Batu Kandung Empedu Dan Ikterik Obstruktif

BATU KANDUNG EMPEDU DAN IKTERIK OBSTRUKTIF

ANATOMI

ANATOMI •

Common bile duct (CBD) memn!n" #e b"in in$e%io% menu!u &&ill o$ 'te% di#oon"#n #e duodenum Pn!n" CBD *+, cm Ditl CBD be%tu den"n &nc%etic duct tu bi !u" mu# #e duodenum mellui lubn" -n" be%bed Gllbldde% 

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&e% .&ed %ee'oi%/ &n!n" 0+12 cm/ dimete% 3+* cm/ #&it 32+42 ml Be%d di &e%mu#n in$e%io% li'e% dn eb"in di elubun"in &e%itoneum5 Te%di%i Te%di%i d%i $undu/ $undu/ bod-/ nec# nec# 5 B"in nec# dn c-tic c-tic duct d &i%l mucol $old ('l'e o$ .eite%) mence". #elu%n- "lltone/ mence". diteni tu #ol& #ol& d%i "llblde%

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ANATOMI •

6#ul% bili%- t%ee –

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Ditl d%i A5 "t%oduodenl/ A5 %et%oduodenl/ A5 &ote%ou&e%io% &nc%etoduodenl P%o#iml A5 .e&ti# de7t%/ A5 c-ticu 

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6#ul% "llblde% in"le c-tic %te%(d&t be%l d%i A5 8e&tic init%/ A5 8e&tic communi/ A5 Meente%ic u&e%io%) Clot9 t%in"le

FISIO:OGI •

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Du#tu bili%i/ "llbldde%/ dn ;n"te% oddi be%$un"i untu# me%ub./ men-im&n dn me%e"uli em&edu Ti& .%i li'e% mem&%odu#i em&edu *22+ 1222 ml Se#%ei di timuli neu%o"enic/ '"l/ c.emicl –

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6"l menin"#t#n e#%ei S&lncn.ic ne%'e menu%un#n e#%ei GI .o%mone

FISIO:OGI •

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Ii em&edu i%/ ele#t%olit/ "%m em&edu/ li&id/ &%otein/ &i"men em&edu G%m em&edu &%ime% diintei di li'e% ole. #olet%ol5 G%m em&edu die#%ei #e em&edu ole. .e&toit dn membntu &en-e%&n lem# di uu5 ,*< #n di#embli#n #e .e&% mellui 'en &o%t .e&tic dn *< die#%ei#n #e $ee5 S;n"te% oddi t%u#tu% #om&le# -" inde&enden d%i otot duodenum5 Be%$un"i men"tu% mu#n- em&edu dn pancreatic juice #e duodenum5 Memili#i te#nn -" tin""i e.in"" mence". %e"u%"iti & -" d di duodenum5 Di&en"%u.i ole. .o%mon &ence%nn m#nn mu# %el7 bile #elu% 

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Ge!l Sim&tomti# •

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Pin Bili%- colic n-e%i menet& di RU= 1 !m tu lebi. etel. m#n dn bin- #%en #ont%#i "llbldde% -n" di&icu ole. e#%ei CCK5 Keti# lumen "llbldde% tid# bi di#oon"#n #%en obt%u#i ole. btu m# 'ice%l ;be% &in di#ti$#n e.in"" menimbul#n n-e%i &d e&i"t%ium tu RU= Fe'e% muncul #%en in$e#i tu in>mi ?undice diebb#n #%en &enin"#tn e%um bili%ubin -n" bi dili.t d%i #le%/ $%enulum lid. tu #ulit5 Se%um bili%ubin @5* m"dl d&t diidenti;#i mellui #le% -" i#te%i#5 ?i# @* m"dl m# mni$etin- di #ulit5 C.%cot9 TRIAS $e'e%/ RU= &in/ !undice u"eti$ &en-umbtn e#%ei bilie% d%i li'e% bu#n .n- d%i "llbldde% 

T%nbdominl Sono"%&.-

8IDA

CT Scn

MRI

ERCP

CA:CU:OUS BI:IAR DISEASE

EPIDEMIO:OGI •

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Btu em&edu &lin" e%in" te%!di &d &ien -" di%t den"n #elu.n GIT5 F#to% Rii#o nit/ obeit/ #e.miln/ e%in" men"#onumi m#nn be%lem#/ c.%on9 diee/ te%minl ilel %eection/ $e%oitoi .e%edite%/ ic#le cell diee/ t.lemi 

PATOGENESIS •

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K%en #etid#mm&un mem&e%t.n#n ci%n em&edu (#olet%ol/ "%m #lium) ?eni btu em&edu –

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btu #olet%ol btu &i"men (.itm tu co#lt)

Bili%- lud"e cm&u%n #%itl #olet%ol/ "%nul #lium bili%ubin dn muin "el mt%i75 Al d%i "lltone5

c.olet%ol "lltone &to"enei 15 u&e%tu%i #olet%ol &d em&edu 5 nu#lei #%itl 35 &embentu#n btu •

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PATOGENESIS •

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Mu#o "llbldde% mem&e%t.n#n #olet%ol dimuli d%i &embentu#n micelle (bile lt+$o$oli&id+#olet%ol com&le7) dn 'ei#el #olet%ol5 P%odu#i #olet%ol tin""i m# 'ei#el te%ebut !u" menin"#t#n #&bilit untu# ment%n&o%t #olet%ol menimbul#n #%itl5 Btu &i"men 

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Btu .itm men"ndun" #olet%ol 2
E5coli mene#%ei Bet+"lu#o%onide -n" men-ebb#n .id%olii d%i con!u"ted bili%ubin "luco%inde -n" men".il#n bili%ubin beb dn end&n #lium

8ISTOR •

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Bin- im&tomti#/ nmun d&t men!di im&tomti# #eti# btu men"obt%u#i du#tu iti#u dn menimbul#n #oli#5 Kom&li#i -n" d&t timbul #oleititi/ #oledo#olitii den"n tu tn& #oln"iti/ "lltone ileu/ "llbldde% c%cinom5 Btu em&edu bin- ditemu#n ec% tid# en"! #eti# l&%otomi tu USG/ CT cn5

C8RONIC CA:CU:OUS C8O:ECSTITIS •

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De;nii &%oe in>mi den"n e&iode %e#u%en d%i #oli# bilie% (n-e%i #ibt obt%u#i)5 8itolo"i &enin"#tn el ube&itelil/ ;b%oi ube%ol dn in;lt%i el mononu#el%5 MK –

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#oli# bilie%/ n-e%i -" menet& 1+* !m &e% .%i5 ?i# n-e%i lebi. d%  !m b%%ti lebi. #emun"#inn #ut #oleititi5 Mul/ munt./ blotin"/ n-e%i UR=5 Pd e&iode tid# n-e%i/ PF dn li'e% tet no%ml5


Di"noi d%i MK dn &eme%i#n %diolo"i USG "old tnd%d &eme%i#n "lltone5 Nmun te%#dn" &d &ien den"n #elu.n #oli# tid# ditemu#n btu &d USG/ t&i .n- ditemu#n lud"e5 ?i# n-e%i dn lud"e ditemu#n &d @ #e!din m# d&t diindi#i#n untu# #oleite#tomi

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Tt :#n –

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Idel electi'e l&%oco&ic c.olec-tectom-5 Diet tn& lem# dn &o%i -" edi#it elm menun""u o&e%i5 Hnit .mil den"n #elu.n im&tomti# "lltone dn #elu.n tid# menu%un etel. modi;#i diet d&t men!lni #oleite#tomi &d t%imete% #ediu5

INDIKASI KO:ESISTEKTOMI URGENT (dlm +0 !m) +cute c.olec-titi +em&.-emtou c.olec-titi +em&-em o$ t.e "llbldde% +&e%$o%tion o$ t.e "llbldde% +&%e'iou c.oledocoliti.ii it. endoco&ic duct cle%nce •

E:ECTI6E +bili%- d-#inei +c.%onic c.olec-titi +-m&tomtic c.olelit.ii •

ACUTE CA:CU:OUS C8O:ECSTITIS •

Pto;iolo"i Pd ,*< #u be%.ubun"n den"n btu em&edu5 Obt%u#i c-tic duct -n" memicu #oli# bilie% ?i# c-tic duct tet& obt%u#i diteni "llbldde% dindin" edem dn in>mi5 Ditndi den"n &%oe in>mi

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&enebln dn .i&e%emi dindin" den"n &e%d%.n ube%ol mu#o .i&e%emi dn &tc.- nec%oi5 Pd #ebn-#n #u !i# umbtn dile&#n m# in>mi ec% be%t.& #n .iln"5 Acute "n"%enou c.olec-titi te%bentu# #%en dn- be tu em&iem di "llbldde%5 •

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MK N-e%i RU= Demm/ mul/ munt./ !undice PF RU= tende%ne/ !i# &e%itoniti m# tende%ne elu%u. l&n" bomen5 ?i# te%b m be%%ti ud. d.ei #e omentum D&t !u" mu%&.- i"n (J) :b

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mild leu#oc-toi (15222+15222mm 3) mild ele'tion o$ bili%ubin (@m"dl) mild ele'tion l#line $o$te/ t%nmine/ dn mile


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Di"noi USG dl. Modlit- o$ C.oice untu# cute c.olec-titi5 Penebln dindin" @mm/ &e%ic.olec-tic >uid/ diteni "llbldde%5 Tt l#n ntibioti# "%m ne"ti$ e%ob dn ne%ob/ I6 >uid/ nl"ei5 De;niti'e t%etment #oleite#tomi +3 .%i etel. #elu.n tu 4+12 min""u etel. initil mediction5 :&%oco&ic c.olec-tectom- lebi. bi# dibndin"#n o&en c.olec-tectom-5 Nmun bin- o&en c.olec-tectom- dil#u#n untu# mem&e%timbn"#n bebe%& $#to% e&e%ti ASA -" menin""i d% ebelumn-/ obeit/ ui tu t&i tid# di%n#n5 ?i# &ien tid# bi di l&%otomi bi den"n &%ecutneou t%n.e&tic c.olec-tectom- den"n netei lo#l untu# d%in "llbldde%/ nmun %ii#o in$e#i lebi. tin""i5

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Kom&li#i em&-em "llbldde%/ em&.-emtou "llbldde%

C8O:EDOCO:IT8IASIS •

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Btu &d common bile duct (CBD) Be%mul di "llbldde% llu mi"%i #e c-tic duct dn #emudin #e CBD5 Btu di#t#n menet& !i# mi. d  t.un &ot #oleite#tomi Btu di#t#n %e#u%en !i# lebi. d%  t.un &ot #oleite#tomi Btu e#unde% bin- b%on tone di CBD/ btu &%ime% be%.ubun"n den"n bili%ti dn in$e#i


MK –

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im&tomti#/ lb tet no%ml/ bin- ditemu#n ec% inidentl im&tomti# #oli# bilie%/ !undice/ %n $ee &uct/ u%in be%%n "el&5 Demm #dn" d Se%um bili%ubin (@3 m"d:)/ e%um minot%n$e%e/ l#lin $o$te menin"#t t&i tnd te%ebut tid# &ei;# mennd#n dn- btu CBD 5

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USG dilti BD @ mm/ bili%- &in/ !undice5 ERCP (endoco&ic %et%o"%de c.oln"i&nc%eto"%&.-) me%u&#n MOC dn untu# di"noti# dn te%&euti# CBD tone5


Tt :#n –

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endoco&ic c.oln"io"%&.- untu# di"noti# dn ;n"te%e#tomi ebelum l&%o#o&i# #oleite#tomi Indi#i c.oln"iti -" membu%u#/ m&ull%- tone im&ction/ billi%- &nc%etiti/ i%oi5 Setel. endoco&i &.incte%ectom- dn tone e7t%ction/ &ien mi. be%ii#o untu# men"lmi bili%com&liction5 :&%oco&ic CBD e7&lo%tion int%o&e%ti'e c.oln"io"%m t #oleite#tomi5 O&en common bile duct e7&lo%tion !%n" di&#i5 Bi di"un#n !i# tone im&cted di m&ull/ !di ulit men""un#n endoco&ic5

SURGER FOR CA:CU:OUS BI:IAR DISEASE :&%oco&ic c.olec-tectom- Kont%indi#i co"ulo&t.-/ e'e%e co&d/ end t"e li'e% diee/ C8F5 T.&n •

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Pien u&ine/ o&e%to% di ebel. #i%i Pneumo&e%itoneum dibut den"n " den"n CO tu den"n o&en tec.niLue tu cloed+needle tec.niLue :&%oco&e dn #me% dimu#n 'i umbilicl &o%t die#i m&e te%li.t c-tic duct dn c-tic %te%- te%li.t li"i c-tic %te%- di ditl dn &%o#iml die#i "llbldde% 

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SURGER FOR CA:CU:OUS BI:IAR DISEASE Int%o&e%ti'e c.oln"io"%mUlt%ound ?i# &ien memili#i bno%ml li'e% $unction tet/ du#tu -" be%/ dn btu -" #ecil/ dilti CBD/ &%eo&e%ti'e endoco&ic c.oln"io"%&.- belum dil#u#n5 O&en c.olec-tectom- B"i &ien den"n &oo% &ulmon%-c%dic %ee%'e/ u&ected "llbldde% cnce%/ i%oi.i&e%teni &o%tl/ #e.miln t%imete% 35 CBD e7&lo%tion Pd &ien den"n btu -" bn-# dn be% tu dilti CBD dn te%&i den"n endo#o&i ""l5 ?i# ""l/ indi#i untu# o&en u%"e%- llu !i# mi. ""l ERCP5 •

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Batu Kandung Empedu Dan Ikterik Obstruktif

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