DR. Dr.

JUWITA SEMBIRING,
SEMBIRING, SpPD-
SpPD-KGEH

DIVISI GASTROENTERO-
GASTROENTERO-HEPATOLOGI
DEPARTEMEN ILMU PENYAKIT DALAM
FK. USU / RSUP. H. ADAM MALIK MEDAN
DEFENISI :

Radang Pankreas Dengan Simtom Sakit Pada Ulu Hati

Menjalar Ke Punggung (95%95%) Dan Gangguan Exocrin
Pankreas, Mual, Muntah (85%
85%)
Terdiri dari : akut dan kronik
Akut : morfologi/struktur dan fungsi pankreas
sebelumnya normal
Kronik : sebelumnya ada kerusakan struktur dan
fungsi pankreas
Figure 1. Normal pancreatohepatobiliary system
ETIOLOGI :

Gall Stone (Batu Empedu) & Alkohol (Terbanyak)

- Mekanikal : Gall Stone,

tone, Mikro Litiasis / 80 %
Ca. Pankreas
- Infeksi : Mumps Flaxsechi, Ascaris -Lumbricoedes,
Chlonorchies Sineusis
- Obat-
Obat-obatan : Steroid, Thiazide, Aza
Azathioprin
- Metabolik : Hyperlipidemia, Hypericelsen
- Trauma : Post Operasi
- Miscellane
Miscellaneus : Gigitan Scorpio
Perforasi Tukak Duodeni
GAMBARAN KLINIK :
Sakit perut tipical, daerah epigastrium
epigastrium,
gastrium, lower
lower upper quadrant
menjalar ke punggung, sakit seperti disayat-
disayat-sayat, sakit
berkurang bila membungkuk kedepan / duduk
Cemas,
Cemas, kelihatan sakit berat, takikardi, demam (60%) dan
hipotensi (40%), mual, muntah, ikterus, peristaltik ↓.
Perdarahan retrosternal : echymose -periumbilikal = Cullen’s
Sign, panggul / paha. Grey Tunner’s Sign
Diagnosa : Klinik, Lab Amilase, Lipase
Pemeriksaan Penunjang : USG
CT SCAN
ERCP
Lab. : Le
Leuukositosis, kadar gula darah & crp ( > 100

insufisiensi pankreas) albumin ↓, creatinin ↑
(dehidrasi), amylase serum ↑, lipase ↑
Radiologi : sentinal loop dari usus halus
calsifikasi
calsifikasi pankreas + sakit
USG : oedematous pankreas, peri
pankreatitis, fluid / pseudo kiste
ERCP : banyak gas
lebih baik dengan CT SCAN
“ gold standard “
diagnosa terapi
KEPARAHAN/SEVERITY : Kriteria – Ranson (48 jam) 11 points
Glagow ( segera ) 8 points
APACHE system
Ranson Criteria Glosgow criteria
(1 points for each criteria) (1 points for each criteria)

oedematous

hemoragic

nekrosis
Organ failure: hipotensi BP <90
hipoxiensi PaO2 < 8kPa (60 mmHg)
Renal failure, creatinin > 200 µmol/l (2mg/dl)
GI bleeding > 500 ml / 24 jam
Creactive protein > 100 mg/l
severe pankreatitis
prognostik jelek
“ sensitive parameter “
 Severity Of Pancreatitis

Ranson criteria Glosgow criteria

(1 point for each factor ) (1 point for each factor )
On Admission On Admission
Age > 55 years Age > 55 years
WBC count > 16,000 / mm3 WBC count > 16,000 / mm3
Glucose > 200 mg/dl Glucose > 200 mg/dl
Serum LDH >350 IU/L LDH > 600 IU/L
Serum ast >250 U/dl BUN > 45 mg /l
PO2 < 60 mmHg
Albumin < 3.2 gr / dl
Calcium < 8 mg / dl
First 48 hours
Serum calcium < 8 mg/dl
Base deficit > 4 mEq/L
Fluid sequestration > 6 L
Arterial PO2 <60 mm Hg
BUN rises > 5 mg / dl
Haematocrit decreases > 10 %
TERAPI / PENATALAKSANAAN :

Ringan : decompresi ( mencegah exocrin )

puasa
IVFD
NGT (aspirasi cairan lambung)
Pain killer – pethidin
tramal syringe pump

Berat : ICU

Nutritional support – TPN
Mild
lapar
beri makan
PPI / ARH2 – mencegah tukak stres
 Figure . Treatment Algorithm for acute pancreatitis
Acute Pancreatitis

Mild Pancreatitis Ranson Establish Severity Severe Pancreatitis Ranson

less than 3 at 48 h more than 3 at 48 h
Glasgow less than 3 Glasgow more than 3

Expected complete Admit to ICU Invasive

recovery in 3-5 days monitoring NPO Analgesia
Fluid resuscitation Consider
antibiotics Treat metabolic
NPO complications Nutrional
Analgesia IV Hydration support

Patient Worsens
No Improvement
Real Time after 48-72 h
Contrast Echanced CT
Ultrasonography
Peripancreatic fluid
Choledocholithiasis Pancreatic Necrosis collection

CT Guided CT Guided percutaneous

Endoscopic papillotomy aspiration
percutaneous aspiration

Infected Infected

Yes
Yes
Purcutaneous
Failed Drainage
Technical Failure Surgery
Antibiotik :
Broad spectrum – cephalosporin - Imipenem 3x500,
- Sulperazone IV / 12 jam
Indikasi severe pankreatitis
necrotizing pankreatitis (dinamik, CT ), cholangitis
Somatostatin : 3 mg / 12 jam drip
Sandostatin : 12 amp / 24 jam
Komplikasi : Sistemik - Paru
- GI bleeding
- Obtruksi
Lokal - Pancreatiuc necrosis
- Pseudo kiste – spleen
- Fistula
 Complication of Acute Pancreatitis

Local Systemic
Pancreatic Cardiovascular
Pseudocyst/fluid collection Phlegmon/sterile Hypotension and shock Pericardial effusion and
tamponade Electrocardiogram Changes
necrosis Infected pancreatic necrosis
Pancreatic abscess Resporatory
Hypoxaemia
Pleural effusion
Nonpancreatic Atelectasis
Pulmonary infiltration
Pancreatic ascites Sympathetic effusion Adult respiratory distress syndrome
Gastrointestinal perforations Mesenteric, Respiratory failure
splenic, portal vein thrombosis Metabolic
Hypocalcaemia
Hyperglyceridaemia
Metabolic acidosis

Renal
Oliguria
Acute tubular necrosis
Renal artery or vein thrombosis

Haematological
Vascular thrombosis
Disseminated intravascular coagulation
(DIC)
Gastrointestinal bleeding
Complication Of Chronic Pancreatitis

Abdominal Pain
Melabsorption
Diabetes
Pseudocysts
Pancreatic Calculi
Biliary Obstruction
Duodenal Obstruction
Splanchnic and mesenteric venous obstruction
PANKREATITIS KRONIK :
Defenisi : - peradangan pankreas yg berlanjut menimbulkan
kerusakan struktur dan fungsi yang irreversible.
- timbul fibrosis dan atrofi kelenjar pankreas, dilatasi
saluran.
- Keparahan: - keparahan sakit
- insufiasiensi pankreas (fat>20gr/hr)
- Rasa sakit : tanda prognosis
pankreatitis kronis, radiasi ke
punggung,hyperamykase
- CT Scan : pseudo kiste
Stop alkohol, pain killer : pethidin, NSAID, Opiad,
enzym pankreas 3x11 antara makan,
ARH2/PPI
ERCP drainage :
Mengurangi sakit kurangi : - lemak+ ARH2 / PPI
- MCT
TUMOR PANKREAS : Jinak & Ganas ( Carcinoma )

Carcinoma : terlambat diagnosis
radical operasi

Keluhan : tergantung bagian yang terkena
kaput
painless joundice
Obesy & tail – sakit + BB ↓
Papilla Vateri – prognosa baik
Ikterus – operasi pankreato
duonectomy
survival 3 thn
50%

kaput
10 %
GAMBARAN KLINIK :

Jaundice, bekas garukan, convoisier sign
pulpable GB

Diagnosa : klinis – ikterus, sakit, BB ↓
USG, CT Scan / MRI
biopsi aspirasi
ERCP – diagnostik + terapi

sitologi / PA
Terapi : - Operasi
- Radiasi
16 minggu survival
- Chemoterapi 5 FU
Chemo + radiasi 40 minggu survival
KOMPLIKASI :

 Lokal : nekrosis pankreatik (20%)

infeksi
Cephalosporin / imipenem
↑ tenderness,demam tinggi,lekositosis,bakteremia

sepsis
Aspirasi biopsi, CT guided
gram stein / kultur

GR (-)

Terapi : infected necrosis
surgical emergency “

debridemant”
mortilitas 10 %-15 %
Steril nekrosis
konservatif
10 %
sistemic
komplikasi
agresif medical atau surgical debri
demant
 Pseudokiste :
fluid collection (30-50%) dgn pankreatitis berat.
Fluid collection : > 4 minggu 10 %
Uncomplicated pseudokiste >6 cm/ > 6 minggu
terapi.
Asimtomatik psk < 6 cm
resolve spontaneus

Terapi PSK :
- ERCP
insertion stent pankreatitis
Cept gastrostomy, cept duodenectomy
- percutaneus drainage
- Operasi: cept gastrostomy
cept jejenectomy, cept duodenectomy
 Fistula : - asites, pleura efusi
cutaneus, bowel,
- amylase / protein
- drainage of fluid collection by thoracosentesis
atau parasentesis.
ERCP : stent pancreatic
infeksi dengan somatostain 600 µgr/hari
Pankreatic reseksi
 Sistemik :
Pulmonary : - drainage pleura efusi
- pankreatic
- ARDS – respiratory support with positif
end expirety
GI hemorahagic
angiografi and emboli
Obstruksi
spasme & odem + reseksi
BATU EMPEDU = KOLELITIASIS

Sering dijumpai pada Praktek sehari-hari

Banyak pasien batu empedu = asimtomatik
Manifestasi klinik :- nyeri episodik
- Kolesistitis akut
- Ikterus obstruktif, Kolangitis,
Pankreatitis bila batu migrasi ke duktus
koledokus.
Banyak ditemukan pada wanita, makin bertambah dgn
meningkatnya usia.
FAKTOR RESIKO UNTUK BATU EMPEDU :
- Bertambahnya usia
- Gender wanita
- Kehamilan
- Estrogen
- Obesitas
- Etnik (penduduk Asli Amerika)
- Sirosis
- Anemia hemolitik
- Nutrisi Parenteral Total
Manifestasi Klinik Batu Empedu tergantung Lokasi di sal.
Empedu :

1. Batu empedu asimtomatik

2. Kolik bilier / kolesistitis akut
3. Sindroma Mirizzi : - nyeri
- ggn tes fungsi hati (Bil, FA/GGT ,
SGOT/PT , USG sal empedu melebar)
4. Kolangitis
5. Pankreatitis akut bilier : amilase / lipase , fungsi hati 
6. Batu Intra hepatik