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LaboratoryAssessment ofThe Digestive
System Disorder
Kemas Ya’kub RahadiyantoClinical Pathologist
2015
Disampaikan dalam kuliah I tanggal ! "a#et 2015
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u$uan Inst#uksional
• "ahasis%a mengetahui dan memahamip#insip peme#iksaan labo#ato#is padakelainan sistem digesti& dan hepatobilie#
• "ahasis%a mengetahui dan memahamiaspek p#e analitik' analitik dan postanalitik peme#iksaan labo#ato#is
• "ahasis%a mengetahui dan dapatmenginte#p#etasi hasil peme#iksaankelainan sistem digesti& dan hepatobilie#
d#( Kemas Yakub )pPK 2
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Konsil Kedokteran Indonesia,SKDI 2012
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Konsil Kedokteran Indonesia,SKDI 2012
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d#( Kemas Yakub )pPK *
Level of Competencies 4
• "outh – Candidiasis – "outh ulce#
+apthous' he#pes,• )tomach and
duodenum – -ast#itis – -ast#oente#itis
• .i/e# – atty .i/e# – epatitis
– 3ncomplicatedepatitis 4 – moebic epatitis
bcess
• e$unum and Ileum – 6nte#itis
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d#( Kemas Yakub )pPK 7
.e/el o& Competencies !
• Pediat#ic – -ast#o8esophageal #e9uks – -ast#o8ente#itis – :o#ms – Pe#itonitis ube#culosis – ood lle#gy
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d#( Kemas Yakub )pPK 10
.e/el o& Competencies ;4• 6sophagus
– Co##osi/e lesion o& esophagus
• cute bdomen – Ileus – ppendicula# abcess
• )tomach and duodenum – -ast#o8duodenal ulce# – -ast#o8intestinal bleeding
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d#( Kemas Yakub )pPK 11
.e/el o& Competencies ;• "outh
– -lossitis• 6sophagus
– Re9u< esophagitis• cute bdomen
– )alphingitis – cute appendicitis
• -all bladde#' 4ileduct and Panc#eas – cute cholecystitis
• Colon – I##itable 4o%el
)yd#ome – =ec#oti>ing
ente#ocolitis – Di/e#ticulosis ?
di/e#ticulitis – Colitis – Rectal anal p#olaps – P#octitis – aemo##oids
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d#( Kemas Yakub )pPK 12
• Pediatric 3B – -ast#o8ente#itis %ith dehyd#ation – Dehyd#ation
• Pediatric 3A – "alabso#bsion – ood Intole#ance – 3mbilical e#nia – epatitis – Ci##hosis o& the li/e#
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d#( Kemas Yakub )pPK 1;
:hat kind o& labo#ato#y test
that #elated %ith thedigesti/e diso#de#@
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E "outh ulce# +apthous' he#pes, – Complete blood count, "erum
– #i$erential leu%oc&te count, Peripheral blood
– 'erritin, "erum – !luca on, Plasma
– ron, "erum – Potassium hyd#oanck smea#' )pecimen – itamin 4 12 ' )e#um
d#( Kemas Yakub )pPK 15
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d#( Kemas Yakub )pPK 1F
)tomach and duodenum
• -ast#itis – 4#ushing cytology' )pecimen' Diagnostic – Campylobacter 8like o#ganism test' )pecimen – olic acid' )e#um – -ast#in' )e#um – !astroscop&, #ia nostic – Helicobacter pylori , uic% o-ce serolo &,
"erum and titer, Blood – .istopatholo &, "pecimen
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– /ccult blood, "tool – Pepsinogen I and pepsinogen II' 4lood – 0rea breath test, #ia nostic
– itamin 4 12 ' )e#um
• -ast#oente#itis – 'ecal leu%oc&tes, "tool, #ia nostic – Meat 1bers, "tool – "tool culture, 2outine, "tool
d#( Kemas Yakub )pPK 1G
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)tomach and duodenum
• -ast#o8duodenal ulce# – 4 g#oup and Rh type' 4lood – mylase' )e#um – 4#ushing cytology' )pecimen' Diagnostic – Complete blood count' 4lood – 6ndoscopic ult#asonog#aphy' Diagnostic – -ast#in' )e#um – !astroscop&, #ia nostic – Helicobacter pylori , uic% o-ce serolo &,
"erum and titer, Blood
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– .istopatholo &, "pecimen – Lipase, "erum
– /ccult blood, "tool – Pepsinogen I and pepsinogen II' 4lood – :ashing cytology' )pecimen
d#( Kemas Yakub )pPK 17
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• -ast#o8intestinal bleeding – Blood urea nitro en creatinine ratio,
Blood
– Complete blood count, Blood – 6sophagogast#oduodenoscopy' Diagnostic – /ccult blood, "tool – T&pe and crossmatch, Blood ("creen)
d#( Kemas Yakub )pPK 20
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6sophagus• Re9u< esophagitis• Co##osi/e lesion o& esophagus• -ast#o8esophageal #e9uks
d#( Kemas Yakub )pPK 21
Pediat#icE -ast#o8ente#itisE :o#ms
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Peritonitis Tuberculosis
• bdominal ult#asound'Diagnostic• mylase' )e#um• 4lood cultu#e' 4lood• 4lood gases' #te#ial' 4lood• 4ody 9uid + scitic 9uid,'
mylase' )pecimen• 4ody 9uid + scitic 9uid,'
nae#obic' Cultu#e• 4ody 9uid' ungus' Cultu#e• 4ody 9uid + scitic 9uid,'
Mycobacteria ' Cultu#e• 4ody 9uid + scitic 9uidH
3#ine,' Routine' Cultu#e
• 4ody 9uid analysis + scitic 9uid,'Cell count' )pecimen• Bod& uid c&tolo & (Ascitic
uid), "pecimen• Ce#eb#ospinal 9uid' .actic acid'
)pecimen
• Chest #adiog#aphy' Diagnostic• Complete blood count, Blood• Computed tomog#aphy o& the body
+ bdomenH %ith Cont#ast,'Diagnostic
• C+reactive protein, "erum or
plasma• *lectrol&tes, Plasma or serum• lat8plate #adiog#aph o& the
abdomen' Diagnostic
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– -enital' Candida albicans ' Cultu#e – -enital' Neisseria gonorrhoeae ' Cultu#e – istopathology' )pecimen – .actic acid' 4lood – .actate dehyd#ogenase' 4lood – .i/e# batte#y' )e#um – "agnetic #esonance imaging' Diagnostic – Pa#acentesis' Diagnostic – P#oth#ombin time and inte#national no#mali>ed #atio'
4lood – )edimentation #ate' 6#yth#ocyte' 4lood
d#( Kemas Yakub )pPK 2;
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Acute Abdomen
• )alphingitis• cute appendicitis
• ppendicula# abcess – Blood culture, Blood – Bod& uid (Abscess), Anaerobic, Culture – Complete blood count, Blood
– Comp#ession ult#asonog#aphy' Diagnostic – Computed tomog#aphy o& the body + bdomen,'
Diagnostic
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d#( Kemas Yakub )pPK 2F
ColonE I##itable 4o%el )yd#omeE =ec#oti>ing ente#ocolitisE Di/e#ticulosis ? di/e#ticulitisE ColitisE Rectal anal p#olapsE P#octitis
• aemo##oids – Complete blood count' 4lood – Proctoscop&, #ia nostic
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Liver
• lanine aminot#ans&e#ase')e#um
• lkaline phosphatase' )e#um• ntimitochond#ial antibody'
)e#um• ntinuclea# antibody' )e#um• 4ili#ubin' otal' )e#um• Ce#uloplasmin' )e#um• Complete blood count' 4lood• -amma8
glutamylt#anspeptidase' 4lood
• epatitis se#ologies' )e#um
• .eucine aminopeptidase' 4lood
• E .i/e# batte#y' )e#um• .i/e# biopsy' Diagnostic• .i/e# scan' Diagnostic• .i/e# ult#asonog#aphy'
Diagnostic• 5 8=ucleotidase' 4lood• #nithine
ca#bamoylt#ans&e#ase' 4lood• P#oth#ombin time andinte#national no#mali>ed #atio'
Plasma• )t#iational antibody' )pecimen
d#( Kemas Yakub )pPK 2*
Fatty Liver
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• epatitis – cetaminophen' )e#um – lanine aminot#ans&e#ase' )e#um – lbumin' )e#um – lbumin?globulin #atio' )e#um – lkaline phosphatase' Isoen>ymes' )e#um – lkaline phosphatase' )e#um – lpha8antit#ypsin' )e#um – lpha8&etop#otein' )e#um – ntimitochond#ial antibody' 4lood
d#( Kemas Yakub )pPK 27
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– ntiLsmooth muscle antibody' )e#um – spa#tate aminot#ans&e#ase' )e#um – E 4ili#ubin' Di#ect' )e#um
– 4ili#ubin' Indi#ect' )e#um – 4ili#ubin' 3#ine – C1M immune comple< detection' )e#um – C; complement' )e#um – C! complement' )e#um – Chemist#y p#oAle' 4lood – Cytomegalo/i#us antibody' )e#um
d#( Kemas Yakub )pPK ;0
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– 6pstein84a## /i#us' )e#ology' 4lood – -amma8glutamylt#anspeptidase' 4lood – epatitis antibody' Ig" and Ig-' 4lood
– epatitis 4 co#e antibody' 4lood – epatitis 4 e antibody' )e#um – epatitis 4 e antigen' 4lood – epatitis 4 su#&ace antibody' 4lood – epatitis 4 su#&ace antigen' 4lood – epatitis C antibody' )e#um – epatitis C genotype' )e#um
d#( Kemas Yakub )pPK ;1
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– epatitis delta antibody' )e#um – E epatitis se#ologies – istopathology' )pecimen
– .actate dehyd#ogenase' Isoen>ymes' 4lood – E .i/e# batte#y' )e#um – .i/e# biopsy' Diagnostic – .i/e# scan' Diagnostic – .i/e# ult#asonog#aphy' Diagnostic – .upus test' 4lood – "ethot#e
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– 5 8=ucleotidase' 4lood – #nithine ca#bamoylt#ans&e#ase' 4lood – P#otein elect#opho#esis' )e#um
– P#oth#ombin time and inte#national no#mali>ed#atio' Plasma – )alicylate' 4lood – o
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• 3ncomplicated epatitis 4• moebic epatitis bcess
d#( Kemas Yakub )pPK ;!
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Kemas Yakub R' d#( )pPK ;F
)tool nalysis• -I bleeding'• -I obst#uction'
• bst#ucti/e $aundice'• Pa#asitic disease'• Dysente#y'
• 3lce#ati/e colitis' and• Inc#eased &at e
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Kemas Yakub R' d#( )pPK ;G
• n adult e
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Kemas Yakub R' d#( )pPK ;*
eces a#e composed o& the&ollo%ing mate#ialsO
• :aste #esidue o& indigestible mate#ial +eg' cellulose,om &ood eaten du#ing the p#e/ious ! days
• 4ile +pigments and salts,O stool colo# is no#mally dueto bile pigments that ha/e been alte#ed by bacte#ialaction(
• Intestinal sec#etions• :ate# and elect#olytes• 6pithelial cells that ha/e been shed• .a#ge numbe#s o& bacte#ia
• Ino#ganic mate#ial +10N820N,' chie9y calcium andphosphates• 3ndigested o# unabso#bed &ood +no#mally p#esent in
/e#y small Muantities,
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Kemas Yakub R' d#( )pPK ;7
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Kemas Yakub R' d#( )pPK !0
. 4 R RY 6) 6P 4I.I RY DI)6 )6) =DDI)6 )6) 6 P =CR6 )
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Kemas Yakub R' d#( )pPK !1
i
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!2
natomi isiologi ati
• isce#al o#gan
• 4e#at 1(; kg +adult,(• e#letak pada sisi kanan ba%ah diaph#agm(• e#lindung diba%ah a%cus costae dan pada
o#ang sehat no#mal tidak te#aba + palpated,(
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!;dr. Kemas Yakub SpPK 43
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!!
• Pe#da#ahan O – ( hepatica
;00 ml?’
– ( po#ta 1050 ml?’• .obulus Q unit
&ungsional – 50(000 L
100(000lobulus?hepa#
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!5dr. Kemas Yakub SpPK 45
Principal Function of the Liver
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!F46
Principal Function of the Liver Formation & secretion bile
Nutrient & vitamin metabolism•Glucose & other sugars• Am !o ac ds•" p d•#at$soluble % tam !s• ater$soluble % tam !s
Inactivation various substances
• 'o( !s•Stero ds•)ther hormo!esSynthesis of plasma proteins• Acute phase prote !s• Album !•*lott !g +actors•Stero d$b !d !g & other hormo!e$b !d !gprote !s
Immunity •Kup++er cells
"enggolongkan tes &ungsi
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!Gdr. Kemas Yakub SpPK 4,
enggolongkan tes &ungsihati
• )i#kulasi da#ah media kont#as• )istem bilia# bili#ubin metabolit• )el8sel hati >at disintesis
• ' dak dapat memast ka! causa• -era at kerusaka!
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!*
Tu5uan pemeri%saan 'aal.ati
1( 3ntuk diagnosisO ada?tidaknyapenyakit hati $enis penyakit hati
2( )k#iningO dilakukan bila diduga adapenyakit hati laten
;( ollo% up penyakit hati!( P#ognosisO pada umumnya makin be#at
kelainan &aal hati makin besa#ke#usakan p#ognosis makin bu#uk
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!7
5( Diagnosis 4andingOE epatomegaliE scitesE Pe#da#ahan )alu#an Ce#naE Ikte#us
a, Ikte#us emolitik +P#ehepatik,b, Ikte#us Pa#enkimatik + epatik,
c, Ikte#us bst#uksi +Post epatik,
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50
Peme#iksaan ungsi ati• Total bilirubin, direct bilirubin• Al%aline phosphatase,• -- '• Total protein,• ?- #atio' albumin,• A"T 6 ALT•
.D '• /i#al hepatitis panel'• P
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51dr. Kemas Yakub SpPK 5/
Bilirubin
• P#oduk akhi# %atabolisme heme • be#asal da#i O b' myoglobin dan
en>im pe#na&asan• )ebanyak 20 N bili#ubin' bukan da#i
heme e#it#osit tua da#i sel+sel
immatur di lien dan sumsum tulang komponen ini akan meningkat padakeadaan hemoliti%
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52
!" 0bGlob !
0eme0emos der !
1 l rub !2plasma
$1 bebas
$ ter kat Alb$'ak larut dlm a r
$ !d rek 1 l.
0epar
$Pelepasa! kata!album !
$- ko! ugas o asamGlukoro! dase
1 l. - glukoro! dase21 l. - rek 1 l.
#$pedu
%sus
%ro&ilino'en
!akteri ususen (
%ro&ilin
Feses (
Sterco&ilin
S e b a g a ! k e c l
"etabolisme 4ili#ubin
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5;dr. Kemas Yakub SpPK 53
M*TAB/L "M* B L 20B 7
Kata&olis$e
)& !iliru&in*erikat al&u$in%ncon+u'atedPLAS A
Su$&er lain
-A I./A. /in+al
ikroso$hepar
F
usus
!akteri usus
!iliru&indi'lukoronida
%ncon+ &iliru&in
uro&ilino'en
sterko&ilin
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5!
1 l rub ! totalde asa
,57 d rek 857 !d rek
9e!e!tuka! :e! s kterus Pe!t !g u!tuk9e!e!tuka! 'erap
• 1 l rub ! total ora!g de asa ;
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55
P#ocedu#e• btain a 58m. nonhemoly>ed sample om
a &asting patient( bse#/e standa#dp#ecautions( )e#um is used(
• P#otect the sample om ult#a/iolet light+sunlight,(
• /oid ai# bubbles and unnecessa#y shakingo& the sample du#ing blood collection(
• I& the specimen cannot be e
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5F
4ili#ubin dalamu#ine
• =o#mal tidak ditemukan bili#ubindalam u#ine
• danya bili#ubin dalam u#ine se#ingmendahului ge$ala kuning
• Pende#ita se#ing men$elaskanu#inenya be#%a#na kuning gelap 2 L; ha#i sebelum timbul kuning padaskle#a dan kulit
3# bili d l
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5G
3#obilinogen dalamu#ine
• es u#obilinogen me#upakan . yangpaling lemah nilai diagnostiknyaka#ena hasilnya selalu meningkat
mulai da#i ke#usakan hati yang paling#ingan sampai kelainan yang palingbe#at
• es ini tidak dapat menge/aluasikelainan hati ka#ena banyak penyakitlain yang menyebabkan u#obilinogenu#ine meningkat
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3# bili #i i&
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57
3#obilinogen u#ine negati&menun$ukkanO
• bst#uksi total da#i salu#an empedu• nemia
• Pembe#ian obat8obatan sepe#ti 4#oad)pect#um ntibiotic yang menekanpe#obahan bili#ubin men$adi
u#obilinogen oleh bakte#i usus
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F0
ypical acute epatitis( ingkat p#od#omal
Pada tingkat ini ikte#us belum tampak)- )-P meningkat seca#a p#og#esi&
mulai da#i G L 1! ha#i sebelum ikte#uslkaline &os&atase no#mal atau sedikit ↑Ikte#us indeks no#mal4ili#ubin sedikit ↑ te#utama bil(Digluko#onida3#obilinogen u#ine ↑ kemudian ↓4ili#ubin u#ine kadang8kadang + , positi&
4( i k t ikt #ik
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F1
4( ingkat ikte#ikDitandai dengan timbulnya ikte#us bili#ubinu#ia $elas te#lihat seca#amak#oskopisKada# bili#ubin total ↑ te#utama bil(Digluko#onida(
4ila te#lihat skle#a ikte#us bil( otal S ;mg3#obilinogen u#ine &eses ↑
lkaline &os&atase↑' )- )-P ↑Koleste#ol total +=, tetapi kolest( 6ste# ↓P#otein total #atio ?- be#ubah6lekt#o&o#ese O ditemukan ↑ γ globulin
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F2
C( ingkat Kon/alesenPende#ita mulai be#angsu# sehat T 2 LF minggu
Peme#iksaan lab( be#angsu# no#mal+kembali no#mal ; L ! bulan,
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F;
lcoholic .i/e# Disease
Pemakai alkohol $angka %aktu lamamenyebabkan gangguan padametabolisme sel hati no#mal' yangditandai dengan peningkatan sintesa&atty acid( kibatnya menyebabkanpembekakan sel lemak hati disebut
&atty li/e#
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F!
• Pada keadaan lebih lan$ut penyakitini dapat menyebabkan nec#osispada sel8sel hati yang se#ing dise#taidengan stasis bili#ubin dan $aundice
alcoholic hepatitis• Pada keadaan k#onik da#i alcoholic
li/e# disease ini se#ing menyebabkanpo#tal ci##hosis
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F5
-amba#an labo#ato#ium• )- )-P ↑ nec#osis sel8sel hati• Ratio )- )-P S 2 te#$adi pada G0N
alcoholic li/e# disease
• -- ↑ en>im ini me#upakan indikato#yang sensiti& pada pemakai alkoholk#onis
• .P ↑ ka#ena cholestasis tapi tidakmempunyai ko#elasi dengan alcoholichepatitis
• 4ili#ubin se#um ↑ ka#ena cholestasis
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FF
• )e#um immunoglobulin ↑• P ↑ ka#ena ↓ sintesis p#ot#ombine'
II' IU U• Di$umpai anemia mac#ocytic ka#ena
deAsiensi &olic acid' anemia palingse#ing te#$adi pada alcoholic li/e#
disease• e#dapat leucocytosis #adang padahati
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FG
epatitis K#onis• Disebut hepatitis k#onis apabila
ditemukan ge$ala klinik lebih da#i Fbulan setelah &ase akut hepatitis(
• epatitis tidak menyebabkanhepatitis k#onis
• 5 L 10N disebabkan oleh hepatitis 4• 20 L !0N disebabkan oleh keadaan
lain
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F*
-amba#an labo#ato#ium• .epatitis %ronis
a%tif – Peningkatan )-
)-P 7 L 10 < da#i
no#mal – Peningkatan γ globulin te#utama Ig-
– Peningkatan se#umbili#ubin +S ! mg?dl,
– Peningkatan .P – Penu#unan se#um
albumin
• .epatitis %ronispersisten – Peningkatan )-
)-P V 5 < = – Peningkatan se#um
bili#ubin V ! mg?dl – Peningkatan γ
globulin
– Peningkatan .P
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F7
Ci##hosis epatis• Yaitu ke#usakan hati bentuk lan$ut
yang ditandai oleh ke#usakanp#og#esi& pa#enkhim hati penambahan $a#ingan pa#ut( – Po#tal ci##hosis +.aennec,
be#hubungan dengan malnut#isi
alkoholism – 4ilie# ci##hosis post nec#otic ci##hosis me#upakan lan$utan hepatitis
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G0
• Pada keadaan inakti&' %alaupuntingkat ci##hosis sudah lan$utpeme#iksaan lab( sepe#ti O – 4ili#ubin se#um – .P – 6n>ym – est &aal metabolisme
9as h?ormal
Aka! tetap test 1SP me!u! ukka! rete!s @a!g me! !gkat
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G;
• 4ila ada ascites' bisa di$umpaigangguan keseimbangan ai# elekt#olit' dan $uga hypoalbuminemia
• Pada coma hepaticum amonia da#ah↑ sedangkan kada# u#eum ↓ ka#enakemampuan hati untuk mengubahamonia men$adi u#eum te#ganggu
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G!
epatic ailu#e• Ke#usakan pada sel hati dapat
disebabkan oleh be#macam >at to
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G5
-amba#an labo#ato#iumO
Ditandai dengan ↑ bili#ubin S !0 mg ↓ sek#esi bili#ubin
• Ke#usakan lebih pada hati dapatmenyebabkan gagal hati dimana te#$adinec#osis sel hati
• Dapat te#$adi oligou#i sebagaikomplikasi da#i penyakit hati
hepato#enal synd#ome
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GF
• ↓ albumin disebabkan sintesis p#otein ↓• Koleste#ol ↓ penu#unan sintesis
koleste#ol di hati• )- )-P ↓ lebih cepat• -lukose ↓ ka#ena penyimpanan
glikogen di hati ↓• P ↑ ka#ena penu#unan sintesis
p#ot#ombin' III' IU U di hati
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8lasi1%asi
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G*dr. Kemas Yakub SpPK ,=
8lasi1%asi 9aundice i%terus
:; Prehepati% 8 bili#ubin total se#um meningkat +bili#ubin
uncon$ugated?indi#ek, 8 #ansaminase O = 8 lkali &os&atase O =
8 P#otein O = PenyebabO hemolisis %elainanmetabolisme bilirubin
8lasi1%asi
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G7dr. Kemas Yakub SpPK ,>
8lasi1%asi 9aundice i%terus
< .epati%
8 $aundice?ikte#usO cepat 8 #ansaminase meningkat 8 lbuminO menu#un
Pen&ebab = penyakit hepa#
8lasi1%asi
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*0dr. Kemas Yakub SpPK =;
8lasi1%asi 9aundice i%terus
3 Post hepati% 8 kegagalan cai#an empedu mencapai
duodenum 8 4ili#ubin con$ugated meningkat 8 lkali &os&atase meningkat 8 Koleste#ol total meningkat 8 )teato##hoe 8 "alabso#psi it 'D'6'K
Pemeri%saan Laboratorium
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*1dr. Kemas Yakub SpPK =/
untu%pen&a%it hati (hepatobilier)
• 4ili#ubin total0';81 mg?dl 4ili#ubin di#ek V 0'25 md?dl• lkali &os&atase +;00C, G;820G 3?.• spa#tate t#ansaminase laki8laki sp 25 3?. + ) ?)- , %anita sp 21 3?.• lanin t#ansaminase laki8laki sp 27 3?. + . ?)-P , %anita sp 22 3?.• -amma -lutamyl laki8laki *8;* 3?.
#anspeptidase %anita5825 3?. +γ - ,
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*2dr. Kemas Yakub SpPK =8
Pemeri%saan Laboratoriumuntu%
pen&a%it hati (hepatobilier)
• lbumin ;'585g?d.• γ globulin 0'581'5 g?d.• P#ot#ombin time +P , 10W81!W
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*;dr. Kemas Yakub SpPK =3
6=XI"86=XI" 4) R3K I
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*!dr. Kemas Yakub SpPK =4
AL8AL '/"'ATA"*• e#dapat pada semua $a#ingan
• u pada epitel usus' tubulus gin$al'
tulang +osteoblas,' hati' plasenta• Yang be#ada dlm se#um tu be#asal
da#i hati?t#aktus bilia#is dan 50Nbe#asal da#i tulang
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*5dr. Kemas Yakub SpPK =5
AL8AL '/"'ATA"*
• "eningkat ta$am pada keadaanO 8 obst#uksi ekst#ahepatik +10812U=, 8 Kanke# tulang + 10825U=,
8 steitis de&o#mans +Peny Paget,
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*Fdr. Kemas Yakub SpPK =6
AL8AL '/"'ATA"*
• "edi%it menin %at pada = 8 bst#uksi int#ahepatik 8 hipe#pa#ati#oidisme
8 penyembuhan sesudah aktu#
!T( !lutam&l
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*Gdr. Kemas Yakub SpPK =,
!T( !lutam&lTransverase)
• 4e#asal da#i sistem hepatobilier
• "eningkat pada semua $enis penyakit hati
• Peningkatan >+3? @ 7 pada obst#uksiint#a ?post hepatik
• Lebih sensitif daripada al%ali fosfatase
untuk mendeteksi obstructive jaundice kolangitis' kolesistitis' ka#ena meningkatlebih dini dan menetap lebih lama
!T ( !lutam&l
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**dr. Kemas Yakub SpPK ==
!T ( !lutam&lTransverase)
• 4ila kada#nya meningkat 7 hepatitis' &atty li/e#
• Pada penyakit skeletal dan tulangnilainya no#mal sehinggapeme#iksaan ini dapat dipakai untukmemasti%an apa%ah penin %atan
al%alifosfatase berasal daripen&a%it tulan atau hati
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*7dr. Kemas Yakub SpPK =>
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70dr. Kemas Yakub SpPK >;
Peme#iksaan lainO
• 5’ nucleotidase• .eusine aminopeptidase
"!/T #A7 "!PT
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71dr. Kemas Yakub SpPK >/
"!/T #A7 "!PT
• e#dapat dalam sitoplasma danmito%ondria sel hati
• Pada %erusa%an hati rin an ' )-yang masuk dalam plasma' adalah)- yang be#asal da#i sitoplasma
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"!/T #A7 "!PT
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7;dr. Kemas Yakub SpPK >3
"!/T #A7 "!PT
• )-P S )- pen&a%it hepar
• )-P V )- )- S)-P pen&a%it mio%ard
02*0M
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7!dr. Kemas Yakub SpPK >4
02 0M
• asil akhi# katabolismeprotein asam amino yang te#banyak
• Disintesis da#i amonia di dalam hati
• 6ksk#esi tu melalui in5al= urin 'sedikit melalui %erin at
• 3#eum mengalami deg#adasi olehba%teri usus
%reu$
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75dr. Kemas Yakub SpPK >5
%reu$
reum d + ltras secara pas + d 'lo$eruli'in+al034056
rea ? 2ka!du!ga! ! troge! dalam ureumdalam whole blood 7 plas$a atau seru$
Kadar ureu$ dala$ plas$a dipen'aruhi ( $ !take prote ! dalam maka!a! $ kapas tas ekskres oleh g ! al
02*0M d 02*A 7
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7Fdr. Kemas Yakub SpPK >6
02*0M dan 02*A 7
• 8adar normal dalam plasma 3#ea = O G81* mg?d. 3#eum O 158;5 mg?d.
• 8adar normal dalam urine 3#ea = O 12820 mg?d. 3#eum O 258!; mg?d.
A /T*M A
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7G
dr. Kemas Yakub SpPK >,
A /T*M A• Peningkatan kada# ureum dan
%reatinin yang be#makna• ADotemia prerenal = ka#ena pe#&usi gin$al tidak cukup
Alt#asi glome#ulus menu#un• *tiolo i= =
dehid#asi' shock' penu#unan /olumeda#ah' bendungan $antung' katabolismep#otein yang meningkat
A /T*M A
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7*
dr. Kemas Yakub SpPK >=
A /T*M A• ADotemia renal disebab%an=
8 -lome#uloneitis 8 =eitis k#onis 8 =eoskle#osis 8 ubula# nek#osis
• ADotemia Post renal= 8 ka#ena obst#uksi salu#an kemih sehingga
u#eum diabso#psi ke dalam si#kulasi
P*70207A7 8A#A2
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77
dr. Kemas Yakub SpPK >>
02*A+7 "*20M• =ut#isi yang miskin
• Intake cai#an yang be#lebihan
• Pembe#ian cai#an int#a /ena yangbe#lebihan
• Kehamilan
.*PAT T "
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100
• Pe#adangan hati – Peningkatan ma#ke# hepatitis• kut K#onis
epatitis A
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101
dr. Kemas Yakub SpPK /;/
.epatitis A
)A
IK*# %S
243 8 hari
Fase akut
Anti )A I'/ 9I' 6
Anti )A I'
Fase penye$&uhan03:0 hari
I$unitas*hn6
epatitis B
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102
dr. Kemas Yakub SpPK /;8
.epatitis B
)!eA'
)!sA'
Anti )!cA'
Anti )!cI'
Anti )!e Anti )!s
!kubas4$/8 mg
Fase akut2312 $'
Post fase akut231; $'
Post !+eks6bl!$th!
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epatitis C
-
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10!
epatitis C
-
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105
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106/129
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10*
Tumor markersTumor markers
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107
Tumor markersTumor markers
• Tumor markers are usually proteinswhich are produced from cancer cells or
as response to cancer• Cancer specific
• Tissue specific
T kT k
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110
Tumor markersTumor markers
• Cancer specific of certain canceroustissue BUT large overlap (low specificity)
• Tissue specific i.e PS ! "P! B#$C%!
thyroglo&ulin
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111
'n oncology tumor markers are used
• Screening i.e PS
• onitoring i.e "P• *iagnosis (when &iopsy is not feasi&le)• *etermine prognosis
Tumor markers C+Tumor markers C+
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112
Tumor markers CTumor markers C
• Comple, glycoprotein that is associated withthe plasma mem&rane of tumor cells! fromwhich may &e released in the &lood
• +levated specially in Colon cancer! But lso inPancreatic! %astric! -ung! &reast and variancancer
• -S in cirrhosis! inflammatory &oweldisease! chronic lung disease! pancreatits! /01of smokers! 21 of healthy population
Tumor markers C+Tumor markers C+
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11;
Tumor markers C+Tumor markers C+
• 3 T satisfactory for screening for ahealthy population
• onitor of recurrence
• onitor of treatment
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Tumor markers "PTumor markers "P
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11F
Tumor markers PTumor markers P
• Testicular germ cell tumor (em&rional orendodermal)diagnosis
monitor of recurrence ; responseprognostic marker (9/66.666
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11G
AS"< SP#"IAL A *I"L#
2000 %pdate of eco$$endations for the %se of *u$or arkersin !reast and "olorectal "ancer("linical Practice /uidelines of the A$erican Society of "linical
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11*
/>>, Becomme!dat o! C *DA s !ot recomme!ded to be used as a scree! !g test +or colorectal ca!cer.
8;;; Becomme!dat o! C ?o cha!ge.
/>>, Becomme!dat o! C *DA ma@ be ordered preoperat %el@ ! pat e!ts th colorectalcarc !oma + t ould ass st ! stag !g a!d surg cal treatme!t pla!! !g. Although ele%ated preoperat %e *DA 2E 5 !g m" ma@ correlate
th poorer prog!os s< data are !su++ c e!t to support the use o+ *DA to determ !e hether to treat a pat e!t th ad u%a!t therap@.
8;;; Becomme!dat o! C ?o cha!ge.
"#A as a arker for "olorectal "ancer
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117
/>>, Becomme!dat o! C + resect o! o+ l %er metastases ould be cl ! call@ !d cated<t s recomme!ded that postoperat %e serum *DA test !g ma@ be per+ormed e%er@
8 to 3 mo!ths ! pat e!ts th stage or d sease +or 8 or more @ears a+ter d ag!os s.
A! ele%ated *DA< + co!+ rmed b@ retest !g< arra!ts +urther e%aluat o! +or metastat c d sease but does !ot ust +@ the !st tut o! o+ ad u%a!t therap@ or s@stem c therap@ +or presumed metastat c d sease.
8;;; Becomme!dat o! C ?o cha!ge.
"#A as a arker for "olorectal "ancer
"#A k f " l t l "
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120
/>>, Becomme!dat o! C Prese!t data are !su++ c e!t to recomme!d rout !e use o+ the serum *DA alo!e +or mo! tor !g respo!se to treatme!t.
+ !o other s mple test s a%a lable to !d cate a respo!se
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121
"A 1:3: As a arker for Pancreatic "ancer
2006 recommendation for use of CA 1 ! as a screenin" test# *A />$> s !ot recomme!ded +or use as a scree! !g test +or pa!creat c ca!cer.
2006 recommendation for use of CA 1 ! to determine operability#
'he use o+ *A />$> test !g alo!e s !ot recomme!ded +or use ! determ ! !g operab l t@
or the results o+ operab l t@ ! pa!creat c ca!cer.
2006 recommendation for use of CA 1 ! to provide evidence of recurrence# *A />$> determ !at o!s b@ themsel%es
ca!!ot pro% de de+ ! t %e e% de!ce o+ d sease recurre!ce thout seek !g co!+ rmat o! th mag !g stud es +or cl ! cal + !d !gs a!d or b ops@.
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122
2006 recommendation for use of CA 1 ! for monitorin" response to therapy# Prese!t data are !su++ c e!t to recomme!d the rout !e use o+ serum *A />$> rules alo!e +or mo! tor !g respo!se to treatme!t.
0o e%er< *A />$> ca! be measured at the start o+ treatme!t +or locall@ ad%a!cedmetastat c d sease a!d e%er@ / to 3 mo!ths dur !g act %e treatme!t.
+ there s a! ele%at o! ! ser al *A />$> determ !at o!s< th s ma@ be a! !d cat o! o+ progress %e d sease< a!d co!+ rmat o! th other stud es should be sought.
"A 1:3: As a arker for Pancreatic "ancer
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Kemas Yakub R' d#( )pPK 12;
• ischbach' #ances alaska• itleO "anual o& .abo#ato#y
Diagnostic ests' Gth 6dition• Copy#ight Z200! .ippincott
:illiams :ilkins
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d#( Kemas Yakub )pPK 12!
Re&e#ence
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125
Re&e#ence• Rohen :' Chihi#o Y' 6lke .DH Color Atlas of Anatomy ' ! th ed• ischbach' HManual of Laboratory & Diagnostic Tests ' Gth
6d' 200!' .ippincott :illiams :ilkins' ;!F L *' ;*F 8 75• lte#ations in epatobilia#y unction' 6ssential o&
Pathophysiology
P3I)I -6. P
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12F
I%an )ulistia%anH "iskin tapi )ombong'2007
ante#a si#na pu#nama-adis layu pada nisan te#luka.ahan ke#ing pe#ti%i gulita
a#apan menyu#am di dinding tema#am ikam menta#i pada $i%a yang kelam asad hitam se#igala te#sungku#=gan8angan' mpi8mimpi' de%a langit te#kubu#Kausalitas dalam galau tak tuntas
=omo#8nomo# pada buku tanpa ke#tasDamp#at memunc#at pada batuItu sunyi tak $uga membeku
P3I)I -6. P
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12G
I%an )ulistia%anH "iskin tapi )ombong'2007
9Ante#a si#na pu#nama!A dis layu pada nisan te#lukaLA. an ke#ing pe#ti%i gulita.A #apan menyu#am di dinding tema#amT kam menta#i pada $i%a yang kelam
9Asad hitam se#igala te#sungku#7!A7 8angan' mpi8mimpi' de%a langit te#kubu#8A0 salitas dalam galau tak tuntas
7/mo#8nomo# pada buku tanpa ke#tas
#A mp#at memunc#at pada batutu sunyi tak $uga membeku
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12*
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