Gastroduodenal Mucosal Integrity and Influencing Factors

Gastroduodenal mucosal integrity has important role in the pathogenesis of gastroduodenal ulcer. It depends on imbalance between aggressive and defensive factors. However, many experts believe that defensive factors has more dominant role. Maintenance of gastrointestinal endothelial integrity appears to define the “cytoprotection” phenomenon and, as discussed below, is a critical component of NSAID- induced GI injury and a potential target for therapeutic intervention

Management of Gastroesophageal Reflux Disease (GERD)

Even though there are still no epidemiological data on the prevalence of Gastro Esophageal Reflux Disease (GERD) in Indonesia, data from The Division of Gastroenterology Department of Internal Medicine Cipto Mangunkusumo Hospital demonstrate signs of esophagitis in 22.8% of all patients with dyspepsia who underwent endoscopic examination. Western countries report a higher rate of GERD than Asian and African countries, possibly due to dietary factors and increased obesity. Besides adequate history and physical examination, there are many other supporting examinations that could be performed to establish the diagnosis of GERD, especially endoscopy of the upper gastrointestinal tract and 24-hour esophageal pH monitoring. Even though this condition is rarely fatal, GERD patients should still receive adequate management. Most patients demonstrate a satisfactory response towards therapy, which includes life-style modification as well as medication. Currently, the drugs of choice for GERD are proton-pump inhibitors. A combination of proton-pump inhibitors and prokinetics produces a better effect. Patients resistant to medical treatment or those with recurrent esophageal stricture should be considered for anti-reflux surgery

Mirizzi Syndrome in Gallstone Complication

Mirizzi syndrome is a rare complication of gallstone which is characterized by the presence of gallstone impaction in cystic duct that leads to inflammatory stricture in the biliary duct and results in obstructive jaundice. In this report, we highlighted the diagnostic approach and management of Mirizzi syndrome in a 58 year-old male complaining of nausea, vomiting, and appearing jaundice. The role of imaging such as abdominal ultrasonography in depicting the characteristics of Mirizzi syndrome was also discussed and compared the findings with the classification of the disease in the literature. In this patient, Mirizzi syndrome was suspected by the appearance acoustic shadow in the gallbladder with dilated cystic duct suggesting the impaction of common bile duct (CBD). We performed endoscopic retrograde cholangiopancreatography (ERCP) as both diagnostic and therapeutic modalities by which we allowed sphingterectomy to evacuate the gallstone. However, due to the risk of further stone evacuation, the procedure was followed by elective cholecystectomy

Current Diagnostic Approach of Inflammmatory Bowel Disease

Inflammatory bowel disease (IBD) has begun to emerge in Indonesia. The disease is further classifiedinto two types, ulcerative colitis (UC) and Crohn\u27s disease (CD). Diagnosis of IBD is initiated from symptomfindings such as diarrhea, abdominal pain, bleeding diarrhea, and weight loss, and supported by physicalexamination and additional tests. The options for additional examinations of IBD are mainly endoscopy (esophagogastroduodenoscopy, colonoscopy, and also intestinal endoscopy), imaging techniques, and laboratory examinations either from blood or feces. The application of these modalities should be prompted by sufficientclinical suspicion to promote their efficiency as well as prevent underdiagnosis or overdiagnosis. In primaryhealth care settings, patients with IBD are expected to be recognized for therapy or to use appropriate referralsystem to warrant a proper treatment

Role of Double Balloon Enteroscopy in the Diagnosis of Obscure Gastrointestinal Bleeding

Obscure gastrointestinal bleeding (OGIB) is bleeding in the digestive tract which persist or recur and with unclear aetiology. OGIB is one of the important problems in the gastrointestinal field due to difficulty in diagnosing the aetiology and determining the source of digestive tract bleeding in patients. In diagnosing the cause of OGIB, clinical approach through history taking and physical examination still have important roles. Most of the sources of bleeding in OGIB is from the small intestine, which cannot be reached by esophagogastroduodenoscopy (EGD) or colonoscopy. Therefore, role of diagnostic tool which is able to perform total enteroscopy becomes important in diagnosing the cause of OGIB.Double balloon enteroscopy (DBE) technique is a safe endoscopy procedure which may use oral or even rectal approach. In finding the cause of OGIB, where most of the lesions is found in the proximal region of the small intestine, oral approach is more beneficial. When bleeding is not found after conventional endoscopy is performed, it needs to be suspected that the source might come from the small intestine. Currently, the two main modalities which can be used in the evaluation are video capsule endoscopy (VCE) and DBE. However, based on cost effectiveness DBE without prior VCE has benefit because it can also administer therapy in the abnormalities being found

Vasoactive Intestinal Peptide-Secreting Tumor

Vasoactive intestinal peptide-secreting tumor (VIPoma) is one of the tumors which cause “ watery diarrhea, hypokalemia, hypochlorhydria and acidosis syndrome” (WDHHA syndrome). These tumor caused by to non-insulin-secreting pancreatic islet tumor that associated with elevated vasoactive intestinal polypeptide (VIP) plasma level. VIP is a potent stimulator of gut cyclic adenosine monophosphate (cAMP) production, which leads to massive secretion of water and electrolytes mainly potassium. Over expression of VIP causes diarrhea and cancerous growth. The other clinical features of VIPomas such as hypercalcemia, abdominal discomfort, tetany, facial flushing are associated with the actions of VIP, which stimulate intestinal secretion, inhibit gastric acid secretion. VIP also regulates the synthesis, secretion, and action of neuroendocrine hormones such as secretin, glucagon, prostaglandin E, somatostatin and pentagastrin as well as cytokines and chemokines. Diagnosis is based on clinical, laboratory test show elevation VIP level, electrolyte and acid base imbalance also imaging such as CT scan or magnetic resonance imaging (MRI) which shows primary tumor in the pancreas and metastasis especially in the liver. Somatostatin receptor scintigraphy may be useful in identifying extrapancreatic VIPomas, i.e. the sympathetic chain, colon, bronchus and occult or distant metastases. Initial treatment is to correct volume, electrolyte, and acid-base abnormalities with intravenous normal saline, potassium chloride, and, sodium bicarbonate. Somatostatin or long acting ocreotide is effective in reducing serum VIP levels and promptly controlling diarrhea. Interferon alpha and glucocorticoid may be useful for reducing symptoms. Surgical resection depends on staging of pancreatic tumor

The Prevalence and Risk Factors of GERD Among Indonesian Medical Doctors

Background: Based on our knowledge, the study of gastrointestinal reflux disease (GERD) among certain profession has never been conducted. The aim of this study is to determine the prevalence and risk factors of GERD among Indonesian doctors. Methods: A consecutive study involving 515 doctors was conducted in October 2015. The GerdQ score was used to the diagnosis of GERD and determined its impact on daily life. All possible risk factors were also analysed. Results: A total of 515 subjects completed the questionnaire. The mean age of them was 41.37 ± 11.92 years old. Fifty-five percent of them were male and 60.6% general practitioners. The prevalence of GERD was 27.4% of which 21.0% was had GERD with low impact on daily life, and 6.4% was GERD with high impact on daily life. The statistically significant risk factors of GERD was found in age >50 y.o (p = 0.002; OR = 2.054), BMI >30 kg/m2 (p = 0.016; OR = 2.53), and smokers (p = 0.031; OR = 1.982). Sex and education level were not found significant statistically as the risk factors of GERD. Conclusions: The prevalence of GERD among Indonesian physician was 27.4%. We found that age over 50 y.o, obesity and smoking habit were the risk factors of GERD in Indonesian doctors.&nbsp

Gastrointestinal Amyloidosis: Diagnostic Approach and Treatment

Amyloidosis is a disease marked by deposition of misfolded proteins, known as amyloids, in the extracellular space, including gastrointestinal tract. According to the precursor protein, amyloidosis is classified into six types; all of which can be involved in the gastrointestinal tract. Amyloidosis has weight loss and gastrointestinal bleeding as the most frequent symptoms. Gastrointestinal tract biopsy is diagnostic in most cases of amyloidosis and Congo red stain is used to confirm the amyloid proteins deposit. Treatment of amyloidosis consists of controlling symptoms, terminating protein formation and deposit, and treating the underlying diseases. Chemotherapy might be applied depends on the type of amyloidosis

Factors Found on the First Variceal-Bleeding Episode in Liver Cirrhosis Patients with Portal Hypertension

Background: The dietary protein restriction that was commonly recommended to hepatic encephalopathy (HE) patients, often leads to malnutrition, whereas malnutrition can deteriorate cirrhosis prognosis. The aims of this study were to find out encephalopathy improvement that was measured by critical flicker frequency (CFF) test and nutritional status by measuring prealbumin level after L-Ornithine L-Aspartate (LOLA) treatment with adequate calories and protein intake in patients with HE. Method: Patients with liver cirrosis who visited Cipto Mangunkusumo hospital on June-October 2009 was evaluated by CFF test using HEPAtonormTM device. Encephalopathy was defined when CFF < 39 Hz. Nutritional status was measured by the mid-arm muscle circumference (MAMC) and was stated as malnutrition when the MAMC was below the 15th percentile. Patients had been treated by 3 x 6 mg LOLA granules for 2 weeks, and adequate calories and protein intake with branched-chain amino acid (BCAAs) substitution. The change of encephalopaty was evaluated by the CFF test and the nutritional status by measuring prealbumin blood level. Results: There were 17 patients with liver cirrhosis who fulfilled the inclusion criteria. The mean CFF Result increased from 34.1 ± 2.5 Hz to 36.5 ± 2.9 Hz after LOLA treatment with the adequate calories and protein intake including BCAAs substitution, which was statistically significant (p < 0.001) compared to before treatment. The prealbumin level also increased significantly compared before treatment, i.e. from 5.4 ± 2.1 mg/dL to 6.4 ± 2.6 mg/dL, p = 0.008. Conclusion: HE patients with malnutrition could be given adequate calorie and protein with BCAAs substitution to improve their nutritional status, and LOLA granules for the improvement of HE