MUAL

&
MUNTAH

Prof. Dr. Rifai Amirudin, SpPD-KGEH

Sering dihadapi dokter dan memerlukan perhatian serius.

Perlu diagnosis segera dan terapi yang tepat.
Dapat disebabakan oleh :
kelainan organik
psikogen
Mual-muntah dapat terjadi secara sendiri-sendiri, tapi dapat
pula bersamaan.

MUAL
Perasaan bahwa sebentar lagi akan muntah
Sensasinya terasa di kerongkongan atau ulu hati

MUNTAH
Pengeluaran paksa isi lambung lewat mulut dengan kuat

MEKANISME MUAL
Dapat disertai dengan fenomena objektif seperti
aktivasi sistem saraf simpatis ( hipersalivasi, pucat,
keringat, tahikardi )
Pada umunya merupakan pengalaman subjektif
Jalur neural belum disepakati oleh para ahli

MEKANISME MUNTAH
Kontraksi otot-otot perut memegang peranan efektif,
sedangkan lambung relatif berperan pasif.
Kontraksi otot-otot dinding perut diagfragma
kontraksi anular pilorus lambung dan gastroesofageal
sehingga isi perut dipaksa keluar dari lambung
esofagus mulut.

JALUR NEURAL MUNTAH

Refleks muntah merupakan interaksi kompleks
dari sinyal-sinyal sistem saraf otonom dan
saraf somatik ( terjadi pada pusat muntah,
di daerah dorsolateral fomatio-retikularis )

MEKANISME TERJADINYA MUNTAH

sea, vomiting and disorders of gastric emptying in motor disorder of the gastrointestinal.
what to do. Edit by Fisher Rs, et al. Acad.Prof.Information Serv.Inc., New York, 1993 : 58.(3)

PUSAT MUNTAH DAPAT DIAKTIVASI OLEH :

A.

Korteks serebral

B.

Aparatus vestibuler

C.

Nervus Vagus

D. Rangsangan langsung pada pusat muntah

E.

Chemoreseptor trigoer zone (CT2) ( terletak pada

caudal ventrikel IV )

Berbagai Stimuli Muntah

dan Organ Efektor Yang Terlibat
Visceral
Afferents

Chemoreceptor
Trigger zone

Mid-brain ICP
receptors

Limbic
system

Vestibular
system

Emetic Center

Salivatory Center
Vasomotor Center
Respiratory Center
Cranial Nerves

Somatic
Abdominal muscles

Diaphragm

Visceral Efferents
Stomach

Esophagus

Clarfield HR, Roth JLA. Anorezia, nausea and vomiting in Bockus Gastroenterology.
Edit by Berk JR. WB Sounders Co., Philadelphia, 1985 : 48-58.

ETIOLOGI MUAL & MUNTAH (1)

Medications
NSAIDS
Cardiovasculer drugs (e.g., digoxin, antiarrhytmics, antihypersensitves)
Diuretics
Hormonal agents (e.g., oral antidiabetics, contraceptives)
Antibiotics (e.g., Erythromycin)
Gastrointestinal drugs (e.g., sulfasalazine)

Gastrointestinal and peritoneal disorders

Gastric outlet obstruction
Obstruction of small intestine
Superior mesentric artery syndrome
Gastroparesis
Chronic intestinal pseudo-obstruction

Pancreatits
Cholecystitis
Acute Hepatitis
Pancreatic carcinoma

Yamada T. Handbook of Gastroenterology. Lippincot-Raven Publishers, Penn

ETIOLOGI MUAL & MUNTAH (2)

Central nervus system disorders
Tumors
Cerebrovascular accident
Intracranial hemorrhage
Infections
Congenital abnormalities
Psychiatric disease (e.g., anxienty, depression, anorexia nevrosa,
bulimia nervosa, psychogenic vomiting)

Endokrinologic and metabolic conditions

Nausea of pregnancy
Uremia
Diabetic ketoacidosis
Thyroid disease
Addisons disease

Yamada T. Handbook of Gastroenterology. Lippincot-Raven Publishers, Penn

ETIOLOGI MUAL & MUNTAH (3)

Infectious disease
Viral gastroenteritis ( e.g., Hawaii agent, rotevirus,reovirus,
adeno virus, Snow mountain agent, Norwalk agent)
Bacterial causes (e.g,. Staphylococcus spp, salmonella spp, Bacillus
ceceus, Clostridium perfringes)
Oppurtinistis infection (e.g., Cytomegalovirus, herpes simplex virus)
Otitis media

Miscellanous causes
Posterior myocardial infarction
Congestive heart failure
Excess ethanol ingestion
Jamaican vomiting sickness
Prolonged starvation
Cyclic vomiting

Yamada T. Handbook of Gastroenterology. Lippincot-Raven Publishers, Penn

DIAGNOSIS
Anamnesis
Karakter muntahan :
bau,makanan, getah lambung, mukus getah
empedu, nanah

PEMERIKSAAN
Fisis : dehidrasi, nyeri epigastrium, massa perut
Laboratorium : darah rutin, elektrolit, ureum, creatine,
gula darah, tes faal hati, tes kehamilan
Radiologi : USG, foto polos barium, CT scan perut/kepala
Endoskopi

History and physical examination

Suspect
metabolic
Screening
cause

Significant
dehydration

Intravenous hydration
possible hospital
admission

laboratories including electrolytes

Suspect
Intra-abdominal
inflammation

Suspect
obstruction

Calcium
Glucose
CBC
Blood urea
Amylase
Nitrogen Liver chemistry studies
Creatinine
Cortisol
Thyroid Tests
Ultrasound
Pregnancy
CT
Test as
Scintigraphy
indicated
As indicated
If abnormal

Medical or surgery
therapy

Abdominal
Radiography
Upright
And supine

Suspect
neurologic
disease

Head CT or MRI
scans

If non diagnostic
And intracranial pressure
not increased

Lumbal puncture
To exclude infection
Or hemorrhage

Barium radiography
Or upper endoscopy
If abnormal

Medical or surgery
therapy

If normal

Rule out motility

disorder

Yamada T. Handbook of Gastroenterology. Lippincot-Raven Publishers, Pen

History
Reccurent
Physical examination
or
Laboratory screen
Chronic
Plain abdominal reonigenogram

Acute
(less than 24 hours)

Consider :
Endoscopy
Neurologic, muscle,
Gastrointestinal
No Mechanical
collagen, endocrine,
contrast seriesObstruction Psychiatric disease

Mechanical Obstruction

Screen for :

Metabolic
Drug
Infections
Intoxication

Therapeutic trials

Optional

If severe or nutritional
compromise
Laparatomy plus full thickness
Histology biopsy of small intestine
Electropysiology

No cause

identified

Gastric emptying
Manometry

If no response

Normal

Obtain :
Consultations
Further blood tes

Abnormal
Electrogastrography
Therapy :
Medical (liquid, meals, enteral
nutrition, prokinetic
drugs)
Surgical (antrectomy)

Thank
you
S I R .