The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy
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Proximal Jejunal Diverticle: Cause of Upper Gastrointestinal Bleeding
No full textFive percents of patient presenting with gastrointestinal (GI) bleeding, the etiology of bleeding could not be found by upper endoscopy and colonoscopy. Almost 75% of which, the abnormality is detected in small bowel. One of the etiologies in small bowel bleeding is jejunal diverticle. In this paper, we reported a female, 38 years old, came with upper GI bleeding since one month ago. She had undergone several diagnostic procedures, such as abdominal ultrasound, abdominal computed tomography scan (CT-scan), upper and lower endoscopy, but there were no conclusion to explain the cause of bleeding. However, barium follow through examination found a diverticle, pouch-like shape, at jejunal proximal projection. Then, she underwent surgical treatment. Small intestine bleeding is best investigated by capsule endoscopy and double balloon enteroscopy. However, in limited conditions, small bowel follow through can be used to screen the source of bleeding in small intestine. The specific diagnosis of small intestine diverticle is possible by radiologic contrast study using various form of barium. Small bowel diverticle does not require surgical treatment, unless refractory symptoms or complications occur. Jejunal diverticle is one of sources in small intestinal bleeding. Small bowel follow through can still be used to diagnose jejunal diverticle. Keywords: diverticle, proximal jejunal, upper gastrointestinal bleeding, barium follow throug
The Effect of Domperindone on Intestinal Motility and Bacterial Overgrowth in Patients with Liver Cirrhosis
No full textABSTRACTBackground: Spontaneous bacterial peritonitis (SBP) is a common serious complication of liver cirrhosis mainly caused by bacterial translocation (BT) into ascites fluid. The most essential issue that affects BT is small intestinal bacterial overgrowth (SIBO), which usually caused by gastrointestinal dysmotility. This study was aimed to evaluate the prokinetic effects of domperidone on gastrointestinal motility and small intestinal bacterial overgrowth and the correlation between restoration of motility and the incidence of SIBO in patients with liver cirrhosis.Method: A cross-over double blind clinical trial was conducted on patients who were treated at the ward and outpatient clinic from Division of Hepatology in Cipto Mangunkusumo Hospital, Jakarta and Soedarso Hospital, Pontianak between September 2010 and March 2011. All patients suffered from liver cirrhosis with ascites, gastrointestinal dysmotility and SIBO were included in the study. Out of 34 eligible patients, 16 patients received placebo and 18 patients received prokinetics (domperidone). Wilcoxon test was performed to analyze the comparison of SIBO before and after treatment in the placebo group; while paired T-test was employed for the prokinetics (domperidone) group. To evaluate improved balance of SIBO in the placebo and domperidone group, a Chi-square test was performed.Results: In the placebo group, 61.8% patients experienced SIBO; while in the prokinetics group, SIBO occurred only in 2.9% patients. Restored gastrointestinal motility took place in the prokinetics group with reduced median value for orocaecal transit time from 120 minutes into 90 minutes (p = 0.0001). In contrast, it went worse in the placebo group, i.e. from 90 minutes into 110 minutes (p = 0.002). There was a significant correlation between restored gastrointestinal motility and SIBO (p = 0.0001). Similarly, so does the effect of administering prokinetic agent on restored gastrointestinal motility (p = 0.0001) and SIBO (p = 0.0001).Conclusion: The administration of prokinetics has been proven effective to restore gastrointestinal motility that may lead to reduced incidence of SIBO in patients with liver cirrhosis. Keywords: prokinetics, breath hydrogen test, dysmotilitas, bacterial overgrowth
Esophagus and Its Function Related to Gastro-esophageal Reflux
No full textABSTRACTThe main function of the esophagus is to transport food from the mouth into stomach. Anatomical structures, innervations and blood supplies are needed in order to transport the food into stomach. Mastication stimulates the parasympathetic nerves that regulate salivary, gastric and pancreatic secretion. Saliva secretion stimulates swallowing and increases primary esophageal peristalsis, helps in clearing the esophagus from refluxed material. Swallowing induces peristaltic of esophagus that propulses a solid bolus down the esophagus into the stomach. Innervations are important for esophagus to do its function. One of the most important is coordination between the various reflexes. Delayed clearance of acid from the esophageal and decreased pressure of the lower sphincter esophagus (LES) are the major mechanisms involved in the development of esophagitis. The resistance of the mucosa to the noxious effect of the refluxed material (acid, pepsin, chymotrypsin and trypsin, bile, etc.) is different from person to person. The LES pressure is a defense mechanisms to prevent gastro-esophageal reflux disease (GERD). The LES pressure decreases postprandially. The frequency of postprandinal GER is related to the meal size. Gastric bolus feeding is related to greater intragastric pressure causes more of transient LES relaxations. Osmolality and volume of the feeding slow gastric emptying and incrase postprandial GER. The occurrence of GERD is associated with whether or not the preventive factors are functioning. Other preventive factors for GERD are esophageal peristalsis, secretion and mucosal resistance, gravity and position, the LES tone and angle of his. Patient with GERD should be searched for any disturbances on those factors. Keywords: gastroesophageal reflux diseases, lower esophageal sphincter, esophagitis, peristaltic
The Effect of Branched Chain Amino Acids and L-Ornithine L-Aspartate Combination as The Late Evening Snacks on Nutritional Status and Minimal Hepatic Encephalopathy in Liver Cirrhosis
No full textABSTRACTBackground:Minimal hepatic encephalopathy (MHE) in liver cirrhotic patients is critical manifestation of low grade hepatic encephalopaty (HE), is caused quality of life decrease and risk of deteriorating into distinct HE. The study was conducted to asses the effect of combination of branched-chain amino acids (BCAA) and L-ornithine L-aspartate (LOLA), which was given late evening, on nutritional status and degree of HE.Method: This single-blind randomized study was conducted on liver cirrhotic outpatients in hepatology clinic of Cipto Mangunkusumo Hospital period June 2011-June 2012. The study subjects were divided into two groups, group of late evening snack (LS) and day snack (DS). Each group was supplemented with combination of milk of BCAAs and LOLA (3.7 g/serving). Evaluation based on history, physical examination, laboratory tests and critical flicker frequency (CFF) was performed one month after the intervention. Data were statistically analyzed with SPSS 15.Results: Thirty-two patients whose the inclusion criteria were divided into 16 subjects for each group, LS and DS. After one month of the intervention, the average level of prealbumin for DS group was increased statistically significant (p < 0.001), but not significant for LS group (p = 0.259). The increase of average body weight,mid-arm muscle circumference (MAMC) and CFF test result in both groups. There was no improvement on subject global assessment (SGA) score after one month intervention in both groups.Conclusion: This study proved that giving combination of BCAAs and LOLA may improve the condition of MHE, however for nutritional status can not be assessed. Keywords: minimal hepatic encephalopathy, BCAAs, LOLA, prealbumin, SGA score, nutritional statu
Mortality Risk Factors in Acute Upper Gastrointestinal Bleeding
No full textBackground: Upper gastrointestinal bleeding (UGIB) is one of the emergency cases in gastroenterology. The mortality rate does not change in the last 4 decades, however, there is no precise data in Cipto Mangunkusumo Hospital. Identified risk factors are expected to increase early awareness and optimal planning in management of patients. This study was aimed to know the mortality risk factors in acute UGIB in Cipto Mangunkusumo Hospital. Method: Case control study was performed between August and December 2011 by collecting and studying medical records of acute UGIB patients who were admitted and hospitalized between January 2003 and June 2011 in Cipto Mangunkusumo Hospital. Cases were acute UGIB patients who passed away during hospitalization in that period of time. Controls were patients who did not pass away and hospitalize in same period (date/month/year index). Samples were taken randomly with the proportion of case and control 1 : 2. Bivariate analysis was perfomed by chi-square test and continued with multivariate analysis. Results: Study subjects consisted of 87 cases and 174 controls. Significant variables as risk factors were multiple co-morbidities (OR = 2.66; 95% CI = 1.21-5.85), recurrent bleeding (OR = 9.07; 95% CI = 3.87-21.26), decreased consciousness (OR = 7.60; 95% CI = 1.94-29.88), endoscopy not performed (OR = 11.95; 95% CI = 4.75-30.11), and sepsis (OR = 4.83; 95% CI = 2.03-11.48). Conclusion: Multiple co-morbidities, sepsis, decreased consciousness on hospital admission, and recurrent bleeding are mortality risk factors in acute UGIB. Mortality risk increases in patients, to whom endoscopy was not performed. Keywords: UGI bleeding, risk factors, mortalit
Influence of Fucoidan in Mucus Thickness of Gastric Mucosa in Patients with Chronic Gastritis
No full textBackground: Chronic gastritis is commonly found with complains of dyspepsia, which may decrease work productivity. Imbalance between agressive and defensive factors is the cause of chronic gastritis. Therapy is mostly directed to the agressive factors, particularly gastric acid and very few studies are directed on defensive factors. Mucus is the first defense mechanism of gastric mucosa. Fucoidan is a phytopharmaca, which is thought to increase the thickness of gastric mucosa. The objective of this study was to know the thickness of gastric mucosa in patients with chronic gastritis and to evaluate the effect of fucoidan to the gastric mucosa thickness in patients with chronic gastritis. Method: In this double-blinded randomized clinical trial study, 41 patients in the Endoscopy Unit Cipto Mangunkusumo Hospital between October 2009 and October 2010 were enrolled consecutively. Selected patients were divided into 2 groups: a group was given fucoidan and another group was given placebo. Statistical analysis was done using T-test. Results: Of 41 chronic gastritis patients, only 34 patients completed this study. There was difference of mucus thickness of gastric mucosa in patients with chronic gastritis; in the antrum 42.59 µ m (± 8.67) and in the corpus 44.28 µ m (± 9.64). This study also showed that fucoidan administration increased the mucus thickness in the antrum by 7.42 µ m and in the corpus by 7.74 µ m compared to placebo significantly. Conclusion: Fucoidan increased the mucus thickness of gastric mucosa in patients with chronic gastritis. Keywords: mucus thickness, chronic gastritis, fucoida
Clinical Effects of an Amino Acid and Glucose Solution in Non-surgical Gastrointestinal Patients of Internal Medicine
No full textBackground: This study was performed to assess the efficacy and safety of intravenous amino acid and glucose solution with electrolytes in non-surgical gastrointestinal patients. Method: This single, open, and pre-post study was conducted in the internal medicine ward at Cipto Mangunkusumo Hospital between June 2007 and March 2008. Patients were administered solution of amino acid, glucose, and electrolytes via peripheral vein at a dose of 1000 mL/day for one week period. Non-operative gastroenterology patients with age between 16 and 65 years were eligible in this study; patients were excluded if they had diabetes mellitus, severe hepatic or renal dysfunction, electrolyte disturbance, and obesity. The data were analyzed by paired t-test and McNemar test using SPSS version 16. Results: Fifteen patients consisted of 8 (53.5%) female, mean age was 38.47 ± 14.73 years. The body mass index (BMI) at screening was 14.50 ± 2.11 kg/m2. Patients’ BMI increased in day-1, day-3, and day- 7 into 14.5; 14.58; 14.80 kg/m2, respectively (p < 0.05). The increasing of prealbumin, albumin, transferin, and total protein were 7.30 mg/dL vs 11.16 mg/dL; p = 0.018; 2.71 g/dL vs 3.12 g/dL; p = 0.024; 102.37 mg/dL vs 141.95 mg/dL; p = 0.016; 6.24 g/dL vs 6.85 g/dL; p = 0.019, respectively. The clinical symptoms of nausea and weakness in patients decreased from 53.3% to 6.7%; p = 0.016, and 66.7% to 6.7%; p = 0.004. Conclusion: This parenteral nutrition solution was effective to improve clinical nutrition parameters. Keywords: amino acid and glucose solution, non-surgical gastrointestinal patients, peripheral parenteral nutritio
Diagnostic Problems in Crohn's Disease: A Case Report
No full textCrohn’s disease is marked by transmural inflammation of the digestive tract and is categorized into inflammatory bowel disease (IBD). In Indonesia, Simadibrata et al, reported 20% from 107 patients who experienced non-infective chronic diarrhea, actually suffered from IBD. A 33-year old male patient complained of watery stool since 3 months before hospital admission. He experienced stabbing stomachache and loss of body weight. Physical and laboratory examination results were within normal limits. Faecal analysis revealed intestinal infection caused by gram-negative bacteria and intestinal maldigestion. Colonoscopy examination exhibited the presence of hyperemic mucosa, edematous, and positive cobblestone appearance in the terminal ileum. Additionally, the histological evaluation showed the impression of chronic ileitis usually found in IBD. Meanwhile, moderate pangastritis was obtained in the esophagoduodenoscopy examination. results of histological biopsy of the antrum showed absence of Helicobacter pylori infection. An active lesion in chronic ileitis was found in immunohistochemistry examination. Acid fast bacterial culture was also performed to the ileum tissue and revealed negative results in clinical microbiology examination. From the examinations conducted, patient was diagnosed as Crohn’s disease and treated with budesonide capsule 3 mg and mesalazine tablet 1,000 mg twice daily. Later, he felt improvement of the complains. This case illustrated Crohn’s disease which is rarely found in Indonesia. This is because diagnosis requires supporting examinations which could only be done in tertiary health care facilities. However, possibility of other diagnosis should be considered, particularly intestinal tuberculosis and infective colitis. Early diagnosis and prompt treatment may improve patient’s prognosis and quality of life. Keywords: IBD, Crohn’s disease, positive cobbleston
Non-endoscopic Examination as Predictor of Varices Degree in Liver Cirrhosis Patients Who have Experienced Esophageal Variceal Bleeding
No full textBackground: Standard diagnosis for determining the degree of varices is by endoscopy. However, sometimes there are obstacles in the implementation of endoscopy. Based on the factors, we need to know the parameters of non-endoscopic examination which include ascites, splenomegaly, thrombocytopenia, Child-Pugh, portal vein diameter as a predictor of the degree of liver cirrhosis patients with varices who have experienced esophageal variceal bleeding. Method: The study design was cross-sectional study. The study was conducted on hospitalized patients in Cipto Mangunkusumo hospital, Gatot Subroto hospital, and Kraton hospital from September 2008 to November 2009. The patients were liver cirrhosis patients with history of upper gastrointestinal bleeding, no present bleeding, and hemodynamically stable. Examination of predictor factors in the patients such as ascites, splenomegaly, thrombocytopenia, Child-Pugh and portal vein diameter were done. Statistical analysis was performed with student’s t-test, Mann-Whitney test, and stepwise multivariable logistic regression. Results: The study involved 44 patients with liver cirrhosis who have esophageal variceal bleeding. Based on the results of endoscopic examination, large varices (F3) were found in 21 (47.73%) patients, small varices (F1 & F2) in 23 (52.27%) patients, located on the distal esophagus extending to the medial (86.4%), with red color sign present (54.5%). Results of non-endoscopic examination such as splenomegaly, ascites, thrombocytopenia, portal vein diameter and Child-Pugh score was known not to be associated with the degree of esophageal varices (p > 0.05). Conclusion: Non-endoscopic examination was not related to the degree of varices in liver cirrhosis patients who have experienced esophageal variceal bleeding. Keywords: esophageal variceal bleeding, liver cirrhosis, predictor factors, endoscopic criteri