Get That Cow Milk Away

From Me, Please!!

August 28th, 2009
Group 10
Tutor : dr. V Wiwing
Faculty Medicine of Tarumanagara
University

MEMBERS
Name

NIM

Ivo Ariandi

405070015

Fiona

405070016

Andi

405070022

Novi Ayunita Santoso

405070040

Boyke Sitompul

405070050

Lovina

405070054

Miske Marsogi

405070055

Algri Wijaya

405070108

Meilie Arianie

405070111

Merlin Kodir

405070117

Rika Stefani TJ

405070119

Anne

405070147

SCENARIO
You receive a call from Mrs. Melati, mother of Rosa, a
previously healthy 2-month old girl. For the past 3
days, Rosa developed an occult bleeding and
mucous in the stool accompanied by a moderate
degree of emesis. However, her temperature hasnt
increased, no abd cramping or colic, but today she
seems a bit pale and more irritable.
Unfortunately Mrs. Melati didnt breastfeed Rosa
about a week ago, and give her regular cow milk
formula. While you are discussing her family history,
Mrs Melati reports that Rosas brother and sister are
having food allergy, her 6 year old brother is
asthmatic as well as his father. The mother assumed
that he has the same dairy product allergy like his 3
year old sister.
You tell her to bring him for further diagnostic
investigation and call the lactation clinic for a
counseling appointment in order to return to
exclusive breastfeeding.

Learning Objective
Anatomy of digestive tract
Physiology of digestive tract
Pathophysiology:
Emesis
Occult bleeding & mucous in the stool
Differential diagnosis from:
Emesis
Occult bleeding & mucous in the stool

DIFFICULT WORDS
emesis /emesis/ (em-sis) vomiting.
occult bleeding escape of blood in such small quantity
that it can be detected only by chemical test or by
microscopic or spectroscopic examination.
irritable /irritable/ (ir-tah-b'l)
1. capable of reacting to a stimulus.
2. abnormally sensitive to stimuli.
3. prone to excessive anger, annoyance, or impatience.
colic /colic/ (kolik)
1. acute paroxysmal abdominal pain.
2. pertaining to the colon.
(Dorland's Medical Dictionary for Health Consumers. 2007 by
Saunders, an imprint of Elsevier, Inc. All rights reserved.)

ANATOMY OF DIGESTIVE
TRACT

PHYSIOLOGY OF
DIGESTIVE TRACT

MOUTH
Saliva:
-Glands: parotid, sublingual
& submandibular
-Minor gland: Buccal
-99.5% H2O, 0.5% protein
(amylase, mucus, lysozyme,
& electrolyte)
Functions:
-Amylase:polisaccharide
dissacharide
-Mucus: lubrication, foodcondensing
- as a solvent stimulate d
tastebud
- articulation
-Hygiene
-HCO3- netralizing acid from
foods + bacteria prevent
caries

Other input: tanpa rangsangan oral, cth: berpikir, melihat, membaui,

mendengar

PATHOPHYSIOLOGY

Mucose barrier weakened due to

infection

Exudate formation & blood

vessel in lamina propria

Blood & mucous in stool

Pathophysiology of Stool with Blood &

Mucous

Pathophysiol
ogy of
Emesis

DIFFERENTIAL DIAGNOSIS
DIAGNOSA BANDING PENYEBAB EMESIS
Infeksi

Sepsis, Menigitis, ISPA/URI,

Otitis media, Parasit ( giardiasis, ascaris ),
Gastritis dari H. pylori, GEA ( virus,
bakteri ), Hepatitis, Pertusis, Pneumonia,
Faringitis Streptokokus

Toxin

Aspirin, Theophylin, Digoxin, Anti-convulsant, Barbiturate

Neoplasma

Tumor intarakranial, Hamil

Trauma

Hematoma duodenum, Trauma pada pankreas, Hematoma

intrakranial

Kongenital/anatomic

Stenosis pylorus hipertofik, Duodenal Atresia, Malrotasi, Kelainan

Hirschprug, Anus Imperforata

Inflamasi

Cholecystitis atau cholelthiasis, Apenddictitis, Necrotizing

enterocolitis, Peritonitis, Penyakit Ciliac, Peptic ulcer, Pancreatitis

Gastrointestinal

Refluks Gastro-esofageal ( GRD ), akalasia, Intussusepsi,

Volvulus, Hernia Inkarserata, Benda Asing

Metabolic/genetic

Galactosemia, Intoleransi Lactosa, Intoleransi Fruktosa, Diabetes

REGURGITATION
Definition:
effortless movement of stomach contents Into the
esophagus and mouth. It is not associated with distress,
and infants with regurgitation are often hungry
immediately after an episode

Regurgitation is a result of GER (gastroesophageal

reflux) through an incompetent, or in infants,
immature lower esophageal sphincter
This is often a developmental process and
regurgitation or spitting resolves with maturity
Usually revolves in 80% infants by 6mo, 90% by 12mo

REGURGITATION
Sign & Symptoms:
Weight loss
Halitosis
Indigestion
Chronically raw and chapped lips

GERD
Gastroesophageal reflux (GER) is a common, selflimited process in infants that usually resolves by
six to 12 months of age. The prevalence of GER
peaks between 1 ~ 4 mo of age
If complications develop or regurgitation persists, GER is
considered pathologic (considered as gastroesophageal
reflux disease, GERD) rather than merely developmental
& deserves further evaluation & treatment

GERD or acid reflux, is a condition in which the

liquid content of the stomach regurgitates (backs
up or refluxes) into the esophagus

Classifying GERD
Gastroesophageal
Reflux

Physiological
Gastroesophageal Reflux GER

Primary GERD:
Motility problem
Affecting lower
Esophageal sphincter

Gastroesophageal Reflux
Disease GERD
(Symptomatic)

Secondary GERD:
External factor causing
transient relaxations of
lower Esophageal sphincter
(eg. Food allergy)

Pathophysiology
GER occurs when the lower esophageal sphincter (LES) opens
spontaneously, for varying periods of time, or does not close
properly and stomach contents rise up into the esophagus. GER
is also called acid reflux or acid regurgitation, because digestive
juicescalled acidsrise up with the food. The esophagus is the
tube that carries food from the mouth to the stomach. The LES
is a ring of muscle at the bottom of the esophagus that acts like
a valve between the esophagus and stomach.
When acid reflux occurs, food or fluid can be tasted in the back
of the mouth. When refluxed stomach acid touches the lining of
the esophagus it may cause a burning sensation in the chest or
throat called heartburn or acid indigestion. Occasional GER is
common and does not necessarily mean one has GERD.
Persistent reflux that occurs more than twice a week is
considered GERD, and it can eventually lead to more serious
health problems. People of all ages can have GERD.

Symptoms

GER is common in healthy infants. More than half of all babies

experience reflux in the first 3 months of life, but most stop
spitting up between the ages of 12 to 24 months. Only a
small number of infants have severe symptoms.
An infant with GER may experience :

spitting up
vomiting
coughing
irritability
poor feeding
blood in the stools

In a small number of babies, GER results in symptoms that cause

concern. These symptoms include

poor growth due to an inability to hold down enough food

irritability or refusing to feed due to pain
blood loss from acid burning the esophagus
breathing problems

Examination

Endoscopy
Biopsies
X-rays
Examination of the throat and larynx
Esophageal acid testing
Acid perfusion test

Treatment
Treatment
Life style
modification

Elevation of the upper body at night generally is recommended for all

patients with GERD

GERD Diet

* These foods should be avoided and include:

Chocolate, peppermint, alcohol & caffeinated drinks
* Fatty foods (which should be decreased) and smoking (which should
be stopped) also reduce the pressure in the sphincter and promote
reflux
* Chewing gum stimulates the production of more bicarbonatecontaining saliva and increases the rate of swallowing.

Antacids

Antacids neutralize the acid in the stomach so that there is no acid to

reflux
they do so for only a short period of time
The best way to take antacids, therefore, is approximately one hour
after meals or just before the symptoms of reflux begin after a meal.
Since the food from meals slows the emptying from the stomach, an
antacid taken after a meal stays in the stomach longer and is
effective longer

Histamin
Antagonist

The first medication developed for more effective and convenient

treatment of acid-related diseases, including GERD, was a histamine
antagonist, specifically cimetidine (Tagamet)
Histamine is an important chemical because it stimulates acid
production by the stomach

Treatment
Protein Pump
Inhibitor

The second type of drug developed specifically for acid-related

diseases, such as GERD, was a proton pump inhibitor (PPI),
specifically, omeprazole (Prilosec)
The advantage of a PPI over an H2 antagonist is that the PPI
shuts off acid production more completely and for a longer period
of time
Five different PPIs are approved for the treatment of GERD,
including omeprazole (Prilosec), lansoprazole (Prevacid),
rabeprazole (Aciphex), pantoprazole (Protonix), and esomeprazole
(Nexium). A fifth PPI product consists of a combination of
omeprazole and sodium bicarbonate (Zegerid). PPIs (except for
Zegarid) are best taken an hour before meals

Pro Motility Drug

Pro-motility drugs work by stimulating the muscles of the

gastrointestinal tract, including the esophagus, stomach, small
intestine, and/or colon. One pro-motility drug, metoclopramide
(Reglan)
Pro-motility drugs increase the pressure in the lower esophageal
sphincter and strengthen the contractions (peristalsis) of the
esophagus

Foam Barriers

Foam barriers are tablets that are composed of an antacid and a

foaming agent.
There is only one foam barrier, which is a combination of
aluminum hydroxide gel, magnesium trisilicate, and alginate
(Gaviscon).

Surgery

The surgical procedure that is done to prevent

reflux is technically known as fundoplication and is
called reflux surgery or anti-reflux surgery

INFECTION
PARASITES
BACTERIA
VIRUSES

OCCULT BLEEDING
IN STOOL

EMESIS

Salmonella

++

Campylobacter

++

Shigella

++

+++

E.Coli

+++

++

Vibrio

++

++

Entamoeba histolytica

++

Crytosporidium

++

Cyclospora

++

Giardia

++

Norovirus

+++

Rotavirus

+++

Bacteria

Parasites:

Viruses:

- disappear
often

+ seldom

++ common +++

Giardia Lamblia
(PATHOGENESIS)

Patologi dan gejala :

Diare, disertai
steatore kaerena
gangguan absorpsi
lemak.
Gangguan absorpsi
karoten, folat, dan
vit. B12.
Produksi enzim
mukosa juga
berkurang
Sindrom
malabsorpsi
Penyerapan bilirubin
shg menghambat
aktivitas lipase
pankreatik

FOOD ALLERGY

FOOD ALLERGY
Food allergy is a group of disorders in which
symptoms result from immunologic responses to
specific food antigens
Epidemiology:
Males > females; more in infants w/ history of
atopy
6% of children during 1st 3yr of life
Reactions: IgE mediated & non IgE mediated
IgE mediated are caused by inflammatory
mediators released when food antigen binds
specific IgE antibody on mast cells and basophils
rapid development of symtomps
Non IgE mediated reactions are cell mediated and
develop over hours to days

FOOD ALLERGY
In infancy hypersensitivity is most often associated
with ingestion of cow's milk or soy protein.
Although nursing can prevent the development of
food illergy, manifesiations of food allergy,
especially proctocolitis, can occur with nursing.
Cow's milk in the mother's diet is the most common
identifiable cause of food-allergic reactions in
nursing infants; reaction to peanut, soy, or egg in
the mother's diet occurs less often.
Among infants and children with food allergy, 90%
of reactions are to egg, milk, peanut, soy, or wheat.
Seventy-five per cent of children with proven food
allergy react only to a single food.

Major Food Allergens

Class 1
Food

Protein

Allergen Name

Cows milk

-Lactoglobulin
Casein

Bos d-8
Bos d-5

egg

Ovomucoid

Gal d1

Peanut

Vicilin
Conglutin

Ara h 1
Ara h 2

Fish

Paralbumin

Gad c1

FOOD ALLERGY
IgE mediated:
Oral allergy syndrome
GI anaphylaxis
Others
Non IgE mediated:
Allergic protocolitis
Food induced enterocolitis
Celiac disease

Food Allergy IgE Mediated

Food Allergy
IgE Mediated
Oral Allergy
Syndrome

Allergen contact to oropharynx itching

or tingling and angioedema of the lips,
tongue, palate, and throat
These symptoms may precede other IgEmediated manifestations of food allergy.
Allergy to pollen (hay fever) is also common
In these patients.
Facial erythema from contact with citrus
and tomato products is not consideredn
immune response.

GI Anaphylaxis

Rapid onset of nausea, cramping

abdominal pain, vomiting, or diarrhea or a
combination of these conditions occurs
after ingestion of an allergen.

Allergic Proctocolitis
1day ~ 3 mo age presents w/ spots or streaks of
blood and mucus in stool & occasional mild diarrhea
Increased numbers of white blood cells in stool and
peripheral eosinophilia may be present; nodular
lymphoid hyperplasia occurs in ~ 25 %of case
Most often, caused by hypersensitivity to cows
milk; soy sensitivity < common
This disorder also occurs in exclusively breast-fed
patients and occasionally abates with maternal diet
modification with elimination of milk products.
Non-breast-fed infants can be treated with protein
hydrolysate formulas. Occasionally, an amino acidbased formula may be required.

Food Induced Enterocolitis

Protracted vomiting and diarrhea begin
between 1 wk and 3 mo of age. Less severe
reactions can occur in older children and
adults
Stools contain occult blood, neutrophils, and
eosinophils. Jejunal biopsy demonstrates
flattened villi, edema, and inflammatory cells
Symptoms resolve within 72 hr of removal of
the offending food and recur within 1-6 hr of
reintroduction

Diagnosis
Food allergy is suspected when typical
symptoms occur with the introduction of
specific food
Other non allergic mechanisms of food
intolerance should be rulled out (ex:
compromised digestive or absorptive
process, contamination w/microbes &toxins,
or pharmacologic activity of foods)
Elimination diet and subsequent double-blind,
placebo controlled food challenge (DBPCFC)
gold standart for diagnosis food allergy

Treatment & Prognosis

Elimination of diet. Most manifestations resolved within
several days, some may take weeks
Infants at high risk for developing food allergy may benefit
from breast-feeding and the elimination of solids and
cow's milk protein from their diet for the 1st 6 mo of life
Child w/ severe & life threatening IgE mediated reactions
should have access to injectable antihistamine &
epinephrine
Hydrolysate formula, amino acid based formula
Removal of cows milk from mothers diet
85% infants w/ non IgE mediated food hypersensitivity to
milk proteins no longer have symtomps on food challenge
by 3 yr of age
Resolution of symptoms from cow's milk or soy protein
hypersensitivity is common by 1 yr of age

INTUSSUSCEPTION

INTUSSUSCEPTION
Intussusception is the most frequent cause of
intestinal obstruction in the first 2 years of life.
Male > females.
The predisposing factors are:
Polyps
Meckel diverticulum
Omphalomesenteric remnants
Duplications
Henoch Schnlein purpura
Lymphoma
Lipoma
Parasites
Foreign bodies
Viral enteritis with hypertrophy of Peyer patches.

INTUSSUSCEPTION
Clinical Findings:
Characteristically, a thriving infant between the
ages of 3 and 12 months develops recurring
paroxysms of abdominal pain with screaming and
drawing up of the knees.
Vomiting and diarrhea occur soon afterward (90%
of cases), and bloody bowel movements with
mucus appear within the next 12 hours (50%).
Diagnosis:
history, x-ray, barium enema
Treatment:
Barium enema, surgery

LACTOSA INTOLERANCE

Lactose Intolerance
Definition
Lactose intolerance, also called lactase deficiency,
means you aren't able to fully digest the milk sugar
(lactose) in dairy products.

Symptoms
Begin 30 min ~ 2 hrs after ingestion foods that
contain lactose
Common sign&symptoms: diarrhea, nausea,
flatulence, bloating, abd cramps

Risk factor:
Age.
Ethnicity.
Premature birth.

Lactose Intolerance
Types:
Normal result of aging for some people
(primary lactose intolerance)
Result of illness or injury (secondary lactose
intolerance)
small intestine decreases lactase production
after an illness, surgery or injury to your
small intestine.
It can occur as a result of intestinal diseases
Condition you're born with (congenital lactose
intolerance)

Test & Treatment

Tests and diagnosis
Lactose tolerance test.
Hydrogen breath test
Stool acidity test

Treatment:
Use lactase enzyme tablets.
Take a calcium supplement
Try probiotics

Conclusion
in this case we studied about :
Anatomy of digestive tract
Physiology of digestive tract
Pathophysiology:
Emesis
Occult bleeding & mucous in the stool
Differential diagnosis from:
Emesis
Occult bleeding & mucous in the stool

Suggestion
We recommended Rosas mother to
join with lactation clinic
Follow the doctors instruction
We suggest Rosas mother to give
exclusive breast feed

References
Current. Diagnosis & Treatment in Pediatrics.
2007. USA : Mc Graw-Hill companies
Sudoyo, Aru W. Buku Ajar Ilmu Penyakit
Dalam. 2006. Jakarta: FKUI
Kliegman RM, Berhman RE, Jenson HB,
Stanton BF. Nelsons Textbook of Pediatrics.
18th ed. Philadelphia: WB Saunders Co, 2007.
www. Emedicine.com
www. Medicinenet.com

Thank you