Harrison

Indigestion: term nonspesifik, termasuk di dalamnya:

- nausea
- vomiting
- heartburn
- regurgitation
- dyspepsia: presence of symptoms thought originate in gastroduodenal region:
++ epigastric burning
++ gnawing (spt diremas2) discomfort
++ nyeri
+ postprandial fullness
+ early satiety
+ bloating
+ eructation (belching, bersendawa)
+ anorexia
Dispepsia fungsional:
- postprandial fullness, early satiety, or epigastric pain/burning with symptom
s onset at least 6 months before diagnosis in absence of organic cause
- prior to GI infection
--------------------
Approach:
1. alarm features: BB V, muntah rekuren, GIT bleed, ikterus, massa/adenopati, ri
w kanker GIT, odinofagi: endoskopi; UBT, blood serologym stool antigen
2. tdk ada: empirik
a. tdk berhasil: endoskopi
3. <5 thn durasi heartburn, <50 thn: endoskopi (barrett's)
ambulatory esofageal pH, bernstein test, manometry
PPI/AH2, antasida, sukralfat
eradikasi Hpilori
other:
- antireflux surgery (fundoplication
--------------------
Emesis:
1. unpleasant thought/smells
-> cerebral cortex
-> cranial nerves (gag reflex) -> vomit
-> mungkin pathway cannabinoid CB1
2. motion sickness
-> inner ear (labyrinthine apparatus)
-> reseptor muskarinik M1 & histaminergik H1
3. gastric irritants & cytotoxic agents (such as cisplatin)
-> gastroduodenal vagal afferent nerves
-> reseptor 5HT3
4. Nongastric visceral afferents
-> intestinal & colonic obs & mesenteric ischemia
5. emetogenic drugs/toxins
-> bacterial toxins, drug, metabolic factors (uremia, hipoksia, ketoasidosis)
-> area postrema (nukleus medulari)
-> reseptor 5HT3, M1, H1, dopamin D2
Ex:
1. INtraperitoneal
a. Obstruksi
- pilorik/small bowel/colonic obst
- superior mesenteric artery syndrome
+ after weight loss or prolonged bed rest
+ duodenum terkompresi oleh overlying superior mesenteric artery
b. infeksi usus
- viral (CMV or herpes simplex in immunocompromise)
- bakteri (staph aureus, bacillus cereus, esp in child)
c. inflammatory disease
- kolesistitis
- pankreatitis
- app
- hepatitis
d. altered sensorimotor funct
- gastroparesis
+ post vagotomi, dgn adeno ca pankreas, DM, skleroderma, amiloidosis
+ idiopatik: gejala prodormal virus
- intestinal pseudoobst
- GERD
- chronic idiopatic nnausea: several times weekly
- functional vomiting: >=1 episode muntah dalam seminggu tanpa eating disorder
atau psikiatri
- cyclic vomiting syndrome
+ langka, sering pada anak
+ berhubungan dgn migrain
+ rapid gastric emptying, chronic cannabis use
e. biliary colic: visceral afferent
f. abdominal irradiation: impairs motor function, induces strictures
2. ekstraperitoneal
a. cardiopulmo
- kardiomiopati
- MI
b. labyrinthine
- motion sickness
- labyrinthitis
- malignancy
c. intracerebral
- malignancy
- hemoragik, hidrosefalus
- abses
d. psikiatrik
- anoreksia/bulimia
- depresi
e. post op vomiting
3. medications/metabolic
a. drugs
- ca chemotherapy
- antibiotics
- cardiac antiarryhthmics
- digoxin
- OHO, KB oral
b. endokrin
- pregnancy
- uremia, KAD
- tiroid, paratiroid
- insufisiensi adrenal
c. toksin: liver failure, ethanol
==========
Drugs:
1. Antiemetic agents
a. Antihistamin:
- dimenhidrinat, meclizine
- motion sickness, inner ear
b. antikolinergik
- skopolamin
- idem
c. antidopaminergic 5HT3 antagonist
- proklorperazine, thiethylperazine
- medication, toxin, metabolic induced emesis
d. NK1 antagonist
- ondansetron, granisetron
- kemo, radiasi, post op emesis
e. tricyclic antidepressant
- aprepitant
- kemo
f. other antidepressant
- ami, nortriptilin
- chronic idiopatik, functional vomiting, cyclic vomiting synddrome, gastropar
esis
+ mirtazapine
+ functional vomiting, gastroparesis
2. prokinetic agents
a. 5HT4 agonis & antidopaminergik
- metoklopramid (tardive diskinesia <25%)
- gastroparesis
b. motilin agonist
- eritromisin
- gastroparesis, intestinal pseudoobst
c. periferal antidopaminergik
- dompe (dont cross brain, except hipofisis -> hiperprolaktin)
- gastroparesis
d. somatostatin analogue
- ocreotide
- intestinal pseudoobstr
e. aCh esterase inhibitor
- piridostigmin
- small intestinal dysmotility/pseudoobst
3. Special settings
a. benzo (lorazepam)
- anticipatory nauseea & vomiting with chemo
b. glucocorticoids
- metilpred, dexa
- kemo
c. cannabinoids
- tetrahydrocannabinol
- kemo