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Teaver # 6c ~ Pacu = Zatvlerns Olvcase | bias ~ Brung com Parise '© Cara menentukan clubbing finger: Pertemukan ke-2 jari yg sama dgn iy kukey berhadapan. Hasilnya, tak ada sudut/ celah, Saling © Icteric mudah dilihat di sclera Karena: aa IT RN RR Mata mengandung scrabut elastic yg sen, sitiy bilirubin, © tha © Pada kasus Sepsis + Hepatic Encephalopati: Pilihan antibiotika sbb: Gentamycin utk Gram (-) 2 x 80 mg Clindamycin 4 x 300 mg. © Pada kasus Chronic Liver Disease: Tuj Tx utk Hepatitis B-nya adih menekan serendah mungkin HBV DNA. © Pada kasus Hepatitis B & C: Hepatitis B jauh lebih bahaya daripada C, karena Virus Hepatitis B berikatan dgn sel langsung, Pada Hepatitis C, berikatan dgn cytosol. © ©. Pada kasus peningkatan kadar LIPASE (N 0-160 mg/dL): 1, Pankreatitis 2. Spasmolitic drugs 3. Sphincter oddie drugs. 9 Pada. kasus Chronic diarrhea: Amoebiasis > kista & topozoit di FL i Basiler > tenesmusProtap utk penanganan Hematemesis Melena : 1, Pasang NGT > Gastric lavage/ 6-8 jam | 2. Puasa dulu. 3. IVFD NS 20-30 tetes/ menit. 4. Metoklopramide 3x10 mg IV. 5. Omeprazole 40-80 mg/ hari IV, Dilanjutkan 8-12 me/ jam selama 24 jam hari 1 4 mg/ jam sclama 24 jam hari {I s/d It ATAU dengan drip 2 ampul dim 500 ce NS > 20 tetes/ menit hari 1 1 ampul dim 500 ce NS > 20 tetes/ menit hari II s/d III. bila pasien tak mampu, dpt diganti dgn : 6. Ranitidin 50-100 mg/ hari, IV. Dilanjutkan 16 mg/jam selama 24 jam hari I 8 me/jam selama 24 jam hari II s/d IIL ATAU dengan drip : 2 ampul dim 500 ce NS > 28 tetes/ menit hari I 1 ampul dim 500 cc NS > 28 tetes/ menit hari II s/d I. i . 7. Ciprofloxacin 500 mg/ hari viaNGT/OTA\ C2 Cita ) 8. Laktulosa 3x30 ce via NGT (hanya bila etiologi karena Cirrhosis). | 0. Beriken Vit. K 3x1 ampul bila PPT memanjang, (@-e.CH) | 10. Berikan FFP 10-15 ce/ Kg BB/ hari bila APTT memanjang. con) | 11, Berikan transfusi 7C’ 4 labu bila trombosit <20.000. Cc #0) 12. Bila anemia, - Transfusi dgn JVB bila profus/ semua komponen drh turun. - Transfusi dgn PRC bila tidak profas i ‘ : imbangkan utk 13. Bila masih profus juga, saat gastric lavage, pertim! oi memberikan J "Adrenalin 2 ampul ke dalam cairan utk lavage yang terakhirPenyebab peningkatan Transaminase Penyakit Hepatobilier Penyakit Myokardial Penyakit pancreas Penyakit otot Alkohol Tone hepatobilicr yg dpt melibatkan Liver DM Defisiensi o 1-antitripsin Infeksi HIV Hipertiroid Penyakit Celiac Penyebab peningkatan Transaminase. kelainan intra hepatic KADAR PENYAKIT Hepatitis virus akut SGPT > 100x ban Hepatitis imbas obat Hepatitis iskemik Hepatitis virus kronis Hepatitis imbas obat Hepatitis autoimun - a. CAEL Ofk toksin L Infeksi virus lain (CMV, DHF) Fatty liver | Hepatitis virus kronis Cirthosis ; Peny. Hati kolestasis Infeksi virus lain (CMV, DHF) SGPT <5x banLama pnggunaan PPI pada Tukak Peptik. . Pylori Disease’ Lamu Pemberian a Gasirie Uleer | Smingga Fdkadakaitan dsm | ee enal Uleer_| 6 minggu | tnfebsi H. Pylori Berkaitan dgn Infeksi H. Pylori PPI + minimal 2 antibiotika selama 7-14 hari 1. Terapi tripel (selama 1 atau 2 minggu) : PPI+ Amoxycillin + Clarithromyein © PPI+ Metronidazole + Clarithromycin © PPI+ Amox + Tetracycline (bila alergi Clarithromycin 2. Terapi kuadripel (selama 1 atau 2 minggu) > jika gagal Tx diatas : Bismuth + PPI+ Amoxycillin + Clarithromycin e Bismuth +PPI+ Metronidazole + Clarithromycin 3. Pada daerah dgn resistensi tinggi : © Bismuth + PPI+ Metronidazole + Tetracycline Dosis : 1. PPI 2x/ hari : 2. Amox 2 x 1000 mg/ hari 3. Clarithromyoin 2 x 500 mg/ hari 4, Metronidazole 3 x 500 me/ hari | Tetracycline 4 x 250 20 mgObstuldf eaundice 7 - Ge: Charcot ’s feiael t- Tcterus a. Qemam 3. Dyspepriae nyen_pert hab: _f Leleos' ( netrf! ”) - wil Tachreck 7 - OT, PT _ AMP tr -_ oat choadard 99 EGRCP Cendoscopic Re cholteyiopancee ad gephy J 1 Batu Cod 2 Tumor porille Volts _ 7 Caper parce’ 4. Paslecoak HF aluf sn Mefey se Tenor p) Kee ports Hepa tik a) Gol® brogeade JERolOg febanyok 2Feneoacey Dx p? pasite B90 Ler BRyU Ss - UL pealesa : i Bilirubin T/O/T x pila wasil: Semue Normal —9 ngka otis 5 oo adi 9 ofh VEPs trricin & a ilienbs nue a conjugated hy pe by Lieu bi fbi liu bnem in Bil Tot gtr Seder (ts pr _ ALP - Oo oT [ee ~ cae Compl! blood count) \ Dx 6-) ot | epijkas, ot kepa KET Ab, B.C ite |e ¢-) Cole pany. pvisinue: — Apa ~ Aati LEM (Livte LiVary Mier somal ~ Ant! Sravoth mus le [0x ¢-) Use Abd Jct scar ey tty fa » cw Y Ox b-7 AFORE) J P10! us aGen Uncenj Ft pee bilire yu - treme iT - Tatunieast obat = Gilleetss £107" = Aeon toma. 3..9ibirabn urine C-) - Gu TOF T Bil ae A Tabel | Lateaheyatic (Con): rAy Pe x gaenne atm = Gall sronel _ Sucgical Shae Te . Taf: COM. CY bie ) Suctal eacc - col qog'0 Ca a. Ente’ de as¥e ductal cc Ca © Rankrtnts \ayrepornn) _ pancrea h iS. Tabel 2 c Post = Policy se Live BY ~ Carts OF ; - Acs - Cholnago Ca Ciclatsa’s Tumer) b . Scleame9 cho (aagitiy o paps Kiar 9 wile Buck: sdoyatic) / EG hepa te 7B. Obste. V3 Kogah — Cholaagio Go — Galt lad 8 Ca. , 5 - pares | _ wisi 28 SP - Scleasis chilaggih's = Cystic fiteosis C. Obst: Ya bw. ~ cholaagid Ca 7 Filensiny dholagg ifr) - Ju mor pan keeas _ Tuer Ampulé _ pancera ROE anit - sft afingtt- Opae = Qavekle ber Dvodeas . pens kes’ 9— Quodinal vler - Lim pm > D)-aya ute mulknopulae of the Livers 1 Circnosis Malignant Beg ener etre Maks baie 2 Hepatocenre ore t fata mee tuk dni Snr a i es oe waste - ye gels fealty stance alubat Lie a lee t 9 proses” pe cena | _dClinical Jaundice in Adults Check urinalysis; measure serum total and direct bilirubin levels Unine positive for bilirubin; increased total bilirubin fevel and increased Alltests normal Look for direct bilirubin level “pseudojaundice” Conjugated High vegetable hyperbilirubinemia intake Liver function tests (AST, ALT, AP, GGT, and CBC t No diagnosis apparent? Screen for hapatitis A.B, and C t No diagnosis apparent? Screen for autoimmune disorders(ANA, anti-LKM. anti-smooth muscle) if no abvious diagnosis, abdomina| US or CT Screen for autoimmune disorders(ANA, anti-LKM, anti-smooth muscle) ino abvious diagnosis, © abdominal US or CT Urine negative ‘or bilirubin; increases. total bitirubin leve’ and normal direct bilirubjn leve Uncojugates hyperbilirubine™ 2 Hemorysis, drug tor ty genetic syncrom@ (Gilbert syndrome hematoma Intrahepatic disease (see table 1) ~———, Extrahepatic disease (see table 2) Stil no aa diagnosis? Consider cholangiography or liver biopsyCara pemakaian Sandostati | i I. Dua ampul 0,1 mg dim 500 ce D5% diberikan selama | 4 jam | / Jika belum berhenti Lanjutkan untuk 4 jam kedua dan ketiga Il. Satu ampul 0,1 mg + 9 cc NS atau D5% > berikan s bolus pelan2 Atau i| i| Dua ampul 0,1 mg masukkan kedalam 500 cc NS atau i D5% > Drip selama 8 j | Tika berhenti Lanjutkan utk 8 jam ke-2 & 8 jam ke-3 Dosis hariannya : 3x1_ampul sub cutan (SC) selama 5 hari Catatan : © Bila terjadi fi RAM perdarahan — profu Kk hukumnya untuk memakai : oa 1. Propanolol > boleh diber setelah bleeding berhenti. Vitamin K > kecuali i ad: FH memanjang, a evidence base bahwa rikan pada hari ke-5 2.Stadium Encephalopathy Hepaticum Fungsi Stadium | Kesadaran | Kognitif | Behaviour | Motorik 0-1 Normal Normal Normal ‘Normal Lambat No ‘Sub Klinis sbmormalitas 1 Gangguan Gangguan | Gangguan | Diskoordinasi | Sangat lambat_| VEP+P300 + tidur Atensi ‘mood 2 Letargis Gangguan | Disinhibisi Asterixis Sangatjelek | Deceleration ‘memori ‘Rach ‘Abnormal ~ Bingung Disorientasi ‘Marah? refleks Phase 3 Dilier Tnkoheren Paranoid Nystagmus : “waves” Semistupor ‘Amnesia Kejang? Babinski 4 ‘Coma “no Hilang Hilarig, Pupil dilatasi - Delta activity response” SSphooke iajlan Barchea Se, Bila Hrwkeskop 8-0 (Ag foveal 2) UOrB j pedacshan SCBA). : ® Cierhot k @ Non Circhot / Priagip “Teaps Sarna + Q) Shop pleedag 2) Regusit) Coin, 3) Korabinast prokeiankle + PPL + qroteleh gb roy Keon lambug. 4) Gaskric Lavage So membataken me Cicrhobd + 1) Baatean gap bohle ube skealisas your: Cipro arwey ; atou Vine \ papheon ota AKA / 2) Ber Lawatev® c Lge tulera 3x30 65) 3) Way pyssa Jebch \xear Cd 2S 6L nay af ) 4) Shih Hon Ka-S. BR ay ben proprons'|ree Volume {cc} st Seo Uta eyP ies! Capillary refill rer eB ert aerate) Wajah Stet eat| 2) Cite yey — Pe h u ek 77 {Poa bum renin.» Mek ve Quly hes Lt pete . 2 aang — Keys: poten Kayon ipl bu tings pe Ion 0 — balay tHepke Enrey halyod