ibd (crhon's disease, kolitis)
DESCRIPTION
KuliahTRANSCRIPT
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KOLITIS ULSEROSA
Divisi Gastroentero-Hepatologi
FK USU / RSUP HAM.
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IBD ( INFLAMMATORY BOWEL DISEASE)
ULCERATIVE COLITIS
CRHON’S DISEASE
DEFINISI : INFLAMASI KRONIK DIFUS NON SPESIFIK PD MUKOSA KOLON DGN KLINIS REMISI & EKSASERBASI.
LOKALISASI :RECTUM – SIGMOID – COLDES – COLTRANS - COLASS44% PROCTITIS - PROCTOSIGMOIDITIS
36% PROCTOCOLITIS
18% PANCOLITIS
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EPIDEMIOLOGI
EROPA & USA :
INSIDENSI = 7/100.000/TAHUN
PREVALENSI = 90-170100.000
SEMUA GOL UMUR : SAMA
PUNCAK I DEKADE : 2, II : (5), III : (6).
JAHUDI >> EROPA
ASIA – AFRIKA DI ISRAEL – INTERPLAY – LINGKUNGAN - GENETIK
1875 : WILKS & MOXON (PERTAMA SEKALI)
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ETIOLOGI
1940 : PSIKOSOMATIK ?
1950-1990 : AUTOIMMUN ?
> 1990a : MULTIFAKTORIAL
MULTIFAKTORIAL :
* GENETIK
* INFEKSI
* EMOSI / PSIKIS
* LINGKUNGAN
* MEROKOK
* IMMUNOLOGI
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PATOLOGI / PATOGENESELAPISAN:MUKOSA-SUB MUKOSA-L PROPRIA-MUSKULARIS
GAMBARAN : ERITEMA, EDEMA, KONTAK BLIDING.
ABSES KRIPTUS PECAH
PSEUDO POLIP TUKAK PERFORASI
(FULMINAN)
PATOLOGI ANATOMI :
RADANG KRONIK NON SPECIFIK
- GOBLET SEL
- MIKROABSES
- EOSINOFIL SEL
- PMN LEUKOSIT
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PATOFISIOLOGI :
STIMULUS
MULTI FAKTORIAL
ACTIVATOR CEL
MASTCELL
PHAGOCYTIC MACROPHAGE NEUTROPHIL EOSINOPHIL
T. LYMPOSYT
PROTEASE, OXYRADICALCYTOTOXIC LYMPOSYT COMPLEMEN, CYTOKININ
INTESTINAL RESPONS
EPITHEL DAMAGE & EXFOLIATION
EROSION & ULCERASI
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KLINIS INITIAL SYMPTOM’S COL-ULCERATIVE PD 113 PASIEN
SYMPTOM % SYMPTOM %
DIARRHEA 96,4 LOSS OF APPETITE 15,2
BLOOD IN STOOL 89,3 OPHTHALMO PATHIES 7,1
PAIN 81,3 NAUSEA 6,3
GENERAL UNWEIL 40,2 VOMITING 4,5
WEIGHT LOSS 38,4 ABSCESSES 3,6
ARTHRALGIA 27,7 FISTULA 3,6
FEVER 20,5 LYMPH NODE SWELLING 1,8
SKIN CHANGES 15,2
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INTESTINAL SIGN AWAL /TAHUNINTESTINAL BLEEDING 80% 100%
DIARRHEA 52 % 85%
ABDOMINAL PAIN 42% 35%
ANAL FISURA 4% 4%
ANAL FISTULA 0% 0%
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MANIFESTASI EXTRA INTESTINAL
MATA : IRIDOCYCLITIS, UVEITIS
MULUT : STOMATITIS, APHTAE
KULIT : ERYTHEMA NO DOSUM, PYODERMA GANGGRENOSUM
HATI : PRIMARY SCLEROSING, CHOLANGITIS PERICHOLANGITIS.
PANKREAS : PANKREATITIS
SENDI : MONOARTRITIS, OLIGOARHTRITIS ANKYLOSING, SPONDILITIS.
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TINGKAT KEPARAHAN
MILD MODERATE SEVERE
STOOL FREQUENCY < 4 X > 6 X > 10X
BLEEDING SLIGHT PROFUSE CONTINUOUS
FEVER ( - ) > 37,5 > 38,8
HEMOGLOBLIN > 10G/DL < 10 G/DL < 8 G/DL
BSR < 30 MM > 30 MM > 50 MM
ALBUMIN NORMAL 3 – 4 G/DL < 3 GR/DL
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KRITERIA DISEASE ACTIVITY INDEX (DAI)/(CAI)
PENILAIANSCORE
0 1 2 3
Frekuensi BAB Normal Diare
1-2 x /hari
Diare
3-4 x /hari
Diare
>4 x /hari
Hematochezia (-) Darah
Bercak
Darah
Campur Feses
Darah Predominan
Perendoskopi
(Kondisi Mukosa)
Normal Kontak Bleeding Sedikit
Kontak Bleeding Banyak
Exudasi, Perdarahan
Spontan
Penilaian Dokter
Berat-Ringan
Normal Ringan Sedang Berat
Maximum CAI = DAI adalah 12
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GAMBARAN ENDOSKOPIC
GRADE 0 REMISION PALE MUCOSA, TARQUET VESSEL
GRADE I SLIGHT ACTIVITY ERYTHEMA, SLIGHTY GRANULALED SURFACE, LOSS OF VASCULAR PATTERN.
GRADE 2 MODERATE ACTIVITY SINGLE ULCER, VELVETY MUCOSA, CONTACT DAN SPONTANEUS BLEEDING
GRADE 3 HIGHT ACTIVITY PUS, SPONTANEUS BLEEDING, LARGER ULCERACE.
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DIAGNOSTIK
KLINIK : DIARRHEA, BLOOD, PAIN
HISTORY : GENETIK ?
PHISIC DIAGNOSTIC : ABD PAIN, EXTRAINTESTINAL
L A B : BSR ,CRP , LEUCYTE , TROMBOCYTE , SPE
RADIOLOGY :
AWAL : GRANULATED MUCOSA, EROSION & ULCER
LANJUT : “SHIRT STUD” ULCER, HAUSTRA DAN
PEMENDEKAN COLON.
KRONIK : HIATUS (-)/PIPE LINE,SHRINKAGE, PSUDOPOLIP
USG : PENEBALAN DDG USUS/KOLON OK PERADANGAN.
ENDOSKOPI : KLASIFIKASI ENDOSKOPI 0/1/2/3PA : RADANG KRONIK NON SPESIFIK : SEL GOBLET MUKOSA
MIKROABSES EOSINOFIL CEL PMN LEUKOSIT
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DIFRENSIAL DIAGNOSTIK
DD
INFEKSI
NON INFEKSI
KOLITIS ACUTT BAKTERIAL
KOLITIS AMUBA
AB - KOLITIS
IBS – DIVERTIKULOSIS
CROHN’S DISEASE
KOLITIS ISKEMIK
RADIASI
KEGANASAN
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PERBEDAAN KOLITIS ULSEROSA & CROHN’S
KOLITIS ULSEROSA CROHN’S DISEASE
TINJA DARAH (+) /LENDIR DARAH (-)/STEATERHOE
PAIN ( + ) ( ++ )BB (+)/SEDANG (++)MASSA ABD
JARANG SERING
LESI PERIANAL
RINGAN BERAT
LOKASI KOLON KOLON/USUS HALUS
BA-ENEMA DIFUS, KOLON DISTAL /REKTUM.
SEGMENTAL,STRIKTUR, KOLON
PROXIMAL ILEUM.
1. KLINIS
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KOLITIS ULSEROSA
CROHN’S DISEASE
GOBLESTONE ( - ) ( + + + )
INVOLVEMENT CONTINOUS DISCOTINOUS
RECTAL INVOLMENT ALWAYS 20%
VESSEL ABNORMAL NORMAL
ERYTHEMA/EDEMA (+++) (+)
VULNERABILITY (+++) (+)
BLEEDING (+++) (+)
PUS/MUCOSA (+++) (+)
LOCAL ULCER (+) (+++)
FISSURA ULCER (+) (+++)GRANULARITY ( + ) (+++)STRIKTURA (+) (+++)PSUDOPOLIP (+++) (++)
2. ENDOSKOPI
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KOLITIS ULSEROSA
CROHN’S DISEASE
CRYPT INJURY (++) (++)GRANULANS ( - ) (++)TRANSMURAL INFLAMATION
( - ) (+++)
MUCOSAL INFLAMATION (+++) ( - )LYMPHOID HYPERPLASIA
( - ) (++)
DEEP ULCER (+) (++)MICROSCOPIC FOCALITY ( - ) (+++)CRYPT ABSCESES (+++) (+)GOBLET CELL DEPLETION
(+++) (+)
FLAT ULCER (++) (+)
3. HISTOLOGY
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KLASIFIKASI CROHN MENURUT VIENNA
A1 A2 L1 L2 L3 L4 B1 B2 B3
Umur <40 >40
Lokasi Terminal Ileum
Kolon Ilio
Kolon
Upper GI
Perilaku Penyakit
Strik
tura (-)
Striktura (+)
Perforasi (+)
LABEL ALB
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SEVERE ACUTE COLITIS
PARENTERAL GSC
MILD/MODERATE COLITIS
5-ASA/SASP,(ORALLY)OR RECTALLY ACCORDING TO EXTENT
NO IMPROVMENT
IMPROVMENT IMPROVMENT NO IMPROVMENT
ORAL GCS+5-ASA REMISIONGCS, ORALLY OR
RECTALLY
CHRONICALLY ACTIVE DISEASE
MAINTENANCE WITH 5-ASA
RELAPSE
GCS ORALLY
REPEATED RELAPSE
REMISION
AZATHIOPRINE
CYCLOSPORINE INTRAVENOUSLY
COLECTOMY
ALGORITMA : PENANGANAN KOLITIS ULSEROSA
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Berat
Algoritma : PENATALAKSANAAN PENYAKIT CHROHN
Sedang-Ringan
Kortikosteroid IV antibiotik
Respons (-)
Sisklosporin IV
Surgikal
Respons (+)Respons (-)
Kortikosteroid oral Diet polimerik atau
elemental
Respons (+)
Respons (+)
Tappering dose
Kortikosteroid Dosis normal
Azatioprin/ 6MP
Respons (+)
Respons (-)
Dosis pemeliharaan
azatioprin/6MPMetotrets
atSurgikal
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PRIMARY ATTACK
WRONG DIAGNOSIS
(“SELF-LIMITING”)
REMISSION CHRONIC ACTIVITY
CARCINOMA
RELAPSE
POSSIBLE COURSES OF ULCERATIVE
COLITIS
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KOMPLIKASI :
- PERDARAHAN MASIF
- PERFORASI USUS
- ISCHIORECTAL ABSES.
- PSEUDOPOLIP
- KEGANASAN
- STRIKTURA
- TOXIC MEGACOLON.
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DIAGNOSTIK TOXIC MEGA COLONRADIOLOGIK : DISTENSI KOLON (> 5 CM)
KLINIS : SEKURANGNYA 3 DARI
- FEVER > 380 C
- HR > 120 /MNT
- NEUTRPHOHILIC LEUCOCYTOSIS > 10,5X109.
- ANEMIA
SEKURANGNYA 1 DARI
- DEHYDRATION
- HYPOTENTION
- ELECTROLITE DISTURBANCE
- ALTERED CONSCIOUSNESS
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INDICATION SURGICAL RESECTION
REFRACTORY CONSERVATIVE THERAPY : 76,5%
TOXIC COLITIS : 8,8%
COLORECTAL CANCER : 8,2%
DYSPLASIA : 6,4%
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PENATALAKSANAAN KOLITIS ULSEROSA
UMUM :
1. SUPPORTIV : * - TIRAH BARING, IVFD, - TRANSFUSI, DIET
TKTP.
SYMPTOMATIS : * TRANSQULIARE * ANTI SPASME
2. MEDICAMEN
CAUSAL* SULFASALAZINE/SALAZOPIRIN
* KORTIKOSTEROID
* IMMUNOSUP : - AZATHIPRINE
- 6-MP
- SIKLOSPORIN
3. OPERASI : : * COLOPROTECTOMY
* ILEORECTAL ANASTOMOSIS
* ILEO CANAL POUCH OPERATION
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MILD & MODERATE : (RECTUM/SIGMOID)
1. 5 ASA SUPPOSITORIA 500 MG
ENEMA 4 GR1 X 1 / 2 X 1 (2 MGG)
100 MG MG HYDROCORTISON (ENEMA) + 5 ASA
PREDNISON ORAL 40 - 60 MG/HR
REFRACTORY
IMMUNOSUPPRESIV DRUG
FAIL
FAILTOF
FAIL
DOSIS
TUJUAN : - MENGHILANGKAN & SERANGAN AKUT
- MENCEGAH RELAPSE / KAMBUH
- PERSIAPAN TINDAKAN OPERASI
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2. SEVERE CU. (ILEN & COLON )
500 MG 5 ASA (2X1) 3-4 GR/HARI (>1 MGG)
PREDNISON ORAL 40-60 MG/HR
MELHYL PREDNISOLON 60-100MG/HR
REFRACTORY
IMMUNOSUPPRESIV DRUG
FAIL
FAIL
FAIL
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Jenis obat dan dosis lazim yang dipakai pada pengobatan
Nama Obat Cara Pemakaian
Dosis Harian
Indikasi
5-ASA Supositoria 3x500 mg Terapi KU Distal/proktitis
5-ASA Supositoria 3x250 mg Dosis pemeliharaan KU distal
5-ASA Enema 1-4 g Terapi left side KU
5-ASA Tablet 2-4 g Terapi pan kolitis KU
5-ASA Tablet 1-1,5 g Dosis pemeliharaan KU
Sulfasalazin Tablet 3 g Terapi pan kolitis KU
Sulfasalazin Tablet 1-2 g Dosis pemeliharaan KU
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Nama Obat Cara Pemakaian
Dosis Harian
Indikasi
Budesonid Enema 2 mg Terapi KU distal/proktitis
Hidrokortison Foam 100-200 mg Terapi KU distal/proktitis
Glukortikoid (ekuivalen prednisolon)
Oral 40-100 mg Terapi pan kolitis KU dan PC (ringan-sedang)
Glukortikoid (ekuivalen prednisolon)
IV 1 mg/kg KU dan PC Berat
Sisklosporin IV 1 mg/kg KU dan PC Berat
Siklosporin IV 2,5-4 mg/kg KU refrakter dan PC
Azatioprin IV 2,5-4 mg/kg KU refrakter dan PC
6-Mercaptopurin IV 1-2 mg/kg KU refrakter dan PC
Metroteksat Im 25 mg/mgg PC
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PROGNOSA
TERGANTUNG KEPADA :
* SERANGAN AWAL
* USIA
* LUASNYA LESI
USIA : BAYI JELEK
>60 TAHUN PROGNOSA JELEK
LUASNYA LESI : MINIMAL DAN TERLOKALISIR : BAIK
MENYELURUH JELEK