Kuliah Pengantar

Ilmu Gastroentero-Hepatologi
Penyakit Dalam
________________________
Dr. H. Syafruddin AR. Lelosutan, Sp.PD
Departemen Penyakait Dalam RSPAD GS
ANATOMI SISTIM DIGESTIVUS (The alimentary tract.)
Parotid gland
Salivary glands
HATI
SIRRHOSIS HEPATIS

Berat hati : 1,2 1,5 kg
Faal hati : metabolisma,
sintesis,
detoksifikasi,
regulasi endokrin,
sistim RES,
sistim koagulasi

DEFINISI :
Hepatitis = keradangan hati

PENYEBAB :
1. Infeksi : parasit (malaria, amoeba),
bakteri (tbc, banal), jamur,
viral (hepatitis A, B, C, D, E, F,
TT, CMV, EBV)
2. Kerusakan hati : alkohol, obat-obat (asetaminofen,
metildopa, INH, fenitoin, valproat,
CPZ, amiodaron, TMP-SMZ,
eritromisin), bahan beracun
3. Autoimun
4. Fibrosis kistik
5. Penyakit Wilson : deposit Cu berlebihan dalam hati


Viral Hepatitis
Source of
virus
Route of
transmission
Chronic
infection
Prevention
Feces
Fecal-oral
No
Vaccine,
immune
globulin
A
Type of Hepatitis
Blood/
body fluids
Yes
Vaccine,
immune
globulin,
Childbirth,
needles,
sex,
transfusion
B
Blood/
body fluids
Yes
Blood donor
screening,
risk management,
education
Needles,
transfusion,
sex,
childbirth
C
Feces
Fecal-oral
No
Ensure safe
drinking
water
E
Blood/
body fluids
Yes
Needles, sex,
transfusion
(requires HBV
co-infection)
D
HBV vaccine
CDC fact sheets, available at www.cdc.gov
RIWAYAT RINGKAS HEPATITIS B.
SAKIT KUNING :
(+) sjk abad 5 SM di Babilonia.
Hippocrates (460-375 SM) icterus infectiosa menular >< imunisasi.
Letupan wabah di kalangan militer :
- Franco-Prussian War (1870) - Perang Boer (1948)
- Perang Korea (1952) - Perang Timur Tengah (1956)
Lurman (1885) : epidemi hepatitis virus di Bremen dengan transmisi parenteral.
Water viral hepatitis, wabah di : Inggris (1895), Skandinavia (1916, 1944), New Delhi
(1955-1956).
Flaum (1926) : epidemi hepatitis virus pada penderita DM yang mendapat obat suntikan.
Blumberg BS (1977) : penemu virus hepatitis B (HBV) Australian antigen = HBsAg
(Lihat gambar I.).
Adi Teruna Effendi (1982) : Hepatitis virus merupakan penyakit jabatan pada kalangan
profesi kesehatan, risiko tertular lebih tinggi 2-10 kali dibanding populasi umum.
New York State Workmens Compensatoir Bureau (1984) : mengakui hepatitis virus
sebagai penyakit jabatan pada kelompok petugas kesehatan

Prevalence of HBV
Hepatitis B virus (HBV) is one of the worlds
most common infectious diseases
Around 400 million people have chronic HBV
infection
> 1 million people die every year of HBV-
related chronic hepatitis, cirrhosis or liver
cancer
WHO 1998; Lai et al Lancet 2003

1. Penemuan pertama kali jenis infeksi, dengan sebutan virus hepatitis Non-
A Non-B dan didukung pembuktian klinis

2. Diidentifikasi sebagai virus hepatitis C (HCV) dan dikembangkan di
California tahun 1988.

3. Gambaran klinis berhubungan dengan riwayat transfusi darah,
dengan masa inkubasi 2-26 minggu.

4. HCV : virus dengan amplop ukuran 50 nm genom RNA positif
mengandung 9400-9500 nukleotida, mirip Flavivirus dan Pestivirus

(PRINCE,et al.1974; FEINSTONE,et al.1974
SULAIMAN, 1996)
Riwayat ringkas
Prevalence of HBV and Incidence of
Hepatocellular Carcinoma (HCC)
World prevalence of HBV carriers
HBsAg carriersprevalence
<2%
27%
>8%
Poorly documented
Annual incidence of primary HCC
Cases/100,000 population
13
310
10150
Poorly documented

WHO 1999
Characteristics of HBV and HCV
Double stranded DNA
virus
4 open reading frames
High vireamia
High infectivity
Integrates into host
genome
No cytotoxicity
Single stranded RNA
virus
1 open reading frame
Low viraemia
Low infectivity
No integration into host
genome
Cytotoxicity (?)
HBV
HCV
PATOGENESIS
HEPATITIS VIRAL
Averett DR and Mason WS.
Viral Hep. Rev. 1995; 1:12942
Clinical hepatitis
HBV or HCV
-infected
hepatocytes
Inflammation
and cell death
HBV or HCV
production
Hepatocyte
regeneration
Uninfected
hepatocytes
Infection
Immune
response
Re-infection
Alcohol,
co-infection
etc.
Viral replication
Transplant
or
Death
Immune
response
Tissue
damage
Scarring
HCC
Cirrhosis
Evidence of disease
PATOGENESIS
HEPATITIS VIRAL KRONIK
Adapted from Dr Z Goodman, Armed Forces Institute of Pathology, Washington, DC
Host and
environmental factors
(e.g. alcohol, co-infection)
Perjalanan Klinis HEPATITIS :
Penyakit Hepatitis akut kronik FAILURE
Komplikasi kegagalan hati :
Sirosis hati :
hipertensi portal varises esofagus :
pecah HEMATEMESIS MELENA
hipoalbuminemia asites : SBP
Hepatoma : HCC (diffuse parenchymal)
Lobulated hepatoma
Ensefalopati hepatikum
Sindroma hepatorenal
Faktor risiko dan Gejala

FAKTOR RISIKO HEPATITIS
VIRAL KRONIK

1. IDU (pemakai obat suntik), Tatoo
2. Overdosis asetaminofen, alkohol atau obat lain
3. Kebiasaan seksual risiko tinggi / freesex
4. Terkontaminasi : family, travel, eating, living
5. Resipien : - transfusi darah sblm th. 1990,
- transplantasi organ
6. AIDS
7. Bayi dengan ibu pengidap Hepatitis B atau C
8. Pekerja Kesehatan, Dentists and Dental Hygienists
PENATALAKSANAAN.
Diagnostik :
Klinis, Laboratoris dan Biopsi Hati.

Terapeutik :
Pencegahan.
Pengobatan / medikamentosa.

Edukasi :
Diagnostic of Hepatitis B
Viral markers
HBV-DNA, HBsAg, HBeAg, Anti-HBs,
Anti-HBe and Anti-HBc.
Other markers
ALT (SGPT), Liver histology, Clinical
examination, Ultrasound.
Importance of Serum Markers
Diagnostic of Hepatitis C
HCV antibody tests
enzyme immunoassays (EIA)
recombinant immunoblot (RIBA)

HCV-RNA tests
Qualitative: AMPLICOR HCV Test [50 IU/mL]
Quantitative: AMPLICOR MONITOR Test [600
IU/mL]
Assessing Predicting
Length Response Sustained
Method Screen Confirmation of Therapy to Therapy Response
ALT/AST X
Enzyme X
immunoassay (EIA)
Supplemental assay X
(RIBA*)
HCV RNA qualitative X X
assay
HCV RNA quantitative X X
assay

HCV genotype X
NIDDK. Chronic hepatitis C: current disease management.
Utility of Diagnostic Tests
*No longer widely used.
Role of Liver
Biopsy in HCV
Infection
Confirm clinical
diagnosis
Assess severity of
fibrosis and
necroinflammation
1,2

Evaluate possible
concomitant disease
processes (eg,
alcoholic liver disease,
NASH)
1,2

Assess
therapeutic
intervention
1

1. NIH Consensus Statement Online. Management of hepatitis C.
2. British Liver Trust Information Service. A guide to liver function tests.
Terapi Pencegahan :
Menjaga dan meningkatkan Daya Tahan
Tubuh.
Menghindari :
- pemakaian jarum suntik berulang-
ulang.
- seks bebas
- transfusi darah sembarangan
Memelihara higiene-sanitasi.
Imunisasi / Vaksinasi (untuk HBV).

Terapi Medikamentosa :
Averett DR and Mason WS. Viral Hep.
Rev. 1995; 1:12942
Block HBV or HCV
production and/or re-
infection
with antiviral
therapy
Clinical hepatitis
HBV or HCV
-infected
hepatocytes
Inflammation
and cell death
HBV or HCV
production
Stimulate immune response
with interferon
Hepatocyte
regeneration
Uninfected
hepatocytes
Infection
Lysis of infected hepatocytes
and regulation
of viral replication
Immune
response
Alcohol,
co-infection
etc.
CAM
with Hepatoprotektor/stimulator
Pilihan Obat :
INTERFERON : IFN Standar
Peg-IFN
ANTIVIRAL : Ribavirin
NUKLEOSIDA
ANALOGUE : Lamivudine
Adevofir dipivoxil
IMMUNE SUPPORT : Glicirrhizine
Thymosin
HEPATOPROTEKTOR :
FLEBOTOMI : LIT DI RSPAD GS
Kapan dinyatakan sembuh dari
serangan infeksi Hepatitis
Serangan akut HBV : HBsAg (+),
IgM anti HBc (+).
HCV : sulit diidentifikasi.

Kondisi kronis HBV : Anti HBc total (-)
HBsAg (+)
HBeAg (+) aktif
HCV : Anti HCV (+).

Keadaan sembuh HBV : HBsAg (-),
Anti HBs (+), HBV DNA (-)
HCV : Anti HCV (-), HCV RNA (-)




Adalah :
Proses pengerasan parenkhim hati akibat nekro-inflamasi yang
berlarut-larut/kronik
Cirrhotic = pengerasan, batu
PARENKHIM
HATI
inflamasi
nekrotik
HEPATOMA
CIRRHOSIS HEPATIS
BERBAGAI
PENYEBAB
fibrotik
SIRRHOSIS HEPATIS
Drug Induced
Hepatitis
Viral Hepatitis
Fatty Liver/
Steato Hepatitis
Nodul-nodul
<-----------------------------------------------------------kronik<-----------------akut
6 bulan
GEJALA DAN TANDA
GEJALA : Cepat lelah, mengantuk siang hari,
tidak bisa tidur malam hari.
Ngomong ngaco.
TANDA-TANDA :
Badan kurus, perut membuncit (ascites),
muntah darah (hematemesis), tremor,
berak darah warna hitam/coklat
marun (melena), kesadaran
berkabut
(encefalopati)
LABORATORIUM :
Hiperglobulinemia (rasio Alb/Glob terbalik)
Trombositopenia
KLASIFIKASI KLINIS
SIROSIS HATI
LATEN/TERKOMPENSASI

SIROSIS HATI DEKOMPENSATA
Klasifikasi CHILDs-PUGH
SKOR 1 2 3
Albumin (g/dL) > 3.5 2.8 - 3.5 < 2.8
Ascites None Mild Marked
Bilirubin (umol/dL) < 3.4 3.4 5.0 > 5.0
Ensefalopati None Mild Marked
PT (s prolonged) < 4 4 6 > 6
Nilai SKOR : Jika jumlah angka
Childs A : < 7
Childs B : 7 9
Childs C : > 9 the poorest prognostic group,
is less than 12 months
Hayes, et al. Churchills Pocketbook of Medicine, 3
rd
Edition. China, 2002.
KOMPLIKASI SIROSIS HATI
HEMETEMESIS MELENA
ASITES
SINDROMA HEPATORENAL
HEPATOMA
KOMA HEPATIKUM
Epidemiologi :
Kanker hati banyak didapatkan di daerah
Timur Jauh dan Afrika.
Penyebab utama : infeksi Hepatitis B dan
C
Di Indonesia sering disertai oleh Sirosis
Hati
Gejala dan Tanda:
Bervariasi
Berlangsung perlahan-lahan
ikterus
Nyeri epigastrium
Rasa tidak enak pada perut kanan atas
BB menurun
Asites hemorrhagik
Diagnosis :
Laboratorium : AFP (alfa feto protein)
USG :
CT-scan
Angiografi
Biopsi hati