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FRIDAY MORNING REPORT

DYSPHAGIA in ELDERLY

DYSPHAGIA AND MALNUTRITION

DYSPHAGIA in ELDERLY
MALNUTRITION
FRAILTY

DYSPHAGIA, PNEUMONIA,&
MORTALITY

DYSPHAGIA in ELDERLY
PNEUMONIA RISK &
MORTALITY

THE CASE
Keluhan utama :
Laki-Laki usia 69 tahun dengan Muntah setiap kali makan/minum sejak 2 bulan
Sejak 2 BSMRS OS mulai mengeluh
muntah setelah makan makanan
padat .Dirasakan 2 menit setelah
makan, yg diawali perasaan tidak
nyaman pada dada. Muntah persis
seperti yang di makan . Pasien
masih dapat makan bubur.
Tersedak (-)

2 MSMRS, OS mondok di RS Swasta.


Dikatakan dehidrasi berat. Sempat
dilakukan CT-Scan Kepala karena
penurunan kesadaran, namun
dikatakan tidak ada stroke. OS tidak
dapat makan bubur, hanya dapat
minum susu sedikit-sedikit.
Dilakukan pemasangan SONDE

1 BSMRS, pasien juga


muntah ketika makan
bubur. Namun masih bisa
minum air tanpa
dimuntahkan. Lemas (+).
BAK masih lancar.

HMRS OS periksa poli


gastro disarankan
mondok untuk pelcakan
penyebab. BB turun 10 kg
dalam 2 bulan

Faktor Risiko:
Riwayat dada sering terasa panas (-)
Sering Konsumsi Obat asma oral (+). (Sesak nafas jika beraktifitas berat,
mengi (+), batuk (+) kadang, dahak putih. Dirasakan sudah beberapa tahun)
Riwayat Merokok (+) sejak > 30 th, rerata 5 batang/hari

Pemeriksaan Fisik
KU

: sedang, CM, gizi kurang


TB 165 cm, BB 44 kg, IMT 16,7 kg/m
VS
:
TD 100/60 mmHg, tidur, manset di lengan kanan, large adult
cuff
N 82 x/menit, irama ireguler, isi dan tekanan cukup
R 20 x/menit, irama teratur, tipe pernapasan
thorakoabdominal
T 36,6 C, suhu aksila
Kepala
:
Insp.
:
konj. pucat (-), sklera ikterik (-), Atrofi
musculus temporalis (+)
Palp.
:
tidak ada nyeri tekan, tak teraba massa
Leher
:
Insp.
:
JVP 5+3 cm H20
Palp.
:
lnn ttb, massa thyroid (-)
Thorax
:
Pulmo :
Insp.
:
simetris, KG (-),
retraksi (-), barrel chest (+)
Palp.
:
stem fremitus
kanan = kiri
Perk.
:
hipersonor (+)
Ausk.
:
vesikuler (+) RBK
(-) RBB (-) Wheezing (-)

Pemeriksaan Fisik
Abdomen

Extremitas

Insp.
Ausk.
Perk.
Palp.
Insp.
Palp.

:
:
:
:
:
:

Kontur scaphoid
peristaltik (+) meningkat
timpani di seluruh regio
NT (-), Massa (-), Hepar/Lien tak teraba
edema -/-, kelemahan anggota gerak (-)
akral hangat, tidak ada nyeri tekan

Pemeriksaan Penunjang
Darah rutin
Hb
13,9
AL
6,92
AT
269
AE
4,32
Hmt
39,1
S
L
M
E
B
MCV
MCH

81,4
13
4,2
1,3
0,1
90,5
32,2

g/dl
.103/L
.103/L
.106/L
%
%
%
%
%
%
fL
pg

Ginjal
BUN
Crea

Hati
18
0,59

Elektrolit
Na 135
K 2,68
Cl 97

Glukosa
GDS
105

mg/dl
mg/dl

mmol/L
mmol/L
mmol/L

mg/dl

GOT
310
GPT
367
Alb 3,04

Perdarahan
PPT
15,7
K
14,2
APTT
31,7
K
31
INR
1,16

U/L
U/L
g/dL

detik

detik

EKG : Sinus Rythm, heart rate 82 kali/menit, normoaksis

Ro thorax :
Kedua apex pulmo tenang
Corak paru dalam batas normal
Besar cor normal

MSCT kepala (RS Swasta)

Awal atrofi cerebri


Tak tampak tanda perdarahan, infark maupun massa pada head ct scan

ASSESSMENT

DYSPHAGIA ORPHARYNGEAL DD
ESOPHAGEAL
SUSP. PPOK STABIL KATEGORI B
PENINGKATAN ENZIM TRANSAMINASE
HIPOKALEMIA
HIPOALBUMINEMIA
MALNUTRISI

THERAPY
Diet per NGT 6 x 200cc
Inf Aminofluid : D5% 20 tpm
Inj. SNMC 1 Amp/12 jam
Koreksi Kalium : Premix KCl25 meq

PLAN
ENDOSKOPI + BIOPSI
USG ABDOMEN
Cek HBSAg
Cek Anti-HCV Total

OROPHARYGEAL
ESOPHAGEAL

General Population
Prevalence
6-9%

Movement of Food Bolus


from hypopharynx to
Esogfagus (initiation
process)
Arises in Esophagus and
related to difficulty in
passing food to stomach

ELDERLY

Prevalence

15-22%
(community)
40 60%
(nursing home)

SWALLOWING PHYSIOLOGY
ORAL PHASE
Voluntary
N.V, N.IX, N.XII
Prepare and
propels food
into pharynx

PHARYNGEAL
PHASE
Sealing
airways and
projection the
bolus to
esophagus

PHARYNGEAL
PHASE
Reflexsively
N.V, N.X, N.XI,
N.XII

ESOPHAGEAL
PHASE
Esophageal
peristaltis and
Relaxation of
LES
Propels bolus
into stomach

ETIOLOGY IN ELDERLY

ETIOLOGY IN ELDERLY
DRUGS INDUCED DYSPHAGIA
Chemotherapy,immunosupressan, & longterm Ab oppurtunistic esophageal
infection stricture
Tetracycline, NSAIDs, Alendronate,
Quinidine pill esophagitis
Beta agonist Lower LES pressure
GERD

Risk when taken in supine


position, prior sleeping,
polypharmacy, and insufficient
fluid

DYSPHAGIA IN ASIA

CLUES ARE IMPORTANT !


FIRST....defining anatomic levels :
OROPHARYNXGEALvs ESOPHAGEAL History taken
(clues) can predict anatomic location approximately
by 80%

NEOPLASIA VS ACHALASIA
Clues that can differ Neoplasia vs Achalasia.....

X
X

HOW IMPORTANT IS PHYSICAL EXAM


?
Should be a part of initial examination
Evaluation oral cavity poor dentition,
erosion, masses
Lymphadenopathy malignancy
(lymphoma)
Thyroid Mass
Facial weakness Stroke, Myasthenia,
Face-mask (Scleroderma)
Extremity proximal muscle weakness
(dermatomyositis), sclerotic (scleroderma)
Neurologic exam N. V, VII, IX, X, XI, XII

Lippincot & William

Aslam M., et al., 2013

ENDOSCOPIC FINDING
ESOFAGUS: Plak putih tak
beraturan tersebar dibagian
proksimal, mukosa edemaeritema. Massa mulai kedalaman
25-35cm hampir menutup lumen,
EGJ tak teridentifikasi.
GASTER: LES inkompeten,
Gastroptosis, Mukosa cardia
edemal-eritema.
DUODENUM: Mukosa dan lumen
Pars 1 dan Pars 2.
KESIMPULAN: Panesofagitis,
dengan massa esofaggus mediusdistal hampir menutup lumen
suspek malignan. LES
inkompeten. Edema-eritema

WHAT CAN PATIENTS DO ?


COMPENSATORY MANAGEMENT Strategies or shortterm adjustment that focus on implementation of
techniques to facilitate continued safe oral intake
Consists of :
1.Postural Adjustment
2.Swallow manuever
3.Modification Diet

SWALLOW manuever

MODIFICATION DIETS
Patients offered a step-wise Diet, based
on consistency

NUTRITIONAL IMPACT ON
ESOPHAGEAL CANCER
Extraordinary therapeutical challenge
gastrointestinal passage may obstructed
malnutrition
Therapeutic modality (surgery, chemotherapy, and/or
radiotherapy) may worsening dysphagia
Weight loss in Esophageal cancer ?
> 50% presented with
weight loss at the time of
Dx
Mean
Early Recovery of Weight
Lossweight reduction
10,8kg
in perioperative Period
Influence weight loss on
Oncologic Outcome ?
Patients with > 2%
weight loss
negative influenced in
post-operative
survival
Patients with > 10%

Complication
Outcome

ENTERAL VS PARENTERAL ?
A meta-analysis study by Peter et al (2005)
Compare Enteral vs Parenteral in hospitalized
patients
Hospital LOS
Mortality

Infection

Non-Infective complication

WHAT ENTERAL ROUTES ?

1. NASOGASTRIC TUBE

2. PERCUTANEOUS ENDOSCOPIC
GASTROSTOMY?
INDICATION
Risk forSModerate Severe

malnourishment of NGT within 2-3


week
Stroke
Amiotropic lateral sclerosis (Motor
neuron disease)
Dementia
Cancer (Head & Neck)

ESOPHAGEAL STENTING

First choice in palliative Tx


for Esophageal Cancer
Esophageal Ca with severe
dysphagia + short life
expectancy
Persistent tumor after
brachitherapy

NGT VS JEJUNOSTOMY

Endoscopic assissted NGT VS


ESOPHAGEAL STENT

TIMING OF PLACEMENT

TAKE HOME MESSAGES


Dysphagia in Elderly may lead to
Frailty and Death
Anamnesis play an important role in
differentitating Oropharyngeal vs
Esophageal Dysphagia
Compensatory Managements are worth to
try
Perioperative Nutritional
Managements are important
factors that will determine
Recommendation
for the Case :
Outcome
Consider Using
Gastrostomy/Jejunostomy in

HBD dr.DIAH

TERIMA KASIH
MOHON ASUPAN DAN DO