell
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Mechanism of Acid SecretionCephalic phaseGastric phase
Nervus Vagus
Asetilcholine
ECL‐cell
Histamine
Food in Gaster
G‐cell
Gastrin
Parietal Cell
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Nervus Vagus
ECL‐cell
G‐cell
Gastrin H+
K+
Clˉ
H+
H+
HCl
Mechanism of Acid SecretionCephalic phaseGastric phase
Asetilcholine
Histamine
Food in Gaster Parietal Cell
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Algoritm of dyspepsia management in the public
DYSPEPSIA
AGE < 45 YEARS WITHOUT NATURAL SIGNS
AGE > 45 Years with Natural signs :- vomiting - fever- hematemesis - ictherus- Loose of body WeightThe history of using chronic OAINS The hystory og gastric cancer in the familypasient 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. Goal of Pharmacotherapy in dyspepsia
• Control symptoms
• Promote healing
• Prevent complications
• Improve health‐related quality of life
• Avoid Adverse effects of treatment
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Pharmacotherapy• Antacids
• Acid Suppression drug
• Prokinetic agent
• Surface agent
DYSPEPSIA
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Dyspepsia Treatment 1. 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 night
b. Ranitidindossage 2x (150-300) mg every morning and night or (300-600) mg at night
c. Famotidindossage 200 mg everyday
3. Motilitas GroupDonperidon 3x1Cisapride 3x (5-10) mg/day
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4. Prostaglandin E GroupMisoprostolemprostil
5. Sitoprotectif :Sukralfat, setraksat, Teprenon
6. Others Medicine :Anti anxietyAnti depresiAnti Convulsant
7. If needed :Surgical therapy : vagotomi
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Medicine to Control Gastric AcidAntacida
(cheap, low compilance, inefective for gastric ulcers, not consistence in maintaning pH Intragastric, interaction with others drugs, can be used in esofagitis refluxs lightly/moderate)
Antagonist reseptor‐H2(Cimetidine, ranitidine, famotidine)
(consistence in maintaining pH Intragastric 4‐8 hours, less efective at meal stimulated and day time acid secretion, easy to takhifilaksis, inefective to protect gastric ulcers for the OAINS users, can be used in esofagitis refluxs lightly/moderate)
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Table 8. The Possibility of the Side effect that can appear after using medicine which control gastric acid
Drugs to control gastric acid The possibility Side effect
Antagonist histamin2H receptor:
Proton Pomp barrier :
Sitoprotektif drugs :
headache, dizziness, nausea, mialgia, skin rash, and itchy
Nausea, diarrhea, can be abdominal cholic. headache, dizziness, and somnolen seldom to see the light rising of transaminase serum
Sukralfat seldom give Side effect, if happen : constipated or dryness on mouth, sometimes abdominal discomfort. No serious side effect caused by teprenone except the rise of aminotransferase serum.
(Shirakabe, 1995; Brunton, 1996)
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Acid supression drugs:• H2RA (H2 Receptor Antagonist)
• PPI (Proton Pump Inhibitor)
CimetidineRanitidineFamotidineNizatidine
OmeprazoleLansoprazolePantoprazoleRabeprazoleEsomeprazole
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Trends in Prescribing of Proton Pump Inhibitorsin General Practice in England
“Newer PPIs offer no advantage in terms ofclinical efficacy over established PPIs, areusually more expensive and have lessevidence for long-term safety.”
MeReC Bulletin 2006;16:9-12
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Total Expenditure of OTC Antisecretory Therapy, USA, 2003–2006
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Bioav
ailability (%
)
Tolman et al, J Clin Gastroenterol 1997; 24: 65–70.Fitton & Wiseman, Drugs 1996; 51: 460–82.
Hassan‐Alin et al, Gastroenterology 2000; 118: A16.Swan et al., Aliment Pharmacol Ther 1999; 13(Suppl 3): 11–7.
Howden, Clin Pharmacokinet 1991; 20: 38–49.
PPI bioavailability after the first dose
809080706050403020100
Lansoprazole Pantoprazole Esomeprazole Rabeprazole Omeprazole
77
64
52
40
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Matur Nuwun