RONGGA MULUT

DAN

TRACTUS GASTRO
INTESTINALIS
Dr.Resmi Kartini Ms

Oral Soft tissue

Inflamasi :
Et / H. Simplex tipe 1, HIV (human immunodeficiency
.Epstein- Barr

Ulcus Aftosa

Kandida , Glositis

vi)

Tumor dan Pre cancerous Lesions

Leukoplakia dan Erythroplakia

Mempunyai nilai di
Leukoplakia : Plaque putih pada mukosa dengan epitel
mengalami hiperkeratosis dan penebalan epiteldengandasar terdiri
dari sel spinosum

- prolif epidermal 85-90 %

-- Benign spi Malignant

Plaque putih pada Membr. Mukosa mulut

Tidak dpt diangkat dgn scraping
Gambaran ; penebalan epitel, sitologi
atipik - displasia
Karsinoma in situ prove prekanker
Morfol :
Mukosa bukal
Dasar mulut
High risk
Permuk ventral lidah
Palatum durum
3

Soliter / multiple
Tebal , smooth , indurasi ,
wrinkled,corrugated / verrucose plaques
Histol :
Hiperkeratosis
Acantosis
Displasia CIS
Lesi displastik / Anaplastik --- infilt
Limp,makrofa
- Ganas 5-6 %
4

Erythroplakia ( Dysplastic Leukoplakia )

Erosi superfisial + Displasia -- CIS

Epitel atipik resiko yang tinggi
tranformation malignan
Speckled leukoerythroplakia
Multifact origins Tobacco. Alkohol,chronic
exposure - iritant

Squamous Cell Ca

95 %
Tobacco ,alkohol
Dasar mulut , lidah , palatum durum ,dasar
lidah
Diff baik sampai anaplastik
Metast : KGB Mediastinum , paru ,hati,
tulang
Prog : 5 Th 90% recurrent free:dsr lidah
20-30 %
6

Ameloblastoma

Epit odontogenic T
Epit lining drpd dentigerous cyst
Lamina dental ,enamel
Lapisan basal dp mucosa mulut
Dekade 5
Folikuler dental epit
plexiform
7

Sel kolumner Pulau 2 sentral retikulum stellae

Metaplas skuamosa tipe akantomatous

Stroma jar ikat fibrous
Dentrigerous cist
Foll Cyst

Adenoma pleomorphik

Mixed tumor, Parotis ( 60 % )

Elemen epitelial mucoid

mixoid

chondroid
Morfol : Mass bulat , batas tegas 6 cm

Encapsulated . Abu 2 putih mikoid

Translusent biru
9

Histologi
Element Epit~cell duktal / mioepit glanduler
Asini, ireg tubule , sheet tersebar pada jar
miksoid . Khondroid , tulang.
Sel epitel : duct sel kubis, kolumner
Asal ?
Radiasi
Elemen noeplastik ( termasuk mesenkhimal
Sel mio epitel ,ductal reserve cells. 2-3 % Ca
10

WARTHINS TUMOR / pappillary cyst adenoma lymphomatosum

Parotis, 5 x
Multifokal 10 %

Bilat 10 %
Morfol : bulat ,oval,encapsulated 2-5 cm

bulat abu 2,kista kecil ,cleff like space

Sekresi serous,mucinous sel kolumner
Limpoid + germ center
Metaplasia squamous
Histogenesis ? Small sarivatory gland rest kgb
Aberant incorporation of similar
inclutionlimfoid tissue in parotis
11

Mukoepidermoid Ca
Sel Skuamosa
Mucus secreting cells
60 -70 % parotis
Intermediate hybrids- vacuol kecil / besar --- Musin
Most Common Radiation induced neoplasma
Morfol :diameter 8 cm, circumscribed , lack well
defined

capsul , infiltratif. Abu 2 putih pucat

kista kecil mucin

Histol : cords, sheet ,kistik
12

Low grade : largely of mucus secreting cells glanduler

space.
INV. Lok . Recur 15 % 5 th 90 %

High grade : Largely of squamous cell + scattering

mucus sekr .cells
Intermed
RECUR 25 -30 % INVASSIVE ,5 TH 50 %.

Adenoid cystic Ca :
Morfol : kecil, poorly encap , infiltr . Lesi abu pink
Histol : sel kecil,kompak inti,sitopl.sdkt

- tubuler solid / cribriform

Lumen bahan hialin

Invasi Perineural, 50 % tulang,hati, otak
5 Th 60 -70 % 30 % ( 10 th )

15 % ( 15 th )

13

Acinic cell Ca
normal serous cells of Sm gland
Parotis
Bilat / multi sentrik
Kecil, discrete , encaps
Histol : - sel sheet ,micro
kistik,gland,fol. Papil
Meta KGB 10-15 %
5 thn : 90 % , 20 thn : 60 %
14

Kel Liur pada rongga mulut

Mayor : Parotis

Submandibularis, sub lingualis

Minor : Mukosa mulut
Inflamasi :
Sialadenitis -- obstruksi kelenjar liur yg
lama
Penyebab :Virus , Bakteri, Auto imun
SJOGREN SYNDR DESTRUKSI
MEDIATED IMUNOLOGI

15

XEROSTOMIA

Kerato Conjunctivitis sicca

Mikuliczs Syndrome : inflam lakrimalis

salivary +
xerostomia
Sialolithiasis non specifik sialaoenitis

DUCTAL OBSTRUCTION

16

HISTOLOGIC classification and incidence of benign and malignant

tumors of salifatory gland

BENIGN
MALIGNANT
-----------------------------------------------------1.Pleomorphic aden 45,4 % MUCOID.Ca 15,7
%

low grade
high grade
2.WARTHINS tumor 11 %

Adenoid cystic Ca 8 %

3.Lympho epithelial lesion 0,6% Adeno Ca 8 %

17

4.Oncocytoma 0,7 %

Acinic cell Ca 3 %

5. Monomorphic
Malignant Mixed T
Adenoma 0,2 %
( 5,7 % )

6.Benign cyst 1 %

Epid Ca ( 1,9 % )
Other Anaplastik Ca
( 1,3 % )
18

ESOFAGUS
Agenesis
Atresia
Fistula
I. Stenosis - Defek perkembangan

- Aqured
cidra esof berat
--dispepsia
adult
( reflux gastro esof
jar parut
radiasi, skleroderma
kaustic )
II Mucosal Ring WEB ( upper esof )
SCHATZIKIS RINGS ( dibwh
squamo col junction )
19

I. ACHALASIA
NEUROPATI DM, INFILT
(KANKER, AMILOIDOSIS,
SARKOIDOSIS)
SEKUNDER

TERJADI PROSES
PATOLOGI CHAGASDISIS
PLEXUS MYENTERIK DESTRUKSI

PRIMER

PERUBAHAN DALAM INERVATION

NEURAL (UNCERTAIN)
20

II HERNIA HITAL

- SLIDING
- PARA ESOF ( ROLLING )
III DIVERTICULA :
- ZENKERS ( pulsion )
- TRACTION
- VARICES

21

ESOFAGITIS
Iran 80%
Cina
USA / Western Countries 10 -20 %
1. Reflux esofagitis, gastric content
2. Prologed gastric intubation
3. iritant
4. Sitostatika
5. Bakteremia / uremia

22

6. Inf Jamur os dengan imunosupressed/ AB

7. Uremua
8. Radiasi
9. Peny sistemik ( Hipotiroidism , Sklerosis sist )
10. Desquamasi sitemik ( Pemfigoid,
Epidermolisis Bullosa )

11. Graft versus hits dis

23

PATOGENESIS
- Reflukx gastric content

- Mekanisme antifeflux
- Clearance esof. ( BHN REFLUK ) lambat /
-

inadekuat
Hernia hiatal sliding
Vol gastric
Kapasitas penyembuhan mukosa esof
Morfol : Tgtg causa
Refluk esophagitis tanpa komplikasi :
24

KHAS :

Eosinofil ( Dengan / tanpa leukosit )

( lapisan epithelial )
Hiperplasia basal
Papila lamina propia elongasi
- Severe acute inflamasi :
Nekrosis superfisial
Ulcerasi , jar granulasi , debris purulen
Fibrosis
25

Klasifikasi histologik dan inciden dp tumor

jinak dan ganas kel liur
Jinak
1.Pleomorphic Adenoma 45,4%
2. Warthins tumor 11 %
3.Lymphoidepitelial lesion 0,6 %
4. Oncocytoma 0,7 %
5. Monomorphic Adenoma 0,2 %
6.Benign Cyct 1%

Ganas
Mucoepid.Ca ( 15,7 % )
. Low dan High Grade
Adenoid Cystic Ca 10 %
Adeno Ca 8 %
Acinik cell Ca 9%
Malignant Mixed T 5,7 %
Epid Ca 1,9 %
Other anaplastik Ca 1,3 %
26

ADENOMA PLEOMORPHIC
* Mixed T
* Parotis ( 60 % )
Elemen epitelial mucoid

Mixoid

Chondroid
MORFOL ; Masa bulat , batas tegas 6 cm

Encapsulated , abu 2 putih mixoid

Translucent Hondroid

biru
Hislot ; elemen epit cell duktal / mio epit glanduler tersebar

pd jar miksoid , khondroid, tulang.

sel epit : Duct sel kuboid , kolumner

27

 Asal ?
Radiasi
Elemen Neoplastik ( termasuk Mesenkhimal

sel mioepit

duktal reserve cells

2 3 % - Ca
WARTHINS TUMOR / Pappillary Cyst adenoma
lymphomatosum
Parotis 5 x
Multifokal 10 %

Bilat 10 %
Morfol : bulat encap 2 -5 cm ,sekresi serous , musinous ,
limpoid + germ center, metaplasia squamous
Histogenesis ? Small salivatory gland rest KGB - Aberrant
incorporation of similar inclution limfoid tissue in parotid
28

Mukoepidermoid Ca
* Sel skuamosa

* Mucus secreting cells 60 70 % Parotis

* inter mediate Hybrids Vakuol kecil /besr --Musin
pd umumnya radiasi merngsang neoplasm
Primer pada Sal. Gland
MORFOL : 8cm , circumscribed .capsule ,infilt
kista kecil musin
Histol : Cords, sheets,kistik
Low Grade : banyak sel sekresi mukus gland space
invasi lokal : recur 15 % 5 thn 90 %
High Grade : Banyak sel squamosa + scattering mucus secr.
cell
Recur 25 30% , Invasive 5 THn ---50 % meta 30%
Intermed

29

ADENOID CYSTIK CA
* Minor sal gland
MORFOL : kecil , poorly encap , infilt ,lesi abu
pink
Histol : Sel kecil , inti kompak , tubuler , solid
/ cribriform
Lumen bahan hialin
Invasi peri neural 50 % Tulang ,hati otak
5 th 60 70 % 30 % ( 10 th )
15 thn --. 15 %
ACINIC Cell Ca ~ normal serous of sal .gland parotis bilat / multisentrik

kecil, discrete, encap

Histol : Sel Sheet, mikro kistik , Gland , Fol. Papil

Meta KGB 10 15 % 5 thn : 90 % 20 thn : 60 %

30

Barretts ESofagus

Kerusakan reflux gastroesofageal

dalam waktu lama metaplasia
kulumner
Inflam, ulcerasi ep squamosa -
reepiteliasasi Pluripotent stem cell
Ulcerasi lokal perdarahan--- striktur
Mikrosk : Displasia , lesi prekanker
31

TUMOR
Jinak : Leiomioma

Mesenkhim T

Fibrovaskuler polip / lipoma peduncula

ted

Squamous papiloma

inflamatori polip / inflamatory peudotu

mor

32

GANAS : Ca skuamosa

: : 2 : 1
50 thn
China 100 / 100.000
20 %
USA 2 8 / 100.000 Black : white 4 x
Etiol ? Patogenesis
carcinogen ; ter kontaminasi fungus

nitrosamine

alkohol
Eropa,USA

Smoking

Yg termsk alk ( fusel oil ,nitrosamine,polisiklik

hidro karbon )

33

1/3 upper ---- 20 % KGB cervical

1/3 middle ---- 50 % -- Mediastinum

Para traheal
Tracheobroncheal
1/3 lower ---- 30 %
Gastric

celial
Morfol : 1. Protruded 60 % --- polipoid
fungating

2. Flat 15 % --- difus, infilt tebal,rigid

lumen sempit

3. Excavated 25 % --- Necr cancerous

ulceration deeply - struktur sktr ---erosi respirasi
34

Well Mod DIF

Sist Limfatik sub mucosa - spread :

circum ferential / longitudinal
Intra mural Cluster --- dapat beberapa cm
dari tumor
Lokal extensi mediastinal
Pjln Peny :
insidious onset - dispagia
obstruksi,menelan sukar - BB
Ulcerasi - sepsis, hemorr.
35

5 year survival rate :

Ca Esof superfisial 75 %
Advance
25 %
Limph node metast 5 year surv
Adeno Ca -------- Barrets Esof

> 40 thn ( displasia )

surv. 5 thn < 15 %

Diagnosa dini + Reseksi > 50 %

36

SMALL AND LARGE INTESTINES

KELAINAN Kongenital
Divertikulum Meckel
- Persisten Vitellin Duct
- 30 cm dp iliocecall value
- True Divertikel : Tdd semua tiga lapisan

( mukosa, sub mukosa , muskularis propia )

- Small Pouch / blind segmen 6 cm
- Dapat heterotopik mukosa gaster

Pancreas
50%
kasus
37

Komplikasi :

Ulkus peptik - bleeding

Intussusepsi
Inkaserasi
Perforasi
Congenital aganglionik Mega colon
HIRSCHPRUNG DIS
Migrasi sel 2 neural crest tertahan prox sp anus
segmen kolon distal agnglionik + obstr fungs.
+ dilatasi kolon prox kelainan
-

Meissner s submucosa

- - Auerbach s myenteric Pleannses

lacks
38

Koordinasi neuronal enterik loss Obstruksi

Dilatasi kolon proximal ( Affected segment )

Morfol :
Sel ganglion negatif dinding otot
,submucosa
serat saraf nonmielin tebal , hipertropi
Kolon prox dil , hipertropi , distensi masif 15
20 cm - Megakolon
1 5000 -8000 Live Birth
: 4 : 1
39

ACQUIRED MEGACOLON

- Chagas DIS
- Obstruksi ( Neoplasma , Striktura )
- Toxic MegaColon
- Fungtional Psychosomatic DIS
ATRESIA
STENOSIS

40

Vascular DIS

Ischemic Bowel DIS

oklusi akut : A. MESENT CELIAK SUP +

INF
- infark luas
1. Infark Transmural P D besar
2. Infark MURAl
3. Mukosa Infark
hipoperfusi akut /
kronik
Faktor predisposing
TR ARTERI, Emboli, Tr VENOUS , ischaemia

non occlusive.
Angio Displasia -- 20 % bleeding
Hemorrhoid

41

TYPHOID
SEVERITY, UNTREARED , FATAL ( SERING ) ,
TO FOOD POISINING BIASA
INFLAM KATARAK RINGAN DENGAN DIARE
INGESTION 0F S. TYPHI ( KONTAMINASI H2O
& MAKANAN )
Fase I
INVASION OF INTESTINAL LYMPHOID TISSUE
AND PROLIFERATION OF BACTERIA. THIS
PHASE LASTS FOR 2 WEEKS & IS
VIRTUALLY ASYMPTOMATIC
42

Fase II
DIAGNOSTC TEST
( positive blood & urine cultures selama periode
febril AB to S. TYPHI in blood + )
INVASION OF BLOOD STREAM -
BACTERIEMIA GENERAL TOXAEMIA
IS CAUSED WITH RISE OF TEMPERATURE
IMMUNOLOGICAL REACTION OCCURS
LEADING TO THE NEXT PHASE IN 10 DAYS
TIME ( widal test + at end of this phase )
43

FASE III

LOCALISATION OF BACTERIA IN
INTESTINAL LYMPHOID ----- ( widal test
rising titre )TISSUE,MESENT NODES ,
CALL BLADDER, LIVER,SPLEEN, KDG 2
TULANG, LOKAL NEKROSIS, Rx
hipersensitifitas AG AB lesi khas
( CULTURE OF FAECES )

44

LESI INTESTINAL
Terutama Ileum ,yeyenum,kolon
Ulkus
Fol. Limph. Edem Nekrosis
Infilt MN, Sel plasma
Menyebar
fever
A. Endotoxin release
myocardial deg

nekrosis fokal M.abd

Deg. Zenker

Perub Deg . Hati & Ginj

45

B. Lokalisasi bakteri
Selama bakteriemia

Neutropenia
Relative lymphositosis

Kulit Rose Spot

Splenomegali
Endokarditis
J
Meningitis
A
R
Arthritis
A
N
Peri kondritis
G
Cartil Costae

46

Kompl : Ulkus jar. Parut minimal

Ulkus dalam - Hemor

Perforasi peritonitis
Carrier

47

Mal absorption
Sindrome primer
Lesi patol mirip

( pada pada stadium ini)

villi atropi

reduksi tu yeyenum
1. Atropi villous partial

Bbrp vili menjadi satu , ireg ridges

villi pendek ,luas, lam propria sel

plasma , regen
2. Atropi villous komplit

Epietl kuboid , infilt sel palma

mukosa flat & tipis

48

Penyakit COELIAC
Anak

Bhub dengan sensitivitas thdp

gluten
Dewasa
Villous atropi
atropi lien gangguan respon immune N H L

Tropical SPRUE
Negara 2 tropic , kec afrika
An. Makrositik ( def Fe , B 12 , Folic acid )
49

WHIPPLE DIS
Jrg , dgn Limf adenopathi

Arthropathi

Pigmentasi kulit
Yeyenum khas : infil makrofag L. propria

akumul lemak ok obstr

ma

krofag
Terutama usia pertengahan
50

Malabsorpsi sekunder :
Sekunder akibat py digestion , absorption,
transport nutrisi.
A. Digestion
1. Destruksi mukosa intest pada regional
enteritis, amiloidosis sklerosis sistemik , RD
2. Py Hepatik , Pancreas
3. Following resection of bowel
4.Cong.disach defect
5. Drug. ( Phenindione, neomisin )
51

B.Absorption 1. Stasis intest ( dis , op )

2. Obstruksi khronik
terutama oleh bakt
C. GGN transport : 1. obstruk limfatik
2. Py ggn supply mesenterik
3. A Betalipoproteinemia
KLINIK : Diare bulky / fatty stuol

52

Site of lesion
Duod
Yeyunum

Function Affected

Clinical Manifestation

iron absorption
Prot . Digestion
Pancreatic stim
emulsif of fats
elektr & fluid abs

Makrosite

Ileum

Abs B 12------Reabsor. Grm empedu ------

anemia
wasting
fatty diare
def abs vit
lrt dl lemak
dehidrasi
def vit lrt air
Vit B --- Pellagra
C--- Scurvy
Folic acid An.
An. Makrositer
Thdp abs lemak

53

IDIOPATIK INFLAMATORY BOWEL DESEASE

ETIOLOGI UNKNOWN

CROHNS DIS

KRONIK
RELAPSING
INFLAMATORY
DISORDER OF
OBSCURE ORIGIN

COLITIS ULSERATIVA

GRANULOMATOS
ANY PARSION GIT
SMALL INTESTINE, KOLON

NON GRANULOMATUS
LIMITED KOLON
54

Etiol dan Patogenesis

1. Genetik
2. Infeksious virus, klamidia , bakteri atipik,

mikobakteria

3.Perub mukosa intestin permeabilita intest Polietilen

ggn musin gliokprot
glikol
4. Abnormal host immunoreactivity :
- gg Fg sel ep sbg antigen presenting cell
- cytokinen abn
- induksi cytotoxic anti epith.antibody
- Fg Nk limfosit abn
5. Inflamasi
55