REFERAT MUNTAH PADA ANAK
Disusun Oleh: Ainur Adi
13710546/09700105 13710546/09700105
PEMBIMBING dr. . !"er#$%&"n"' !(. A
SMF Ilmu Kesehatan Anak RSUD Kab. Kediri Fakultas Kedokteran Uniersitas !i"a#a Kusuma Suraba#a $%&'
(A( I PENDAHU)UAN &. )ata )atarr bel belak akan an* *
Mun% Mun%$h $h ($d$ ($d$ $n$) $n$) serin serin* * &eni &eni&+ &+ul ul)$ )$n n )e,e& )e,e&$s$ $s$n n ($d$ ($d$ "r$n "r$n* * %u$' %u$' +$h) +$h)$n $n &en# &en#$d $dii &en$)u &en$)u%)$ %)$n n +il$ +il$ &un%$h &un%$h diser% diser%$i $i d$r$h d$r$h -he&$%e& -he&$%e&esis esis. . Or$n* Or$n* %u$ $)$n $)$n se*er$ se*er$ &en,$r &en,$rii (er%"l"n*$n d")%er +il$ &en*$l$&i h$l ini.1' Mun%$h d$($% se+$*$i $$l (en$)i% s$lur$n ,ern$ ,ern$ $%$u $%$u dilu$r dilu$r s$lur$n s$lur$n ,ern$ ,ern$ +$i) +$i) +eru($ +eru($ in2e)s in2e)si' i' in2l$& in2l$&$si $si $%$u )el$in )el$in$n $n $n$%"& $n$%"&i. i. Penin* Penin*)$%$ )$%$n n %e)$n$ %e)$n$n n in%r$,r in%r$,r$ni$ $ni$ll d$($% d$($% +er&$n +er&$ni2es i2es%$si %$si $$l $$l +eru($ +eru($ &un%$h &un%$h'' +e*i%u +e*i%u #u*$ #u*$ $d$n$ in2e)si si%e&i) d$($% &eni&+ul)$n &un%$h. '3 id$) se&u$ "+$% $n%i &un%$h d$($% di+eri)$n )e($d$ se%i$( $n$) )$ren$ (en$n*$n$nn$ di%u#u)$n )e($d$ (ene+$+ &un%$h sendiri.1'3 P$d$ +$i $n* )e,il d$n s$n*$% &ud$ $%$u )e%erl$&+$%$n &en%$l &un%$h d$($% &e&+$h$$)$n %er#$din$ $s(ir$si h$l ini &ud$h %er#$di )$ren$ $d$n$ )""rdin$si neur"&us)uler $n* +elu& se&(urn$. n%u) &en,e*$h h$l %erse+u% ("sisi +$i d$($% di&irin*)$n $%$u %en*)ur$( d$n +u)$nn$ %erlen%$n*. &ur (enderi%$ $d$l$h h$l $n* (en%in* d$l$& )$i%$nn$ den*$n &un%$h. P$d$ (eri"de ne"n$%$l %er#$din$ s(i%%in* $%$u re*ur*i%$si se#u&l$h )e,il isi l$&+un* &$sih d$l$& +$%$s )e$#$r$n d$n +u)$n &eru($)$n )e$d$$n $n* ($%"l"*is di&$n$ &$sih %er#$di )en$i)$n +er$% $n* n"r&$l. $l l$in $n* (erlu di,er&$%i $d$l$h &un%$h #u*$ &eru($)$n &$ni2es%$si d$ri )el$in$n +$$$n "+s%ru)si *$s%r"in%es%in$l $n* +il$ %id$) di%er$(i se,$r$ &e&$d$i d$($% 2$%$l4'5. Mun%$h $)u% &eru($)$n *e#$l$ $n* serin* %er#$di ($d$ )$sus $+d"&en $)u% d$n in2e) in2e)si si in%r$ in%r$ &$u( &$u(un un e)s% e)s%r$ r$ *$s% *$s%r" r"in in%es %es%i %in$ n$l. l. Berl$ Berl$in in$n $n den* den*$n $n &un% &un%$h $h $)u% $)u%'' &un% &un%$h $h )r"nis/+erul$n* serin* &eru($)$n 2$)%"r $n* (en%in* d$ri *$&+$r$n )lini) su$%u (en$)i%. $ren$ (en$)i% $n* &end$s$ri &un%$h )r"ni)/+erul$n* serin* %id$) #el$s &$)$ serin* dise+ dise+u% u% unexplained unexplained chronic chronic vomiting vomiting . Belu& %erd$($% +$%$s$n $n* #el$s un%u) &un%$h )r"ni)' %e%$(i +$%$s$n &un%$h )r"ni) serin* dis$&$)$n den*$n +$%$s$n di$re )r"ni)' $i%u &un%$h $n* +erl$n*sun* le+ih d$ri du$ &in**u 3.
(A( I PENDAHU)UAN &. )ata )atarr bel belak akan an* *
Mun% Mun%$h $h ($d$ ($d$ $n$) $n$) serin serin* * &eni &eni&+ &+ul ul)$ )$n n )e,e& )e,e&$s$ $s$n n ($d$ ($d$ "r$n "r$n* * %u$' %u$' +$h) +$h)$n $n &en# &en#$d $dii &en$)u &en$)u%)$ %)$n n +il$ +il$ &un%$h &un%$h diser% diser%$i $i d$r$h d$r$h -he&$%e& -he&$%e&esis esis. . Or$n* Or$n* %u$ $)$n $)$n se*er$ se*er$ &en,$r &en,$rii (er%"l"n*$n d")%er +il$ &en*$l$&i h$l ini.1' Mun%$h d$($% se+$*$i $$l (en$)i% s$lur$n ,ern$ ,ern$ $%$u $%$u dilu$r dilu$r s$lur$n s$lur$n ,ern$ ,ern$ +$i) +$i) +eru($ +eru($ in2e)s in2e)si' i' in2l$& in2l$&$si $si $%$u )el$in )el$in$n $n $n$%"& $n$%"&i. i. Penin* Penin*)$%$ )$%$n n %e)$n$ %e)$n$n n in%r$,r in%r$,r$ni$ $ni$ll d$($% d$($% +er&$n +er&$ni2es i2es%$si %$si $$l $$l +eru($ +eru($ &un%$h &un%$h'' +e*i%u +e*i%u #u*$ #u*$ $d$n$ in2e)si si%e&i) d$($% &eni&+ul)$n &un%$h. '3 id$) se&u$ "+$% $n%i &un%$h d$($% di+eri)$n )e($d$ se%i$( $n$) )$ren$ (en$n*$n$nn$ di%u#u)$n )e($d$ (ene+$+ &un%$h sendiri.1'3 P$d$ +$i $n* )e,il d$n s$n*$% &ud$ $%$u )e%erl$&+$%$n &en%$l &un%$h d$($% &e&+$h$$)$n %er#$din$ $s(ir$si h$l ini &ud$h %er#$di )$ren$ $d$n$ )""rdin$si neur"&us)uler $n* +elu& se&(urn$. n%u) &en,e*$h h$l %erse+u% ("sisi +$i d$($% di&irin*)$n $%$u %en*)ur$( d$n +u)$nn$ %erlen%$n*. &ur (enderi%$ $d$l$h h$l $n* (en%in* d$l$& )$i%$nn$ den*$n &un%$h. P$d$ (eri"de ne"n$%$l %er#$din$ s(i%%in* $%$u re*ur*i%$si se#u&l$h )e,il isi l$&+un* &$sih d$l$& +$%$s )e$#$r$n d$n +u)$n &eru($)$n )e$d$$n $n* ($%"l"*is di&$n$ &$sih %er#$di )en$i)$n +er$% $n* n"r&$l. $l l$in $n* (erlu di,er&$%i $d$l$h &un%$h #u*$ &eru($)$n &$ni2es%$si d$ri )el$in$n +$$$n "+s%ru)si *$s%r"in%es%in$l $n* +il$ %id$) di%er$(i se,$r$ &e&$d$i d$($% 2$%$l4'5. Mun%$h $)u% &eru($)$n *e#$l$ $n* serin* %er#$di ($d$ )$sus $+d"&en $)u% d$n in2e) in2e)si si in%r$ in%r$ &$u( &$u(un un e)s% e)s%r$ r$ *$s% *$s%r" r"in in%es %es%i %in$ n$l. l. Berl$ Berl$in in$n $n den* den*$n $n &un% &un%$h $h $)u% $)u%'' &un% &un%$h $h )r"nis/+erul$n* serin* &eru($)$n 2$)%"r $n* (en%in* d$ri *$&+$r$n )lini) su$%u (en$)i%. $ren$ (en$)i% $n* &end$s$ri &un%$h )r"ni)/+erul$n* serin* %id$) #el$s &$)$ serin* dise+ dise+u% u% unexplained unexplained chronic chronic vomiting vomiting . Belu& %erd$($% +$%$s$n $n* #el$s un%u) &un%$h )r"ni)' %e%$(i +$%$s$n &un%$h )r"ni) serin* dis$&$)$n den*$n +$%$s$n di$re )r"ni)' $i%u &un%$h $n* +erl$n*sun* le+ih d$ri du$ &in**u 3.
$. Tu"uan a. Tu Tu"uan "uan Umum
n%u n%u) ) &e&e &e&enu nuhi hi s$r$ s$r$%% d$l$& d$l$& &en* &en*i) i)u% u%ii (r"* (r"*r$& r$& )e($ )e($ni% ni%er er$$n $$n )lin )lini) i) Il&u Il&u eseh$%$n An$) u&$h !$)i% e("lisi$n Pus$% $den !$id !u)$n%". b. Tu"uan Khusus
n%u) n%u) &en*e% &en*e%$hu $huii d$n &e&$h$& &e&$h$&ii &un%$h &un%$h ($d$ ($d$ $n$) $n$) d$ri d$ri se*i se*i de2ini de2inisi' si' e%i"l" e%i"l"*i' *i' ($%"2isi"l"*i' di$*n"sis' d$n %er$(i sehin**$ d$($% di$(li)$si)$n den*$n se+$i) +$i)n$ d$l$& (r$)%e) d")%er.
(A( II TIN+AUAN PUSTAKA &. De,inisi
Mun%$h $d$l$h di)elu$r)$nn$ isi l$&+un* &el$lui &ulu% se,$r$ e)s(ulsi2. s$h$ &en*elu$r)$n isi l$&+un* $)$n %erlih$% se+$*$i )"n%r$)si "%"% dindin* (eru%. !e,$r$ )linis' )$d$n*)$d$n* suli% di+ed$)$n den*$n re2lu)s *$s%r"es"2$*us d$n re*ur*i%$si. e2lu)s *$s%r"es"2$*us -8E dide2inisi)$n se+$*$i )e&+$lin$ isi l$&+un* )ed$l$& es"2$*us %$n($ $d$n$ us$h$ d$ri +$i $%$u $n$). A($+il$ isi l$&+un* %erse+u% di)elu$r)$n &el$lui &ulu%' &$)$ )e$d$$n ini dise+u% se+$*$i re*ur*i%$si. Oleh )$ren$ i%u' &un%$h ($d$ +$i $%$u $n$) h$rus di(i)ir)$n (ul$ )e&un*)in$n su$%u 8E. Mun%$h &eru($)$n re2le) (r"%e)%i2 %u+uh )$ren$ d$($% +er2un*si &el$$n %")sin $n* %id$) sen*$#$ %er%el$n. Mun%$h &eru($)$n us$h$ &en*elu$r)$n r$,un d$ri %u+uh d$n +is$ &en*ur$n*i %e)$n$n $)i+$% $d$n$ su&+$%$n $%$u (e&+es$r$n "r*$n $n* &ene+$+)$n (ene)$n$n ($d$ s$lur$n (en,ern$$n3'4'. $. E-idemiolo*i
!indr"& Mun%$h !i)li) %er#$di se+$n$) 1'9 ($d$ $n$)$n$) se)"l$h. in*)$% (re;$lensi re2lu)s *$s%r"es"2$*us s$n*$% +er;$ri$si d$ri +e+er$($ s%udi $n* %el$h dil$)u)$n %e%$(i re2lu)s *$s%r"es"2$*us &eru($)$n h$l $n* s$n*$% u&u& %er#$di ($d$ %$hun (er%$&$ )ehidu($n. An*)$ )e#$di$n re2lu)s es"(h$*us &en,$($i 1:300 +$i ($d$ %$hun (er%$&$ )ehidu($n. D$%$ &ene+u%)$n se)i%$r 50 ($d$ +$i +eru&ur +ul$n &en*$l$&i re*ur*i%$si )$li seh$ri $%$u le+ih. Pre;$lensi %er%in**i $i%u 67 %er#$di se)i%$r +$i +eru&ur 4 +ul$n d$n )e&udi$n (re;$lensi &enurun &en#$di 1 ($d$ s$$% +$i +eru&ur 1 %$hun 6. . Etiolo*i
E%i"l"*i &un%$h s$n*$% lu$s' seluruh )el$in$n $n* &en$n*)u% rese(%"r &un%$h +$i) d$ri %r$)%us *$s%r"in%es%in$l' +er+$*$i ;iser$ -h$%i' *in#$l' ($n)re$s' #$n%un*' ($ru' ,$n$lis ;es%i+ul$ris' 8he&"re,e(%i;e ri**er <"ne -8< &$u(un !u(r$neur"n $)$n d$($% &eni&+ul)$n &un%$h. G$s%r"en%eri%is $d$l$h (ene+$+ u%$&$ &un%$h ($d$ $n$). Mun%$h +is$ %er#$di $)i+$% l$n*sun* *$s%r"en%eri%is. D$l$& )e$d$$n ini &un%$h +is$ &end$hului %i&+uln$ di$re s$&($i
4 #$&. e%$(i *e#$l$ &un%$h #u*$ &en*hil$n* le+ih ,e($% 14 #$& se%el$h di$re &un,ul. Mun%$h #u*$ +is$ %er#$di $)i+$% *$n**u$n &e%$+"li) se+$*$i $)i+$% di$re/dehidr$si. Mis$ln$ $)i+$% $sid"sis4. Pene+$+ &un%$h ($d$ $n$) s$n*$% +er;$ri$si. Be+er$($ (ene+$+ &un%$h $n* serin* di%e&u)$n ($d$ $n$)' $i%u: 1. !$lur$n ,ern$: $. O+s%ru)si:
$%resi$
es"2$*us'
s%en"sis
(il"rus'
$n%r$l
e+'
&"r+us
hirs,hs(run*' &$lr"%$si usus' ;"l;ulus' hi$%$l herni$' $)$l$si$' ileus &e)"niu&' in%ususe(si. +. N"n "+s%ru)si: GE' *$s%r"en%eri%is' en%er")"li%is ne2ri%i)$ns' )$l$si$ . =u$r s$lur$n ,ern$ : %e)$n$n in%r$)r$ni$l &enin**i' in2e)si -!!P' s$lur$n n$($s' s$lur$n )e&ih' ' hidr"se2$lus' )el$in$n &e%$+"li) 3. N"n "r*$ni) : %e)ni) (e&+eri$n &inu& $n* %id$) +en$r' iri%$si ,$ir$n $&ni"n' "+$%' (si)"*eni)' &"%i"n si,)nes. /. Pato,isiolo*i
e&$&(u$n
un%u)
&e&un%$h)$n
&eru($)$n
su$%u
)eun%un*$n
)$ren$
&e&un*)in)$n (en*elu$r$n %")sin d$ri l$&+un*. Mun%$h %er#$di +il$ %erd$($% r$n*s$n*$n ($d$ (us$% &un%$h ->"&i%in* 8en%re' su$%u (us$% )end$li di &edull$ +erde)$%$n den*$n (us$% (ern$($s$n $%$u 8he&"re,e(%"r ri**er <"ne -8< di $re$ ("s%re&$ ($d$ l$n%$i ;en%ri)el )ee&($% !usun$n !$r$2. ""rdin$si (us$% &un%$h d$($% dir$n*s$n* &el$lui +er+$*$i #$r$s. Mun%$h d$($% %er#$di )$ren$ %e)$n$n (si)"l"*is &el$lui #$r$s $n* )"r%e) sere+ri d$n ss%e& li&+i, &enu#u (us$% &un%$h ->8. Pen,e*$h$n &un%$h &un*)in d$($% &el$lui &e)$nis&e ini. Mun%$h %er#$di #i)$ (us$% &un%$h %er$n*s$n* &el$lui ;es%i+ul$r $%$u sis%i& ;es%i+ul"sere+ell$ d$ri l$+irin% di d$l$& %elin*$. $n*s$n*$n +$h$n )i&i$ &el$lui d$r$h $%$u ,$ir$n "%$) -=8! $)$n %erde%e)si "leh 8<. Me)$nis&e ini &en#$di %$r*e% d$ri +$n$) "+$% $n%i e&e%i). Ner;us ;$*$l d$n ;is,er$l &eru($)$n #$r$s )ee&($% $n* d$($% &ens%i&ul$si &un%$h &el$lui iri%$si s$lur$n ,ern$ diser%$i s$lur$n ,ern$ d$n (en*"s"n*$n l$&+un* $n* l$&+$%. !e)$li (us$% &un%$h %er$n*s$n* &$)$ ,$s,$de ini $)$n +er#$l$n d$n $)$n &ene+$+)$n %i&+uln$ &un%$h 1'4'6'7.
G$&+$r 1. An$%"&i Pus$% Mun%$h Mun%$h
se+en$rn$ &eru($)$n (eril$)u $n*
)"&(le)' di&$n$
($d$
&$nusi$ &un%$h %erdiri d$ri 3 $)%i;i%$s $n* %er)$i%' n$use$ -&u$l' re%,hin*' (en*elu$r$n isi l$&+un*. Ad$ re*i" $n$%"&i di &edull$ $n* &en*"n%r"l &un%$h' ,he&"re,e(%"r %ri**er ?"ne -8< d$n ,en%r$l ;"&i%in* ,en%re -8>8. 8< $n* %erle%$) di $re$ ("s%re&$ ($d$ d$s$r u#un* ,$ud$l ;en%ri)el I> dilu$r +l""d +r$in +$rrier -s$$r "%$). ese(%"r did$er$h ini di$)%i;$si "leh +$h$n+$h$n (r"e&e%i) did$l$& sir)ul$si d$r$h $%$u di ,$ir$n ,ere+r"s(in$l -8!@. E2eren d$ri 8< di)iri& )e 8>8 sel$n#u%n$ %er#$di ser$n*)$i$n )e#$di$n $n* di&ul$i &el$lui ;$*$l e2eren s(l$n,hni,. 8>8 %erle%$) dinu)leus %r$,%us s"li%$rius d$n dise)i%$r 2"r&$%i" re%i)ul$ris &edull$ %e($% di+$$h 8<. 8< &en*$ndun* rese(%"r un%u) +er&$,$&&$,$& sin$l neur"$)%i2 $n* d$($% &ene+$+)$n &un%$h. ese(%"r un%u)
d"($&ine
-%i%i)
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d$ri $("&"r(hine' $,e%hl,h"line'
;$s"(ressine' en)e(h$lin' $n*i"%ensin' insulin ser"%"nin' endh"r(hin' su+s%$n,e P' d$n &edi$%"r&edi$%"r $n* l$in. Medi$%"r $den"sine 3'5 ,,li, &"n"(h"s(h$%e -,,li, AMP &un*)in %erli+$% d$l$& res("n e)si%$si un%u) se&u$ (e(%ide s%i&ul$%"r "leh )$ren$
%he"(hlline d$($% &en*h$&+
%$neur"(e(%i, %erse+u%3'4'5'.
$)%i;i%$s (r"e&e%i) d$ri +$h$n
G$&+$r . e2le)s E&esis 6 E&esis se+$*$i res("ns %erh$d$( *$s%r"in%es%in$l iri%$n &is$ln$ ,"((er' r$di$si $+d"&en' dil$%$si *$s%r"in%es%in$l $d$l$h se+$*$i $)i+$% d$ri si*n$l $2eren ;$*$l )e ,en%r$l ($%%ern *ener$%"r $n* di(i,u "leh (ele($s$n l")$l &edi$%"r in2l$&$si' d$ri &u)"s$ $n* rus$)' den*$n (ele($s$n se)under neur"%r$ns&i%%ers e)si%$si $n* ($lin* (en%in* $d$l$h ser"%"nin d$ri sel en%r",hr"&$22in &u)"s$. P$d$ &$+u) -&"%i"n si,)ness' si*n$l $2eren )e ,en%r$l ($%%ern *ener$%"r +er$s$l d$ri "r*$n ;es%i+ul$r' ;isu$l ,"r%e' d$n ,"r%i,$l ,en%re $n* le+ih %in**i se+$*$i sens"r in(u% $n* %erin%e*r$si le+ih (en%in* d$ri ($d$ $2eren d$ri *$s%r"in%es%in$l4'5'. $n*s$n*$n &un%$h +er$s$l d$ri' *$s%r"in%es%in$l' ;es%i+ul" ",ul$r' $2eren ,"r%i,$l $n* le+ih %in**i' $n* &enu#u 8>8 d$n )e&udi$n di&ul$i n$use$' re%,hin*' e)(ulsi isi
l$&+un*.
%$,hi)$rdi$4'5'.
Ge#$l$
*$s%r"in%es%in$l
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s$li;$si'
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G$&+$r 3. e2le)s Mun%$h es("ns s%ere"%i(i) ;"&i%in* di&edi$si "leh e2eren neur$l ($d$ ;$*us' (hreni,' d$n s$r$2 s(in$l. In(u% un%u) s$r$2 ini +er$s$l d$ri +r$in s%e& C;"&i%in* ,en%re. 8en%re ini %$&($)n$ +u)$n &eru($)$n s%ru)%ur $n$%"&i %un**$l' %e%$(i &eru($)$n #$lur $)hir +ers$&$ d$ri re2le $n* di(r"*r$& se,$r$ sen%r$l &el$lui in%erneur"n &edul$r di nu)leus s"li%$rius d$n +er+$*$i&$,$& %e&($% dise)i%$r 2"r&$%i"
re%i)ul$ris.
In%erneur"n %erse+u% &eneri&$ in(u% d$ri ,"r%i,$l' ;$*$l'
;es%i+ul$r' d$n in(u% l$in %eru%$&$ d$ri $re$ ("s%re&$.
Are$
("s%re&$
$d$l$h
,he&"re,e(%"r %ri**er ?"ne $n* %erle%$) did$s$r ;en%ri)el I> dilu$r s$$r "%$) d$n diiden%i2i)$si se+$*$i su&+er $n* ,ru,i$l un%u) in(u% $n* &ene+$+)$n ;"&i%in*' %eru%$&$ res("ns %erh$d$( "+$% $%$u %")sin 4'5'. 0. Pato*enesis
Mun%$h +er$d$ di+$$h )end$li sis%e& s$r$2 (us$% d$n d$er$h di &edul$ "+l"n*$%$' $i%u nu)leus s"li%er d$n 2"r&$si re%i)uler l$%er$l $n* di)en$l se+$*$i (us$% &un%$h. Pus$% &un%$h di$)%i;$si "leh i&(uls $n* +er$s$l d$ri ,he&"rese(%"r %ri**er ?"ne -8<' $i%u%e&($% +er)u&(uln$ +er+$*$i i&(uls $2eren $n* dih$n%$r)$n &el$lui ner;us ;$*us. P$d$ 8< #u*$ di%e&u)$n +er+$*$i neur"%r$ns&i%%er d$n rese(%"r -s$l$h s$%un$ $d$l$h rese(%"r d"($&in. Pr"ses &un%$h &e&(un$i 3 %$h$(' $i%u n$use$' re%,hin*' d$n e&esis. N$use$ &eru($)$n sens$si (si)is $n* dise+$+)$n "leh +er+$*$i s%i&ulus -"r*$n ;iser$'
l$+irin' $%$u e&"si. @$se ini di%$nd$i $d$n$ r$s$ &u$l $n* diser%$i *e#$l$ "%"n"& se(er%i (r"du)si $ir liur +er%$&+$h' +er)erin*$%' (u,$%' %$)i)$rdi' $%$u $n"re)si$. Ger$)$n (eris%$l%i) $)%i2 +erhen%i' %e)$n$n di 2undus d$n )"r(us &enurun sed$n*)$n %e)$n$n di $n%ru& s$&($i ($rs desendens du"denu& &enin*)$%. P$d$ 2$se re%,hin* %er#$di ins(ir$si d$l$& den*$n "%"% (eru% d$n di$2r$*&$ ser%$ rel$)s$si s2in*%er es"2$*us. B$$h. @$se e&esis di%$nd$i den*$n (eru+$h$n den*$n %e)$n$n in%r$%"r$)s -d$ri ne*$%i2 &en#$di ("si%i2. D$n rel$)s$si s2in*%er es"2$*us sehin**$ isi l$&+un* di)elur)$n di)elu$r)$n d$ri &ulu%.
'.
Fase Muntah Fase Nausea
Nausea $%$u &u$l &eru($)$n sens$si (si)is $n* %id$) n$&$n %$(i +u)$n &eru($)$n sens$si $n* &en$)i%)$n $n* &end$hului r$s$ $%$u )ein*in$n un%u) &un%$h $n* dise+$+)$n "leh +er+$*$i s%i&ulus se(er%i r$n*s$n*$n "r*$n ;iser$' l$+irin' &$u(un e&"si. @$se ini di%$nd$i $d$n$ r$s$ &u$l $n* diser%$i *e#$l$ "%"n"& se(er%i (r"du)si $ir liur +er%$&+$h' +er)erin*$%' (u,$%' %$)i)$rdi$' $%$u $n"re)si$. !el$&$ (eri"de n$use$' %er#$di (enurun$n %"nus )ur;$%ur$ &$"r' )"r(us d$n 2undus. An%ru& d$n du"denu& +er)"n%r$)si +erul$n*ul$n*' sed$n*)$n +ul+us du"deni rel$)s$si sehin**$ %er#$di re2lu)s ,$ir$n duedenu& )ed$l$& l$&+un*. P$d$ 2$se n$use$ ini +elu& %er#$di (eris%$l%i) $)%i2. Mun%$h $n* dise+$+)$n "leh (enin*)$%$n %e)$n$n in%r$)r$ni$l d$n "+s%ru)si s$lur$n *$s%r"in%es%in$l %id$) did$hului "leh 2$se n$use$ 3. Fase Retching
@$se ini d$($% %er#$di %$n($ dii)u%i &un%$h. P$d$ 2$se ini %er#$di )e)e#$n*$n d$n %erhen%in$ (ern$2$s$n $n* +erul$n*ul$n*' se&en%$r$ *l"%is %er%u%u(. O%"% (ern$2$s$n d$n di$2r$*&$ +er)"n%r$)si &ene+$+)$n %e)$n$n in%r$%"r$)$l &en#$di ne*$%i2. P$d$ $)%u $n* +ers$&$$n %er#$di )"n%r$)si "%"% $+d"&en d$n l$&+un*' 2undus dil$%$si sed$n*)$n $n%ru& d$n (il"rus +er)"n%r$)si. !2in*%er es"2$*us +$$h &e&+u)$' %e%$(i s2in*%er es"2$*us $%$s &$sih &enu%u( &ene+$+)$n chyme &$su) )e d$l$& es"2$*us. P$d$ $)hir 2$se ini %er#$di rel$)s$si "%"% dindin* (eru% d$n l$&+un* sehin**$ chyme $n* %$din$ sud$h &$su) )ed$l$& es"2$*us )e&+$li )e l$&+un*. @$se ini d$($% +erl$n*sun* +e+er$($ si)lus3.
Fase Emesis1 Eks-ulsi,1 Muntah
A($+il$ 2$se retching &en,$($i (un,$)n$ d$n didu)un* "leh )"n%r$)si "%"% $+d"&en d$n di$2r$*&$' $)$n +erl$n#u% &en#$di &un%$h #i)$ %e)$n$n %erse+u% d$($% &en*$%$si &e)$nis&e $n%i re2lu)s d$ri s2in*%er es"2$*us +$*i$n +$$h. P$d$ 2$se ini (il"rus d$n $n%ru& +er)"n%r$)si sed$n*)$n 2undus d$n es"2$*us rel$)s$si ser%$ &ulu% %er+u)$. P$d$ 2$se ini #u*$ %er#$di (eru+$h$n %e)$n$n in%r$%"r$)$l d$n in%r$$+d"&in$l ser%$ )"n%r$)si d$ri di$2r$*&$. P$d$ e(is"de e)s(ulsi %un**$l %er#$di %e)$n$n ne*$%i2 in%r$%"r$)$l d$n %e)$n$n ("si%i2 in%r$$+d"&in$l' d$n d$l$& $)%u +ers$&$$n %er#$di )"n%r$)si $n* ,e($% d$ri di$2r$*&$ $n* &ene)$n 2undus sehin**$ %er#$di re2lu)s isi l$&+un* )e d$l$& es"2$*us. Bil$ e)s(ulsi sud$h %er#$di' %e)$n$n in%r$%"r$)$l )e&+$li ("si%i2 d$n di$2r$*&$ )e&+$li )e ("sisi n"r&$l3.
2. Sindroma Muntah Muntah siklik 34#5li5 omitin*6
Meru($)$n )el$in$n 2un*si"n$l *$s%r"in%es%in$l $n* d$($% di iden%i2i)$si den*$n $d$n$ 3 $%$u le+ih e(is"de &u$l d$n &un%$h $n* +erl$n*sun* sel$&$ hi%un*$n #$& hin**$ h$ri $n* diselin*i den*$n &$s$ +e+$s *e#$l$ hin**$ +e+er$($ &in**u $%$u +ul$n. P$d$ sindr"& ini %id$) did$($%)$n )el$in$n &e%$+"li,' neur"l"*i,' $%$u *$s%r"in%es%in$l. @re)uensi d$ri ser$n*$n r$%$r$%$ +er)is$r 1 )$li e(is"de (er %$hun den*$n +$%$s$n 170 )$li (er%$hun. Ge#$l$ l$in $n* &ener%$i $i%u le%$r*i' (u,$%' de&$& rin*$n' s$)i% )e($l$' #er$$% $%$u +isul ($d$ )uli%' s$)i% )e($l$' neri $+d"&en #u*$ d$($% %er#$di' d$n serin*)$li e(is"dee(is"de ini %i&+ul )$ren$ s%res 2isi)$l $%$u e&"si"n$l. Pene+$+ d$ri sindr"& ini &$sih +elu& di)e%$hui. Be+er$($ (en#el$s$n
$n*
&e&un*)in$n
(ene+$+
ini
se(er%i
&i*r$n'
dis2un*si
h("%h$l$&us/$dren$l' dis2un*si $u%"n"&' )e*$*$l$n neur"i&un/$ler*i &$)$n$n' )el$in$n ")sid$si $s$& le&$)' (en$)i% &i%")"ndri$' ion channelopathy' )el$in$n &"%ili%$s *$s%r"in%es%in$l. Ad$n$ s%res &ene+$+)$n &enin*)$%n$ se)resi d$ri A8 rele$sin* h"r&"ne d$n ;$s"(resin d$ri hi("%$l$&us d$n (i%ui%$ri $n* &e&edi$si $)%i;$si d$ri re2le)s e&e%i) $n* &e&+u$% %er#$din$ &u$l d$n &un%$h. 6 Muntah -siko*enik
Pene+$+
)el$in$n
"r*$ni)
%$)
di%e&u)$n'
sindr"&$
ini &ene)$n)$n
(en*$ruh $n* )u$% d$ri )"r%e)' 2$)%"r (si)"l"*i $n* &er$n*s$n* &u$l -n$use$ d$n
&un%$h. 8iri,iri &un%$h (si)"*eni) $d$l$h +er#$l$n )r"nis' %er)$i% den*$n s%res $%$u &$)$n' %id$) $d$ n$use$ d$n $n"re)si$' &un%$h d$($% di(i,u "leh dirin$ sendiri den*$n &e&$)s$)$n &un%$h $%$u &e&$su)$n
%$n*$nn$ )ed$l$& &ulu%. Mun%$h
se&+uh se%el$h dir$$% di ru&$h s$)i%5. Ruminasi
e#$di$n $n* se,$r$ s$d$r d$n &enen$n*)$n &e&un%$h)$n &$)$n$n d$ri l$&+un*' di)un$h)un$h d$n di%el$n )e&+$li '3'4. An$) +es$r $%$u de$s$ &ere*ur*i%$si)$n &$)$n$n den*$n ,$r$ )"n%r$)si "%"% $+d"&en' sed$n* ($d$ +$i &el"*")
)ed$l$& &ulu%n$
den*$n
#$ri
d$l$&
u($$
un%u) &eni&+ul)$n
re*ur*i%$si. @$)%"r (si)"l"*is &e&$in)$n (er$n$n (en%in* ($d$ )e#$di$n %erse+u%' %e%$(i (eril$)u %erse+u% +erhen%i den*$n &en*"+$%i es"2$*i%isn$. $l %erse+u% didu*$ un%u) &eni&+ul)$n *$* re2le) $d$l$h se+$*$i res("ns %erh$d$( neri %en**"r")$nn$. Di)$%$)$n
+$h$
ru&in$si
se+$*$i
&$ni2es%$si
d$ri
GE'
sehin**$ di$*n"sis d$n (en*"+$%$nn$ (erlu &e&(er%i&+$n*)$n 2$)%"r (si)"l"*is d$n es"2$*i%isn$. erd$($% +en%u)
ru&in$si (si)"*eni) d$n
sel2
s%i&ul$%in*.
Psi)"*eni) +i$s$n$ %er#$di ($d$ $n$) n"r&$l den*$n *$n*u$n hu+un*$n "r$n* %u$ $n$)' sed$n*)$n sel2 s%i&ul$%in* serin* %er#$di ($d$ $n$) den*$n )e%erl$&+$%$n &en%$l5'. Abdominal mi*raine
!u$%u sindr"& den*$n *e#$l$ $+d"&in$l (eri"di). Neri e(i*$s%ri) $%$u (eriu&+ili,$l diser%$i n$use' &un%$h' di$re' ($n$s d$n &en**i*il' ;er%i*"' iri%$+el ser%$ ("liuri$. Bil$&$n$ *e#$l$ $+d"&in$l diser%$i s$)i% )e($l$ $n* %er#$di ($d$ 30 40 ($%ien den*$n &i*r$ine )e($l$ di$*n"sis $)$n &ud$h di+u$%' %e%$(i +il$ )e#$di$n
%erse+u% %ersendiri
is"l$%ed $+d"&in$l &i*r$ine $n* +i$s$n$ ($d$ 3
(enderi%$' di$*n"sis #$di le+ih su)$r +el$)$n*$n &e&$n* d$($% %i&+ul &i*r$ine. Is"l$%ed $+d"&in$l ($in ser$n*$n +i$s$n$ &end$d$) +er$)hir d$l$& #$& s$&($i h$ri' d$n ,iri,irin$ sel$lu s$&$ ($d$ se%i$( ser$n*$n %$&($) n"r&$l dilu$r ser$n*$n. Bi$s$n$ %erd$($% 2$&ili den*$n ri$$% &i*r$ine5.
. +enis7+enis (ahan Muntahan Berd$s$r)$n *$&+$r$n d$ri isi l$&+un* -$n* d$($% +eru+$h sesu$i $)%u d$n (er#$l$n$n (en$)i%' &$)$ %i(e &un%$h$n d$($% diiden%i2i)$si &en#$di: Alimentary Vomiting
Meru($)$n &un%$h$n $n* +erisi &$)$n$n $n* +elu& di,ern$ $%$u +$ru se+$*i$n di,ern$' %er)$d$n* d$l$& #u&l$h $n* +erle+ih. i(e ini $n* ($lin* serin* did$($%)$n d$n d$($% %er#$di se*er$ $%$u +e+er$($ #$& se%el$h &$)$n. Mun%$h$n ini ($lin* serin* dise+$+)$n )$ren$ re2lu)s es"2$*us' &$l2"r&$si $n$%"&i d$ri s$lur$n ,ern$ +$*i$n $%$s' $%$u )$ren$ in%"ler$nsi &$)$n$n. "&(li)$si u%$&$ $)i+$% %i(e &un%$h$n ini $d$l$h &$lnu%risi 6. Acid Vomiting
Bi$s$n$ %$&($) se+$*$i se#u&l$h )e,il ,$ir$n &u)us +er$rn$ )e(u%ih$n d$n &en*$ndun* &$%eri$l +us$ den*$n (5' $n* &un*)in %er#$di sel$&$ $%$u seles$i &$)$n d$n %er)$d$n* %er#$di ($d$ $)%u &$l$& h$ri. Bi$s$n$ diser%$i den*$n $d$n$ *$n**u$n +eru($ iri%$+ili%$s' )ur$n* is%ir$h$%' +$i &en$n*is' d$n neri e(i*$s%riu& $%$u r$s$ ($n$s d$l$& (eru% ($d$ $n$)$n$). i(e ini le+ih &eru($)$n (en$)i% re2lu) es"2$*us den*$n )"&(li)$si +eru($ es"2$*i%is d$n s%ri)%ur (e(%i) -#$r$n* %er#$di 6. Bilious vomiting
$r$)%eris%i) d$ri %i(e &un%$h$n ini $d$l$h e)s(ulsi d$ri ,$ir$n +er$rn$ hi#$u )e)unin*$n $n* %e+$l. P$d$ +$i d$n ne"n$%us' &un%$h$n %i(e ini sel$lu &eru($)$n %$nd$ $n* (en%in* un%u) &e&i)ir)$n $d$n$ %"%$l -$%resi$ $%$u se+$*i$n -s%en"sis "+s%ru)si s$lur$n ,ern$ $n* +er$d$ di dis%$l d$ri $&(ull$ >$%er $n* &e&+u%uh)$n di$*n"s$ ($s%i d$n in%ensi2/su+in%ensi2 %er$(i6. Bloody vomiting
Mun%$h +er$rn$ &er$h %er$n* $%$u se(er%i )"(i $n* d$($% di$)i+$%)$n "leh $d$n$ (erd$r$h$n $n* +$ru %er#$di &$u(un sed$n* %er#$di ($d$ s$lur$n ,ern$ +$*i$n $%$s -es"2$*us' l$&+un*' $%$u du"denu&. Mun%$h ini le+ih +$n$) &eru($)$n )"&(li)$si d$ri ($d$ &$ni2es%$si )linis $$l. In%$)e nonsteroidal anti-inflamatory
drugs -N!AIDs d$($% #u*$ &ene+$+)$n %er#$din$ &un%$h ini. e&$%e&esis &eru($)$n )e*$$%d$rur$%$n $n* ("%ensi$l d$n sel$lu h$rus die;$lu$si di ru&$h s$)i%. A($+il$
(erd$r$h$n rin*$n d$n %id$) &eni&+ul)$n $ne&i$ $%$u (eru+$h$n
he&"din$&i) d$($% di+eri)$n "+$% $n%i se)re%"ri. Perd$r$h$n d$ri ;$rises es"2$*us d$($% %er#$di s$n*$% &$si2 $n* #u*$ &eru($)$n )e*$$%d$rur$%$n d$n h$rus se*er$ &end$($%)$n %er$(i. e&$%e&esis %id$) sel$lu +er$s$l d$ri %r$)%us *$s%r"in%es%in$l' %e%$(i d$($% #u*$ +er$s$l d$ri (erd$r$h$n %"nsil' l$rin*' $%$u %r$)e$ den*$n *e#$l$ +i$s$n$ d$r$hn$ $n* )elu$r sedi)i% d$n diser%$i *e#$l$ s$)i% %en**"r") d$n +$%u). Bil$ &un%$h$n +eru($ +e)u$n d$r$h d$n +er$rn$ hi%$& serin*)$li +er$s$l d$ri (erd$r$h$n hidun* +$*i$n ("s%eri"r +i$s$n$ di indi)$si d$ri l$(is$n %i(is d$ri d$r$h di d$l$& "r"2$rin*6. 8. Dia*nosis
Men*in*$% +$h$ &un%$h $d$l$h *e#$l$ d$ri +er+$*$i &$,$& (en$)i%' &$)$ e;$lu$si di$*n"sis &un%$h %er*$n%un* ($d$ di2erensi$l di$*n"sis $n* di+u$% +erd$s$r)$n 2$)%"r l")$si s%i&ulus' u&ur d$n *e#$l$ *$s%r"in%es%in$l $n* l$in. !e%el$h dil$)u)$n $n$&nesis len*)$( &en*en$i &un%$hn$' )e&udi$n dil$n#u%)$n den*$n (e&eri)s$$n 2isi) (enderi%$' &$)$ un%u) &e&+$n%u (ene*$)$n di$*n"sis dil$)u)$n (e&eri)s$$n (enun#$n*. Fenis (e&eri)s$$n (enun#$n* di(ilih sesu$i den*$n du*$$n di$*n"sis +erd$s$r)$n d$%$ $n$&nesis d$n &$ni2es%$si )linis1'4'5'7. Anamnesis1'3'4'5
$n*)$i$n (er%$n$$n $n* d$($% &e&+i&+in* )i%$ ($d$ di$*n"sis $n* %e($%' se+$*$i +eri)u%:
si$ d$n #enis )el$&in en%u)$n le+ih dulu' $($)$h $n* dih$d$(i: s(i%%in*' re*ur*i%$si $%$u &un%$h $($n &ul$i &un%$h Der$#$%/+er$%n$ &un%$h' )e)u$%$nn$ -(r"#e)%il B$*$i&$n$ )e$d$$n )eseh$%$n $n$): $($)$h i$ &en#$di )urus $%$u (en$&+$h$n
+er$% +$d$n n"r&$l Ad$)$h 2$)%"r (redis("sisi -$n* le+ih di)en$l "r$n* %u$ $n* &ene+$+)$n
%i&+uln$ &un%$h ini A($)$h $d$ (en$)i% l$in $n* &ener$n* $n$)' se(er%i hidr"se2$lus' in%"ler$nsi susu' ri$$% "(er$si $+d"&en dll.
B$*$i&$n$ +en%u)/isi &un%$h$n' $($)$h se(er%i susu/&$)$n$n $s$l -isi d$ri es"2$*us' %el$h &eru($)$n susu $n* %el$h &en**u&($l -isi l$&+un* $%$u
&en*$ndun* e&(edu -isi du"denu& d$n $d$)$h d$r$h !$$% &un%$h +erhu+un*$n den*$n s$$% &$)$n/&inu& A($)$h (eru+$h$n ("sisi %u+uh &e&(en*$ruhi )e#$di$n &un%$h Di(erlu)$n in2"r&$si %en%$n* die%: )u$li%$s' )u$n%i%$s' dd$n 2re)uensi &$)$n'
(en%in* %eru%$&$ ($d$ $n$) )e,il B$*$i&$n$ %e)ni) (e&+eri$n &inu& B$*$i&$n$ (ul$ )"ndisi (si)"s"si$l di ru&$h: +$*$i&$n$ si2$% i+u' $$h' $($)$h (en,e&$s' $($)$h $d$ nene) $n* serin* n*"&el.
An$&nes$ %$&+$h$n d$($% +eru($ se+$*$i +eri)u%:
Mun%$h $n* %er#$di s$$% &$)$n$n $%$u &inu&$n +$ru s$&($i di d$l$& r"n**$
&ulu%' (i)ir)$n $d$n$ in2e)si r"n**$ &ulu%. Ad$n$ ri$$% hidr$&ni"n sel$&$ )eh$&il$n' (i)ir)$n )e&un*)in$n $%resi$
es"2$*us B$i den*$n &un%$h &ene&(r"% +e+er$($ s$$% se%el$h di+eri &inu& (i)ir)$n
$d$n$ *$n**u$n gastric outlet Mun%$h den*$n ri$$% )e%erl$&+$%$n (en*elu$r$n &e)"niu& $%$u )"ns%i($si se#$)
l$hir (erlu di(i)ir)$n $d$n$ M"r+us irs,h(run* Mun%$h did$hului neri (eru% d$n (eru% )e&+un* (erlu di(i)ir)$n $d$n$ "+s%ru)si
s$lur$n ,ern$ Mun%$h ($d$ +$i $n* %er#$di +e+er$($ s$$% se%el$h &inu& sed$n*)$n 2$)%"r l$in $n* dise+u% di $%$s %id$) $d$' (erlu di(i)ir)$n )e&un*)in$n GE $%$u 2$)%"r n"n
"r*$ni) se+$*$i (ene+$+ &un%$h Mun%$h ($d$ $n$) $n* sel$lu %er#$di ($d$ )e$d$$n %er%en%u $n* s$&$' (erlu di(i)ir)$n 2$)%"r (si)"*eni) se+$*$i d$s$r )eluh$n %erse+u%
Pemeriksaan Fisik 1'3'4'5'7
e$d$$n u&u&: )"&("s &en%is' le%h$r*i' )e#$n*' *e#$l$ neur"l"*i $n* l$in I)%erus' rhini%is' &"nili$sis !%$%us hidr$si/sir)ul$si: n$di' %ensi' +er$% +$d$n' lin*)$r$n len*$n' lin*)$r$n )e($l$'
M! Bil$ $d$ %$nd$ in2e)si' (i)ir)$n &un%$h se+$*$i s$l$h s$%u *e#$l$ in2e)si %erse+u% Ber,$) (u%ih den*$n d$s$r &er$h ($d$ r"n**$ &ulu% (erlu di(i)ir)$n su$%u
)$ndidi$sis "r$l i(ers$li;$si ($d$ +$i +$ru l$hir' (i)ir)$n $d$n$ $resi$ es"2$*us Mun%$h $n* did$hului *$&+$r$n *er$)$n (eris%$l%i) l$&+un* se%el$h di+eri &inu&' (i)ir)$n s%en"sis (il"rus hi(er%r"2i).
Dis%ensi (eru% d$n ($d$ (e&eri)s$$n ,"l") du+ur di%e&u)$n $&(ul$ )"l$(s' (erlu
di(i)ir)$n )e&un*)in$n $d$n$ &"r+us hirs,hs(run*. O+s%ru)si s$lur$n ,ern$ (erlu di(i)ir)$n +il$ di%e&u)$n (eru% dis%ensi d$n +isin*
usus &enin*)$% ($d$ d$er$h (r")si&$l d$n &enurun ($d$ d$er$h dis%$l. Mun%$h ($d$ +$i $n* diser%$i *e#$l$ )linis l$inn$ se(er%i di$re' )e&+un*' eri%e&$
(eri$n$l' d$n serin* 2l$%us' (erlu di(i)ir)$n $d$n$ in%"ler$nsi l$)%"s$. Mun%$h $n* %er#$di ($d$ +$i seh$% d$n %id$) di%e&u)$n *e#$l$ se(er%i $n* dise+u% di$%$s' (erlu di(i)ir)$n $d$n$ 2$)%"r "r*$ni)' se(er%i %e)ni) (e&+eri$n &inu& $%$u iri%$si ,$ir$n $&ni"n-+$i +$ru l$hir.
Pemeriksaan Penun"an*1'3'4'5
Pe&eri)s$$n l$+"r$%"riu&
Pe&eri)s$$n urin: urin len*)$(' redu)si' )ul%ur Pe&eri)s$$n d$r$h: d$r$h len*)$(' BN' seru& )re$%inin' seru& ele)%r"li%' $n$lisis *$s d$r$h' $n$lisis $s$& $&in"' =@' *lu)"s$ d$r$h' $&"ni$
Pe&eri)s$$n r$di"l"*is d$n (enun#$n* l$inn$:
)e,uri*$$n %erh$d$( $%resi$ es"2$*us d$($% dil$)u)$n (e&$s$n*$n (i($ n$s"*$s%ri)
d$n (e&eri)s$$n 2"%" "en%*en %"r$)s $d$n$ *$n**u$n gastric outlet d$($% di+u)%i)$n den*$n (e&eri)s$$n &inu& +$riu&' sed$n*)$n s%en"sis (il"rus hi(er%r"2i sel$in den*$n &inu& +$riu& d$(
%$
di+u)%i)$n den*$n (e&eri)s$$n ul%r$s"n"*r$2i )e,uri*$$n %erh$d$( M"r+us irs,h(run* d$($% dil$)u)$n (e&eri)s$$n +$riu&
ene&$ d$n +i"(si his$( re)%u& $d$n$ ileus -($r$li%i) $%$u "+s%ru)si d$($% di+u)%i)$n den*$n (e&eri)s$$n 2"%"
("l"s $+d"&en $%$u 3 ("sisi un%u) &elih$% dis%ri+usi ud$r$ $d$n$ in2e)si d$($% di+u)%i)$n den*$n (e&eri)s$$n d$r$h (eri2er len*)$( d$n urin
len*)$( )e,uri*$$n
(e&eri)s$$n (e&$n%$u$n ( es"2$*us 4 #$& )"nsul%$si )e (si)"l"* +il$ di,uri*$i $d$n$ 2$)%"r (si)"*eni) )e,uri*$$n )el$in$n "r*$n di lu$r s$lur$n ,ern$ d$($% dil$)u)$n (e&eri)s$$n sesu$i
$d$n$
re2lu)s
es"2$*us
d$(
%$di+u)%i)$n
den*$n
&el$)u)$n
!PM )el$in$n %erse+u%. Pendekatan Dia*nosis
Men*$d$)$n di$*n"sis +$ndin* den*$n &e&i)ir)$n se&u$ (ene+$+ &un%$h d$l$& (r$)%e)n$ suli% dil$)s$n$)$n )$ren$ (ene+$+ &un%$h s$n*$% lu$s d$n serin*)$li %id$) &ud$h di%e&u)$n. Pende)$%$n di$*n"sis +erd$s$r)$n usi$ $n$)
serin*)$li d$($% &e&(er&ud$h d$n +er&$n2$$% d$l$& u($$ &en,$ri (ene+$+ &un%$h3. Be+er$($ *e#$l$ (en%in* $n* (erlu di(erh$%i)$n d$l$& (ende)$%$n di$*n"sis &un%$h ($d$ +$i d$n $n$) $d$l$h se+$*$i +eri)u%: &. Si,at Muntahan
Ben%u): +en%u) &$)$n$n $n* &$sih d$($% di)en$li ($d$ &un%$h $n* %er#$di
l$&$ se%el$h &$)$n' &enun#u))$n $d$n$ s%$%is ($d$ l$&+un* B$u: +$u $s$& serin*)$li &en$nd$)$n s%$%is ($d$ l$&+un*' +$u +usu)/%in#$
&enun#u))$n $d$n$ "+s%ru)si rend$h $rn$: #i)$ di%e&u)$n &un%$h$n $n* +er$rn$ e&(edu h$rus di(i)ir)$n $d$n$ *$n**u$n di se+el$h dis%$l $&(ul$ >$%eri. !uh$r"n" &en*$n#ur)$n un%u) &el$)u)$n (en$%$l$)s$n$$n "+s%ru)si usus ($d$ se%i$( )e#$di$n &un%$h den*$n
&un%$h$n $n* +er$rn$ hi#$u s$&($i %er+u)%i %id$) %erd$($% "+s%ru)si usus D$r$h: ($d$ &un%$h$n ne"n$%us )e&un*)in$n %er#$di $)i+$% ne"n$%us &enel$n d$r$h i+u s$$% dil$hir)$n $%$u +$i &en*is$( d$r$h d$ri (u%in* $n* (e,$h(e,$h -2isur$. n%u) &e&+ed$)$n (erd$r$h$n $n* +er$s$l d$ri +$i' &is$ln$ ($d$ er"si es"2$*us $%$u de2e) )"$*ul$si' d$($% dil$)u)$n u#i AP 3'5.
$. Frekuensi Muntah
Mun%$h $n* s$n*$% serin* d$n &ene%$( &enun#u))$n 2$)%"r $%$u )el$in$n $n* (er&$nen3.
. Kekuatan Muntah
Mun%$h $n* $&$% )u$% -(r"e)%il ($d$ +$i d$n $n$) serin* %erd$($% ($d$ s%en"sis (il"rus d$n (enin**i$n %e)$n$n in%r$)r$ni$l. P$d$ (enin**i$n %e)$n$n in%r$)r$ni$l' &un%$h %id$) diser%$i n$use$ 3.
/. Hubun*an den*an Makanan
P$d$ +$i &un%$h $n* %er#$di sel$&$ $%$u sesud$h &$)$n' h$&(ir sel$lu dise+$+)$n "leh dis%ensi l$&+un* $n* +erle+ih$n $)i+$% ,$r$ (e&+eri$n &$)$n $n* s$l$h -$er"2r$*i3. 0. 9e"ala )ain
Bil$ di#u&($i u+unu+un $n* &en"n#"l $%$u *e#$l$ neur"l"*is l$in' h$rus
di(i)ir)$n $d$n$ (r"ses in%r$)r$ni$l !e(sis d$n in2e)si l$in se(er%i *$s%r"en%eri%is' &enin*i%is d$n in2e)si s$lur$n $ir
)e&ih &eru($)$n (ene+$+ &un%$h $n* serin* di%e&u)$n ($d$ ne"n$%us i$$% hidr$$&ni"n d$($% +erhu+un*$n den*$n $%resi$ s$lur$n (en,ern$$n Me)"neu& $n* %id$) )elu$r d$l$& 4 #$& serin* di#u&($i ($d$ (en$)i% irs,h(run* $%$u ileus &e)"neu& Ad$ $n* &e&+ed$)$n &un%$h $%$s )el$in$n &edis d$n &un%$h +ed$h' %e%$(i
se+en$rn$ +$%$s$n ini %id$) sel$lu %e*$s. H$n* le+ih (en%in* $d$l$h +il$ &ene&u)$n *e#$l$ &un%$h' h$rus di%e%$()$n $($)$h &un%$h dise+$+)$n )el$in$n $n* h$rus se*er$ di%"l"n* se,$r$ +ed$h $%$u %id$). &u&n$ )$sus se&$,$& ini &en,$)u( )el$in$n $n* di*"l"*)$n $+d"&en $)u%. Ad$ +e+er$($ (e*$n*$n un%u) &endu*$ $+d"&en $)u%:
Neri (eru% &un,ul &end$hului &un%$h d$n/$%$u +erl$n*sun* le+ih d$ri 3
#$& Mun%$h +er,$&(ur e&(edu Dis%ensi $+d"&en3.
B$*$n 4. Pende)$%$n Di$*n"sis Mun%$h ($d$ Ne"n$%us 1
B$*$n 5. Al*"ri%&$ (ende)$%$n un%u) &en*e;$lu$si ($sien den*$n Mun%$h 7
&%. Dia*nosis (andin*
P$d$ d$s$rn$ (ene+$+ &un%$h s$n*$% +$n$). Pende)$%$n &un%$h ($d$ $n$) &eru($)$n (r"+le& $n* suli%' di$*n"s$ +$ndin* +u)$n h$n$ &en$n*)u% &$s$l$h *$s%r"in%es%in$l %e%$(i #u*$ &$s$l$h e&er*ensi ($d$ $n$). Pene+$+ &un%$h ($d$ $n$) s$n*$% +er;$ri$si d$n %er*$n%un* usi$. Be+er$($ )e$d$$n d$($% se+$*$i (en,e%us %er#$din$ &un%$h se(er%i in2e)si' iri%$si &$)$n$n' %r$u&$' $ler*i' *$n**u$n ($d$ (enden*$r$n se(er%i di??iness d$n &"%in si,)es' )el$in$n ($d$ s$r$2 se(er%i %r$u&$ d$n in2e)si.l$si2i)$si
&un%$h
+i$s$n$ did$s$r)$n ($d$ l")us $n$%"&i' u&ur
(enderi%$' $d$n$ *e#$l$ d$n %$nd$ $s"si$si $n* l$in 4'5. Mun%$h h$rus di+ed$)$n den*$n: Possettin*
Pen*elu$r$n sedi)i% isi l$&+un* seh$+is &$)$n' +i$s$n$ &eleleh )elu$r d$ri &ulu%. !erin* did$hului "leh +ersend$$. id$) +er+$h$$. A)$n hil$n* den*$n sendirin$ 1'3. Ruminasi 3merycism6
!u$%u )e+i$s$$n $+n"r&$l' &en*elu$r)$n isi l$&+un*' &en*un$hn$' )e&udi$n &enel$nn$ )e&+$li. $d$n*)$d$n* dir$n*s$n* se,$r$ s$d$r den*$n &en*"re) 2$rin* den*$n #$ri. id$) +er+$h$$. e+i$s$$n s$d$r $n* suli% un%u) dihil$n*)$n. Me&+u%uh)$n +i&+in*$n (si)"l"*i)/(si)"%er$(i $n* in%ensi2 1'3. Re*ur*itasi 3*umoh: spitting 6
Dise+$+)$n in)"&(e%ensi s(in)%er )$rdi"es"2$*e$l d$n/$%$u &e&$n#$n*n$ $)%u (en*"s"n*$n l$&+un*. D$($% &en**$n**u (er%u&+uh$n d$n &eni&+ul)$n in2e)si %r$)%us res(ir$%"rius +erul$n* $)i+$% $s(ir$si. M$l$h$n di(er)ir$)$n +is$ &eru($)$n s$l$h s$%u (ene+$+ sudden infant death syndrome. $(i se+$*i$n +es$r $)$n &en*hil$n* sendiri den*$n +er%$&+$hn$ u&ur +$i 1'3.
Re,luks *astroeso,a*eal 3R9E6
GE $d$l$h )elu$rn$ isi l$&+un* )e d$l$& es"2$*us. e$d$$n ini &un*)in n"r&$l $%$u d$($% (ul$ $+n"r&$l. !e%i$( re2lu)s %id$) sel$lu diser%$i re*ur*i%$si $%$u &un%$h' %e%$(i se%i$( re*ur*i%$si ($s%i diser%$i re2lu)s3.
$+el 1. Di$*n"sis B$ndin* Mun%$h ($d$ B$i4
8"&&"n
$re
An$%"&i, "+s%ru,%i"n
Adren"*eni%$l sndr"&e
G$s%r"en%eri%is
Br$in %u&"r -in,re$sed in%r$,r$ni$l (ressure
G$s%r"es"(h$*e$l re2lu
@""d ("is"nin*
O;er2eedin*
In+"rn err"r "2 &e%$+"lis&
!s%e&i, in2e,%i"n
en$l %u+ul$r $,id"sis
u&in$%i"n
!u+dur$l he&"rrh$*e
$+el . Di$*n"sis B$ndin* Mun%$h ($d$ An$) d$n e&$#$ 4
8hild
Ad"les,en%
8"&&"n
G$s%r"en%eri%is
G$s%r"en%eri%is
!s%e&i, in2e,%i"n
!$%e&i, in2e,%i"n
"i, in*es%i"n
"i, in*es%i"n
Per%ussis sndr"&e
In2l$&&$%"r +"el dise$se
Medi,$%i"n
A((endi,i%id
Mi*r$ine
Pre*n$n,
Medi,$%i"n
I(e,$, $+use/+uli&i$
$re
ee sndr"&e
ee sndr"&e
e($%i%is
e($%i%is
Pe(%i, ul,er
Pe(%i, ul,er
P$n,re$%i%is
P$n,r$%i%is
In,re$sed in%r$,r$ni$l (ressure
In,re$sed in%r$,r$ni$l (ressure
Middle e$r dise$se
Middle e$r dise$se
8he&"%her$(
8he&"%her$(
A,h$l$si$
8,li, ;"&i%in*
8,li, ;"&i%in*
Bili$r ,"li,
Es"(h$*e$l s%ri,%ure
en$l ,"li,
Du"den%$l he&$%"&$
In+ern err"r "2 &e%$+"lis&
&&. Kom-likasi Kom-likasi Fisik
!$l$h s$%u )"nse)uensi $)i+$% &un%$h $n* +erl$n*sun* %erus &enerus $d$l$h ru(%urn$ dindin* )$(iler d$n &en*$)i+$%)$n (erd$r$h$n ($d$ #$rin*$n su+)u%$n $n* %$&($) ($d$ $#$h d$n leher +er+en%u) se(er%i )e($l$ (eni%i. D$($% #u*$ %er#$di Mallory-Weiss Syndrome di$)i+$%)$n )$ren$ %er#$di herni$si 2undus ($d$ 2$se retching d$n e)s(ulsi )$d$n*)$d$n* d$($% &eni&+ul)$n r"+e)$nr"+e)$n l"n*i%udin$l ($d$ &u)"s$. e$d$$n ini di%$nd$i den*$n +$h$n &un%$h$n $n* &en*$ndun* d$r$h se%el$h +e+er$($ si)lus recthing d$n e)s(ulsi. Di$*n"sis d$($% di%e*$))$n den*$n (e&eri)s$$n end"s)"(i d$n )el$in$n ini +i$s$n$ se&+uh %$n($ )"&(li)$si. "&(li)$si +eri)u%n$ $n* &un*)in did$($%)$n $d$l$h $s(ir$si isi l$&+un*. As(ir$si +$h$n &un%$h$n d$($% &ene+$+)$n $s2i)si$. E(is"de $s(ir$si rin*$n +erul$n*ul$n* d$($% &ene+$+)$n in2e)si s$lur$n n$2$s +erul$n*. !el$in $n* dise+u%)$n di$%$s )"&(li)$si l$in $n* d$($% %er#$di $d$l$h *$*$l %u&+uh )e&+$n*. Mun%$h $n* +erul$n*ul$n* d$n ,u)u( he+$% $)$n &ene+$+)$n *$n**u$n *i?i "leh )$ren$ in%$)e &en#$di s$n*$% +er)ur$n* d$n +il$ h$l ini %er#$di ,u)u( l$&$. r$u&$ i*$ d$n "%"% $+d"&en $n* d$($% s$n*$% serius %e%$(i #$r$n* %er#$di.'5
Kom-likasi Metabolik
Dehidr$si/ *$n**u$n ele)%r"li% d$n $s$&+$s$ d$($% %er#$di. Mun%$h&un%$h $n* he+$% d$n +erul$n*ul$n* $)$n &ene+$+)$n hil$n*n$ d$n 8I $n* &$ni2es% se+$*$i $l)$l"sis &e%$+"li)' $n* d$($% &ene+$+)$n %er#$din$ cardiac arrest .'5 Kom-likasi Psikolo*is
"&(li)$si ini %er#$di $)i+$% (en*$l$&$n &$s$ l$lu $n* +erhu+un*$n den*$n &u$l &un%$h d$n neri (eru% $%$u r$s$ %er+$)$r ($d$ e(i*$s%riu& $n* he+$% $n* ,enderun* &eni&+ul)$n )"ndisi $;ersi di )e&udi$n h$ri' (ene&($%$n si%u$si seru($' $%$u sensi%i$si +erle+ih$n %erh$d$( s%i&ulus $n* serin*)$li %id$) s$&$. Ini d$($% &en,e%us)$n %i&+uln$ (eril$)u $n"re)si$ ($d$ $n$)$n$)' &ere)$ &e&ilih un%u) %id$) &$)$n )$ren$ %$)u% $)$n &en*$l$&i h$l $n* s$&$ se(er%i $n* (ern$h di$l$&i se+elu&n$. e$)si %erse+u% di(er)ir$)$n %i&+ul $)i+$% s%i&ulus ($d$ )"r%e)s $)$n (en*$l$&$n &un%$h se+elu&n$' %e%$(i #$rin*$n s$r$2 $n* %uru% +e)er#$ d$n +$*$i&$n$ ("l$n$ &$sih +$n$) +elu& di)e%$hui se,$r$ ($s%i. '5 &$. Penatalaksanaan 1'3'4'5'7' &. Umum a. E,ek )okal
"+e)$n M$ll"reiss +i$s$n$ h$n$ &eni&+ul)$n (erd$r$h$n )e,il sehin**$ %id$) di(erlu)$n su$%u %ind$)$n. !e+$li)n$ r"+e)$n es"2$*us -sindr"&$ Burh$;e &e&erlu)$n %ind$)$n r$di)$l. b. E,ek Metabolik
P$d$ (enderi%$ &un%$h +erul$n* d$n +er)e($n#$n*$n d$($% %er#$di *$n**u$n )esei&+$n*$n ,$ir$n d$n ele)%r"li% $n* &e&erlu)$n ,$ir$n d$n ele)%r"li% (en**$n%i -in*er l$)%$%' )e&udi$n disusul den*$n (e&+eri$n ,$ir$n d$n ele)%r"li% un%u) ru&$%$n 5. As-irasi
As(ir$si isi l$&+un* $n* &$si2 &e&erlu)$n (e&+eri$n $n%i+i"%i)$ d$n )$d$n*)$d$n* )"r%i)"s%er"id. P$d$ inh$l$si isi l$&+un* +eru($ susu d$l$& #u&l$h di)i% de&i sedi)i% d$($% &eni&+ul)$n sensi%is$si %erh$d$( (r"%ein susu s$(i sehin**$ &eni&+ul)$n +r"n)hi%is $ler*i) d. E,ek Nutrisi
Men#el$s)$n )e($d$ "r$n* %u$ &en*en$i ,$r$,$r$ (e&+u$%$n &inu&$n/ &$)$n$n' d$n %e)ni) (e&+eri$n &$)$n$n. D$n $n* %$) )$l$h (en%in*n$ $d$l$h &ene)$n)$n hu+un*$n $n* h$r&"nis $n%$r$ +$i den*$n i+u d$n $$h. Bil$ &un%$h %erus &enerus d$n di(er)ir$)$n $)$n &eni&+ul)$n %er#$din$ *$n**u$n *i?i $%$u (ene&+uh$n &un%$h $)$n +erl$n*sun* l$&$' )$d$n*)$d$n* di(erlu)$n (e&+eri$n nu%risi ($ren%er$l $. Sim-tomatik ;bat Antiemetik
$l$u(un %u#u$n u%$&$ (en$%$l$)s$n$$n &un%$h $d$l$h &en*hil$n*)$n )$us$ s(esi2i)n$'
n$&un
(en$%$l$)s$n$$n
si&(%"&$%i)
un%u)
&en*ur$n*i
$%$u
&en*hil$n*)$n *e#$l$ &un%$h $,$()$li (erlu dil$)u)$n %erle+ih d$hulu. Perlu diin*$% +$h$ ($d$ )e$d$$n $n* $)u% d$n &un%$h $n* he+$%' "+$% $n%i &un%$h h$n$ +er&$n2$
%$#i)$ "+$% %erse+u%
d$($% diser$(
d$l$& #u&l$h $n* ,u)u(.
Men*hen%i)$n &$)$n/&inu& un%u) +e+er$($ #$& d$($% &e&+$n%u &en*ur$n*i he+$%n$ &un%$h sehin**$ &e&un*)in)$n (e&+eri$n "+$%"+$% (er "r$l. Titik tan*ka- ker"a obat anti muntah
i%i) %$n*)$( )er#$ "+$% $n%i &un%$h d$($% %erle%$) di +e+er$($ +$*i$n %u+uh' &is$ln$ rese(%"r )i&i$ %eru%$&$ di(en*$ruhi "leh *"l"n*$n 2en"%i$sin' $n%i his%$&in d$n $n%$*"nis d"($&in. Pus$% &un%$h di(en*$ruhi se,$r$ l$n*sun* "leh *"l"n*$n $n%i )h"liner*i). ese(%"r di ;es%i+ulu& "leh *"l"n*$n $n%ihis%$&in' sed$n*)$n rese(%"r (eri2er di(en*$ruhi se,$r$ +er+ed$+ed$ "leh *"l"n*$n 2en"%i$sin' $n%$*"nis d"($&in' +e%$ne)h"l' (enin*)$%$n $se%il)h"lin "leh *"l"n*$n &e%")l"(r$&ide' d"&(erid"ne d$n
,i,$(rid.
!e,$r$ u&u& d$(
%$di)$%$)$n' $n%ihis%$&in %eru%$&$ +$i)
di(er*un$)$n un%u) $n%i &$+u) -motion sickness' $n%$*"nis d"($&in un%u)
&"%ili%$s *$s%r"in%es%in$l d$n *"l"n*$n 2en"%i$?in un%u) e2e) s$&(in* d$ri "+$% si%"s%$%i)$' r$di$si d$n ure&i$.
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An%ihis%$&in
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Pr"&e%h$?ine
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An%$*"nis d"($&in
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Menin*)$%)$n $se%il)"lin =$n*sun* ($d$ rese(%"r &us)$rini)
-M"%iliu& Me%")l"(r$&id Be%$ne,h"l
Per;en$?in
Berd$s$r)$n (en*$ruhn$ %erh$d$( &"%ili%$s usus' "+$% $n* +i$s$ di+eri)$n se+$*$i "+$% si&(%"&$%i) un%u) &un%$h d$($% di+$*i &en#$di *"l"n*$n: 9olon*an I.
G"l"n*$n s%i&ul$n &"%"r *$s%r"in%es%in$l Meru($)$n +$h$n -serin*)$li neur"%r$ns&i%er $%$u se#enis $n* &enin*)$%)$n $)%i2i%$s "%"% ("l"s. !el$in &er$n*s$n* &"%ili%$s #u*$ &er$n*s$n* se)resi $n* %id$) %er+$%$s ($d$ usus s$#$. 8"n%"h: Be%$ne,h"l' $n* ($d$ $n$) h$n$ di*un$)$n ($d$ GE 9olon*an II.
G"l"n*$n "+$% (r")ine%i) O+$% ini &en"r&$lisir *$n**u$n &"%ili%$s "%"% sehin**$ &e&(un$i si2$% &e&(er+$i)i )""rdin$si $)%i2i%$s (eris%$l%i). Pr"%i(e d$ri *"l"n*$n ini $d$l$h &e%")l"(r$&ide $n* &e&(un$i e2e) $n%$*"nis %erh$d$( rese(%"r d"($&in -$n%$*"nis %erh$d$( inhi+isi &"%"ri) "leh d"($&in $n* %id$) s$#$ %er+$%$s ($d$ %in*)$% *$s%r"in%es%in$l' %e%$(i #u*$ &e&(un$i (en*$ruh ($d$ %in*)$% susun$n s$r$2 (us$% sehin**$ d$($% %er#$di e2e) s$&(in* neur"l"*i).
O+$% *"l"n*$n D"&(erid"ne -M"%iliu& di)$%$)$n &e&(un$i e2e) s$&$ %e%$(i %$n($ &e&(en*$ruhi susun$n s$r$2 (us$%' $l$u(un %id$) s(esi2i).
edu$ "+$% $n%$*"nis d"&($&in ini d$$ (r")ine%i)$ $d$l$h den*$n ,$r$ $n%$*"nis%i) %erh$d$( inhi+isi &"%"ri) "leh d"($&in. A)hir$)hir ini di(r"du)si "+$% $n* &e&(un$i d$$ (r")ine%i) %$n($ e2e) $n%$*"nis%i)' &e&(un$i e2e) l$n*sun* &er$n*s$n* (en*elu$r$n $se%il)"lin se,$r$ 2isi"l"*i) d$l$& (le)sus &ien%eri)us' d$n den*$n de&i)i$n &e&(un$i e2e) s(esi2i) &"%"ri) ($d$ %in*)$% usus +$*i$n dis%$l. $+el 4. O+$%"+$% $n* &e&(en*$ruhi &"%ili%$s usus3 Me)$nis&e $)si
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Be%$ne,h"l
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D"&(erid"ne
Me%")l"(r$&id' 8is$(rid
;bat #an* serin* di-akai men*obati muntah dan *an**uan motilitas lambun*< &. Metoklo-ramid
8u)u( e2e)%i2' ,$r$ )er#$ $d$l$h +l")$de rese(%"r d"($&ine di 8< -chemo receptive trigger zone' sehin**$ d$($% &en*"n%r"l +$i) n$use &$u(un &un%$h se,$r$ sen%r$l. Perlu diin*$%' "+$% ini d$($% &ene+$+)$n re$)si dis%"ni$ d$n dis)ine%i) ser%$ )risis ")ul"*iri) $. Dom-eridone
D$($% di)$%$)$n le+ih $&$n. 8$r$ )er#$ +l")$de d"($&in rese(%"r +$i) di 8<' &$u(un di usus. D$($% di+eri)$n (er "r$l $%$u s u("si%"ri$. Bi"$;$li+i% rend$h se+$+ ,e($% &en*$l$&i &e%$+"lis&e di dindin* usus d$n h$%i' d$n h$n$ sedi)i% &$su) )ed$l$& "%$).
n%u) &en,e*$h n$use$ d$n &un%$h ($d$ (en*"+$%$n si%"s%$%i)$' d"sis (er "r$l 1 &*/)* ++/h$ri -le+ih e2e)%i2 d$ri &e%")l"(r$&id 0'5 &*/)* ++/h$ri. D"sis ($d$ $n$)$n$) 0'0'4 &*/)* ++/h$ri (er "r$l' in%er;$l 4 #$&. . 4isa-ride
O+$% (r")ine%i) $n* +$ru' &enin*)$%)$n (en*elu$r$n $se%il)"h"lin se,$r$ 2isi"l"*is $n* sele)%i2 ($d$ %in*)$% ("s% *$n*li"ni) d$ri s$r$2 ($d$ (le)sus &ien%eri)us. id$) &e&(un$i si2$% +l")$de ($d$ rese(%"r d"($&in' %e%$(i &enin*)$%)$n (eris%$l%i) *$s%r"du"den$l. P$d$ $n$) #u*$ e2e)%i2 un%u) &en,e*$h re2lu)s d$n &e&(er+$i)i )lerens d$ri re2lu)s &$%eri$l di es"2$*us. D"sis 0'0'4 &*/)* ++/h$ri.
/. (etanekhol
!u$%u )h"lines%er den*$n ,$r$ )er#$ sele)%i2 ($d$ &us)$rini) rese(%"r' e2e) )er#$n$ ,u)u( ($n#$n*. P$d$ $n$)$n$) di($)$i un%u) %er$(i GE' d"sis 0'6 &*/)* ++/h$ri' di+$*i 3 d"sis' (er "r$l $%$u 0'150' &*/)* ++/h$ri su+ )u%$n.
Pen5e*ahan dan -endidikan
1. An$) diis%ir$h$%)$n -se+$i)n$ di %e&($% %idur s$&($i &er$s$ le+ih en$) . Minu&$n di+eri)$n den*$n &en**un$)$n send")' sedi)i% de&i sedi)i% $n* din$i))$n se,$r$ +er%$h$( se%i$( 15 &eni% 3. D$($% di+eri)$n &inu&$n &$nis se(er%i #us -)e,u$li #eru) d$n $n**ur )$ren$ %erl$lu $s$&' siru(' $%$u &$du -u&ur di $%$s 1 %$hun 4. ind$r)$n &$)$n$n ($d$% sel$&$ 6 #$& 5. Beri)$n r$s$ n$&$n -%urun)$n suhu %u+uh 6. ind$r)$n $)%i;i%$s +erle+ih$n se%el$h &$)$n
(A( III KESIMPU)AN
Mun%$h &eru($)$n
(en*elu$r$n
isi
l$&+un*/es"2$*us den*$n ($)s$. s$h$
&en*elu$r)$n isi l$&+un* $)$n %erlih$% se+$*$i )"n%r$)si "%"% dindin* (eru%. Mun%$h h$rus di+ed$)$n d$ri ("sse%in*'ru&in$si' re*ur*i%$si d$n re2lu)s *$s%r"es"2$*e$l. Mun%$h d$($% di)$%$)$n s$l$h s$%u d$ri &e)$nis&e (er%$h$n$n %u+uh $n* &en*inden%i2i)$si d$n +eru($$ &en*elu$r)$n $*en $n* &eru*i)$n $n* %el$h %er%el$n. Mes)i(un &un%$h %er)es$n h$l $n* sederh$n$ %e%$(i *e#$l$ ini d$($% &en*$r%i)$n +e*i%u +$n$) )e&un*)in$n (ene+$+ $n* &end$s$rin$ &ul$i d$ri )e$d$$n $n* rin*$n d$n &$sih d$l$& +$%$s n"r&$l' %e%$(i #u*$ &un*)in &eru($)$n )e$d$$n $n* serius. Mun%$h $n* +er)e($n#$n*$n d$n +erul$n* ($d$ $n$) $)$n &eni&+ul)$n )e$d$$n $n* le+ih +uru) d$n $($+il$ %id$) di%$n*$ni den*$n $de)u$% $)$n &ene+$+)$n )"&(li)$si $n* +er$%. Pen*en$l$n d$n (ende)$%$n di$*n"sis s$n*$% di(erlu)$n. Dih$r$()$n &el$lui re2er$% ini' &un%$h se+$*$i su$%u *e#$l$ )linis d$($% le+ih di)en$li den*$n (ende)$%$n di$*n"s%i) $n* +en$r den*$n %u#u$n &en,$ri e%i"l"*i $n* %e($% $*$r d$($% se*er$ di%$n*$ni.
