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MEDICAL FACULTY MUSLIM UNIVERSITY OF INDONESIA 2016

PANEL MODUL ACUTE ABDOMINAL PAIN (NYERI AKUT ABDOMEN)

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Page 1: PANEL MODUL ACUTE ABDOMINAL PAIN (NYERI AKUT ABDOMEN)

MEDICAL FACULTY MUSLIM UNIVERSITY OF INDONESIA

2016

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Innal Hamda 11020150019

Amirah Jihan Afry 11020150042

Rindang Cahyani Abas 11020150101

Gita Refina 11020150130

Ftiri Lestari 11020150142

Haerati Hairil 11020150144

Lilis Lestari 11020150152

Andi Mulia Sudirman 11020150154

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A 17 years old female came to clinic with complaints of pain in the main section of the gastric experienced since 3 days eralier, accompanied by nausea and vomiting, especially after eating or drinking. In anamnesis, aware that she regularly taking medication to relieve pain anticolic due to menstruation.

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Nausea

• A stomach distress with distaste for food and an urge to vomit

Vomiting

• An act or instance of disgorging the contents of the stomach through the mouth—called also emesis

https://www.merriam-webster.com/dictionary/nausea

https://www.merriam-webster.com/medical/vomiting

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A 17 years oldPain in the main

epigastric in 3 days

Accompanied by nausea and

vomiting

Especially after taking

medication to relieve pain due to menstruation

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What is the kind of pain experienced of the female in the scenario?

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Somatic pain Visceral pain

Nociceptive stimulus usually evident Most commonly activated by inflammation

Usually well localized Pain poorly localized and usually referred

Similar to other somatic pains in pit’s evident Associated with diffuse discomfort, e.g., nausea,

bloating

Relieved by anti-inflammatory or narcotic

analgesics

Relieved by narcotic analgesics

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What is the patophysiology of nausea and vomiting?

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• Gastric contents are propelled into the esophagus when there is

relaxation of the gastric fundus and gastro esophageal sphincter

• Follow by a rapid increase in intra abdominal pressure produce by

contraction of the abdominal and diaphragmatic musculature.

• Increased intrathoracic pressure results in further movements of the

material to the mouth.

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• Reflex elevation of the soft palate and closure of the glottis protect the

nasopharynx and trachea and complete the act of vomiting.

• Vomiting is controlled by two brainstem areas, the vomiting center and

chemoreceptor trigger zone.

• Activation of the chemoreceptor trigger zone result in impulses to the

vomiting center, which control the physical act of vomiting.

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What is the relation between after the female eating and drinking with the sign from the scenario?

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What is the the effect of NSAID to the pain experienced from the scenario?

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What is the cause of pain in epigastric?

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CAUSE OF PAIN IN THE EPIGASTRIC

Irregular eating or eating too late.

Consuming food too spicy and sour.

Drinks containing alcohol and caffeine as coffee.

Radiation therapy, bile reflux, corrosive substances (vinegar, pepper) causing damage to the gastricmucosa and cause edema and bleeding.

Stressful conditions (trauma, burns, chemotherapy and damage to the central nervous system)

Bile acid is a liquid that helps the digestion of fats, if the ring pylorus is broken and can not functionproperly or removed because of surgery, the bile acids will flow to the stomach, resulting ininflammation and chronic gastritis.

Attacks against the hull. Cells produced by the body can attack the stomach. This event is calledautoimmune gastritis.

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CONT..

There is some disease can make a pain in the epigastrium such as: abnormalities ofthe organs in the abdominal cavity and abnormalities of the organs in the chestcavity. Some of the organs in the abdominal cavity often give epigastric paincomplaints include:

1. Abnormalities in the stomach : acute gastritis, chronic gastritis, ventrikuli ulcer,gastric cancer

2. Abnormalities in the small intestine : duodenitis, ulcer duodeni

3. Abnormalities in the pancreas : pancreatitis

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Based on the scenario, what is the most probable disease from the scenario?

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DYSPEPSIA

Dyspepsia is any symptom of the upper gastrointestinal tract (GI), present for 4 weeks or more, including upper abdominal pain or discomfort, heartburn, acid reflux, nausea, or vomiting. Dyspepsia as any symptom referable to the upper gastrointestinal tract, present for at least four weeks and including upper abdominal pain or discomfort, heartburn, acid reflux, nausea, and vomiting. Further subdivisions included ‘ulcer-like’ (epigastric pain), ‘reflux-like’ (heartburn and acid regurgitation), ‘dysmotility-like’ (bloating and nausea) and ‘unclassifiable’

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GASTRITIS

Many people with gastritis do not have any symptoms, but some people

experience symptoms such as

• upper abdominal discomfort or pain

• nausea

• vomiting

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GASTRITIS

Acute gastritis Chronic gastritis

Vague abdominal complaints, such as anorexia, belching, or nausea, to more severe symptoms such as epigastric pain, vomiting, bleeding and hematemesis.

The early phase of chronic gastritis is superficial gastritis. The inflammatory changes are limited to the lamina propria of the surface mucosa, with edema and cellular infiltrates separating intact gastric glands. Additional findings may include decreased mucus in the mucous cells and decreased mitotic figures in the glandular cells. The next stage is atrophic gastritis. The inflammatory infiltrate extends deeper into the mucosa, with progressive distortion and destruction of the glands. The final stage of chronic gastritis is gastric atrophy. Glandular structures are lost, and there is a paucity of inflammatory infiltrates. Endoscopically, the mucosa may be substantially thin, permitting clear visualization of the underlying blood vessels.

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ULCER PEPTICUM

• Most patients with peptic ulcer disease present with abdominal discomfort, pain or nausea. The

pain is located in the epigastrium and usually does not radiate.

• Patients may describe the pain of peptic ulcer as burning or gnawing, or as hunger pains slowly

building up for 1–2 hours, then gradually decreasing.

• Use of antacids may provide temporary relief.

• Classically, gastric ulcer pain is aggravated by meals, whereas the pain of duodenal ulcers is

relieved by meals.

• Hence, patients with gastric ulcers tend to avoid food and present with weight loss, while those

with duodenal ulcers do not lose weight.

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What is the physical examination?

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PHYSICAL EXAMINATION

• We should begin physical examination by assessing the patient’s generalappearance and the ABC (Airway, Breathing, Circulation) status. The patient’sability to converse, breathing pattern, potion in bed and facial expression shouldbe observed carefully.

• Obese patient should be asked about unusual abdominal enlargement.• Assessment of bowel sound (auscultation) should be conducted before doing

other examination maneuvers (palpation or percussion).• Perform auscultation for at least two minutes and on more than one abdominal

region before concluding any diminished bowel sound.

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CONT..

The physical examination is usually normal in patients withuncomplicated peptic ulcer disease. Epigastric tenderness is neithersensitive nor specific for ulcer. A systematic review evaluated, for thepatient presenting with upper abdominal symptoms, the utility of theclinical examination and various computer models in predicting ifpeptic ulcer disease is present

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What is the additional examination make sure the most suspected disease?

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EGD

• Indicated in patients with evidence of bleeding, weight loss, chronicity, or persistent vomiting;

• those whose symptoms do not respond to medications; and those older than 55 years

• More than 90 percent sensitivity and specificity in diagnosing gastric and duodenal ulcers and cancers.

Barium or diatrizoate meglumine and

diatrizoate sodium (Gastrografin)

contrast radiography (double-contrast

hypotonic duodenography)

• Indicated when endoscopy is unsuitable or not feasible, or if complications such as gastric

• outlet obstruction suspected

• Diagnostic accuracy increases with extent of disease; 80 to 90 percent sensitivity in detecting duodenal ulcers

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Serologic ELISA

• Useful only for initial testing (sensitivity, 85 percent; specificity, 79 percent); cannot be used to confirm eradication

Stool antigen

• Inconvenient but accurate (sensitivity, 91 to 98 percent; specificity, 94 to 99 percent)

• Can be used to confirm eradicatioN

Urine-based ELISA and rapid urine test

• Sensitivity, 70 to 96 percent; specificity, 77 to 85 percent

• Cannot be used to confirm eradication

Urea breath test

• More expensive

• Sensitivity, 95 to 100 percent; specificity, 91 to 98 percent; can be used to confirm eradication

• PPI therapy should be stopped for two weeks before test

Endoscopic biopsy

• Culture (sensitivity, 70 to 80 percent; specificity, 100 percent), histology (sensitivity > 95 percent; specificity, 100 percent), rapid urease (CLO) test (sensitivity, 93 to

• 97 percent; specificity, 100 percent)

Test to detect

H.pylori

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The decision to perform endoscopy in a patientsuspected of having peptic ulcer disease is based on anumber of factors. Patients presenting withcomplications of peptic ulcer disease such as bleedingneed endoscopic evaluation to allow an accuratediagnosis and for the administration of endoscopictherapy. The presence of “alarm” features such asweight loss or recurrent vomiting may prompt concernfor malignancy.

ENDOSCOPY

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Contrast radiography of the upper GI tract, also referredto as the barium meal or an upper GI series, can oftendemonstrate a peptic ulcer.Contrast radiography of the upper GI tract is nowfrequently performed by technicians, and the availabilityof personnel trained in the interpretation of bariumstudies has decreased. A further disadvantage tocontrast radiography is radiation exposure, which can besubstantial.

CONTRAST RADIOGRAPHY

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What is the treatment for the suspected disease?

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Antacid

Histamine-2 Receptor Antagonists

Proton Pump Inhibitors

Antisecretory and Acid-

neutralizing Agents

Sucralfate

Bismuth

Prostaglandin E Analogs

Mucosa protective Surgical

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Antacid

• Mechanism of action.Later studies showed that far smaller doses of antacids (neutralizing capacity 120mmol HCl per day) had virtually identical efficacy for healing peptic ulcerations.

• Adverse effect. Magnesium-containing agents can cause hypermagnesemia; the use of calciumcarbonate can cause hypercalcemia and alkalosis and further renal impairment and aluminumhydroxide antacids can cause aluminum neurotoxicity.

Histamine-2 Receptor

Antagonists

• Mechanisms of Action. cimetidine, ranitidine, famotidine and nizatidine. These compounds arecompetitive inhibitors of histamine-stimulated acid secretion.

• Adverse Effects. Cimetidine has weak antiandrogenic activity that can cause gynecomastia andimpotence.

Proton Pump Inhibitors

• Mechanisms of Action. Decrease gastric acid secretion through inhibition of H+,K+-ATPase, the protonpump of the parietal cell. Five PPIs are (Prilosec), esomeprazole (Nexium; the S optical isomer ofomeprazole), lansoprazole (Prevacid), pantoprazole (Protonix), and rabeprazole (Aciphex).

• Adverse effect. The most commonly reported side effects are headache and diarrhea. Data fromobservational studies have found that PPIs increase the risk of osteoporosis-related fracture.

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Sucralfate

Mechanism of action. thesucralfate molecule containsaluminum hydroxide, theagent has little acidneutralizing capacity. Whenexposed to gastric acid, thesulfate anions can bindelectrostatically to positivelycharged proteins in damagedtissue, thereby forming aprotective barrier that mayprevent further acid-pepticattack.

Bismuth

Mechanisms of Action. Thebismuth forms complexeswith mucus that appear tocoat ulcer craters.

Effects on increasingmucosal prostaglandinsynthesis and bicarbonatesecretion also have beenproposed, and bismuth hasdocumented antimicrobialactions against H. pylori.

Prostaglandin E Analogs

Mechanisms of Action.Endogenous prostaglandins,including prostaglandin E2(PGE2), regulate mucosalblood flow, epithelial cellproliferation, epithelialrestitution, mucosalimmunocyte function, mucusand bicarbonate secretion,and basal acid secretion.

Misoprostol significantlyreduces nocturnal, basal, andmeal-stimulated acidsecretion at a standardtherapeutic dose, althoughthe effect is not as potent asthat of other classes ofantisecretory agents.

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Surgical

• Surgical intervention in PUD can be viewed as being either elective, for treatment of medically

refractory disease, or as urgent/emergent, for the treatment of an ulcer-related complication.

• The development of pharmacologic and endoscopic approaches for the treatment of peptic disease

and its complications has led to a substantial decrease in the number of operations needed for this

disorder. Refractory ulcers are an exceedingly rare occurrence.

• Surgery is more often required for treatment of an ulcer-related complication. Gastrointestinal

bleeding, perforation, and gastric outlet obstruction are the three complications that may require

surgical intervention.

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What is prevention for the suspected disease?

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PREVENTION

Medication regimen, dose, and potential side effects.

Keep food diary and avoid food and substances that trigger gastritis symptoms.

Life style changes: Limit or avoid alcohol consumption, cigarette smoking.

Avoid the use of aspirin and other NSAIDS if clinical feasible. If client must continue to useNSAIDS, PPI maintenance is recommended to prevent recurrences.

In cases of associated pernicious anemia educate the client about injections of Vitamin B12.

Good hand hygiene and safe food handling to decrease exposure to microbes including H. pylori.

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Close medical follow-up.

Have a healthy weight and ideal.

Limit consumption of liquor. The alcohol content can cause irritation on the part of thestomach is inflamed.

Quit smoking. Smoking can inhibit healing and increase the risk of stomach ulcers.

Reducing the comsumption of tea and coffee because they can increase the levels ofstomach acid.

Consuming milk –based products, such as cheese. Experts suspect that milk can protectthe stomach and neutralize the effects of stomach acid.

Avoid spicy or fatty food consumption.

Eating small portions,but more often.This is useful to reduce the buidup of stomach acid.

CONT..

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How is the perspective islam?

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QS. AL-'A`RAF [7] : 31

بنى ءادم خذوا زينتكم عند كل مسجد وك هۥ ل يحب لوا وٱشربوا ول تسرفوا إن ي

ٱلمسرفين

Son of Adam, wear beautiful clothes in every (enter) mosque, eat and drink,

and do not exaggerate. Allah loves not those who exaggerated.

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See you in the next panel