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"Latar Belakang: Pasien dengan keganasan gaster berisiko tinggi mengalami malnutrisi. Terapi kuratif utama pada pasien keganasan gaster adalah tindakan operasi, sehingga diperlukan dukungan terapi medik gizi perioperatif yang dapat menunjang perbaikan status gizi, kapasitas fungsional, dan kualitas hidup.Metode: Pasien pada serial kasus adalah dua laki-laki dan dua perempuan, berusia 34-64 tahun, dengan diagnosis tiga pasien dengan karsinoma gaster, dan satu pasien gastrointestinal stromal tumor gaster stadium lanjut. Terapi medik gizi praoperasi diberikan dalam bentuk oral dan parenteral. Pada enam jam sebelum tindakan operasi, dua pasien mendapatkan nutrisi parenteral, dan dua pasien mendapatkan nutrisi oral. Pasien pascaoperasi juga mendapatkan nutrisi enteral dini dalam 48 jam pertama.Hasil: Pasien pasca gastrektomi selama mendapatkan nutrisi perioperatif, tiga pasien mengalami proses penyembuhan luka yang baik, sedangkan satu pasien mengalami komplikasi pascaoperasi berupa fistula enterokutan yang kemudian mengalami pemulihan, dan satu pasien mengalami hiperglikemia dipengaruhi oleh tindakan pankreatektomi distal. Lama masa rawat inap pasien antara 21-31 hari. Semua pasien pascaoperasi mengalami peningkatan kapasitas fungsional.

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Background: Patients with gastric malignancy have high risk of malnutrition. The main curative therapy in patients with gastric malignancies is surgery, so it requires the support of perioperative nutritional therapy which could support the improvement of nutritional status, functional capacity, and quality of life.

Methods: Patients in this case series were two men and two women, aged 34-64 years, and the diagnosis of three patients are advanced gastric carcinoma, and one patient with advanced gastric gastrointestinal stromal tumor. Preoperative nutritional therapy was given in oral and parenteral route. At six hours before surgery, two patients received parenteral nutrition, and two patients received oral nutrition. All patients also got early enteral nutrition in the first 48 hours after surgery.

Results: Patients after gastrectomy during obtaining perioperative nutrition, three patients experienced a good wound healing process, while one patient experienced postoperative complications in the form of enterocutaneous fistula which later recovered, and one patient experienced hyperglycemia that affected by distal pancreatectomy. The length of stay for patients was between 21-31 days, after surgery all patients had increased functional capacity.

Conclusion: Perioperative nutritional therapy in gastric malignancies patients undergoing gastrectomy could help improve the nutritional status and functional capacity."

"Latar belakang: MRCP merupakan teknik pencitraan tidak invasif untuk mengevaluasi anatomi dan mendeteksi kelainan sistem bilier. Cairan di saluran bilier akan memperlihatkan sinyal yang tinggi pada MRCP. Salah satu keterbatasan pemeriksaan MRCP ialah cairan di saluran gastrointestinal juga memberikan sinyal tinggi yang dapat mengganggu evaluasi saluran bilier. Sari buah nanas dapat menjadi kontras oral negatif untuk menurunkan sinyal di gastrointestinal. Belum terdapat penelitian penggunaan sari buah nanas pada pemeriksaan MRCP di Indonesia dan belum terdapat penelitian yang menilai visualisasi cabang-cabang duktus intrahepatikus setelah pemberian sari buah nanas. Tujuan: Mengukur perbedaan SNR gaster dan duodenum serta perubahan tingkat visualisasi cabang-cabang duktus bilier intrahepatikus sesudah pemberian sari buah nanas pada pemeriksaan MRCP. Metode: Dilakukan pemeriksaan MRCP sebelum dan sesudah pemberian sari buah nanas pada subjek penelitian. Mengukur perbedaan rerata SNR gaster dan duodenum serta mengukur perubahan tingkat visualisasi cabang-cabang duktus bilier intrahepatikus sebelum dan sesudah pemberian sari buah nanas. Perbedaan rerata SNR gaster dan duodenum dianalisis menggunakan uji Wilcoxon dan perubahan tingkat visualisasi dianalisis dengan uji McNemar untuk menilai diskordans. Hasil: Didapatkan 25 subjek penelitian yang menjalani pemeriksaan MRCP sebelum dan sesudah pemberian sari buah nanas. Terdapat penurunan bermakna SNR gaster dan duodenum setelah pemberian sari buah nanas, 127,1 (18,7-1194,6) menjadi 42.2 (4,2-377,1) untuk gaster dan 64,1 (3,8-613.4) menjadi 44,6 (6,5-310,3) untuk duodenum (p < 0,05). Terdapat perubahan bermakna tingkat visualisasi duktus bilier intrahepatikus (p < 0,05, diskordans >50%) dengan peningkatan tingkat visualisasi duktus intrahepatikus kanan segmen anterior pada 66% pengamatan, duktus intrahepatikus kanan segmen posterior pada 58% pengamatan, dan 70% pengamatan untuk duktus intrahepatikus kiri. Simpulan: Pemberian sari buah nanas dapat menurunkan sinyal gaster dan duodenum pada pemeriksaan MRCP dan mempengaruhi tingkat visualisasi cabang-cabang duktus bilier intrahepatikus.

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Background: MRCP is a non-invasive imaging technique for evaluating anatomy and detecting abnormalities of the biliary system. Fluid in biliary tract will show high signal on MRCP. One of the limitations of MRCP is high signal in gastrointestinal fluid which can interfere biliary tract evaluation. Pineapple juice as negative oral contrast can reduce signal in gastrointestinal tract. There have been no studies on the use of pineapple juice for MRCP in Indonesia, and no studies assessed the visualization of intrahepatic ductal branches after administration of pineapple juice. Objective: Measuring difference in gastric and duodenal SNR and changes of visualization of intrahepatic biliary ductal branches after administration of pineapple juice on MRCP. Methods: MRCP before and after administration of pineapple juice were performed on subjects. Gastric and duodenal SNR mean difference were measured, and analysis were done with Wilcoxon test. Level of visualization of intrahepatic biliary ductal branches were also measured and analysed with McNemar test for discordances. Results: There were 25 subjects underwent MRCP. Gastric and duodenal SNR were statistically decreased after administration of pineapple juice, 127.1 (18.7-1194.6) vs 42.2 (4.2-377.1) and 64.1 (3.8-613.4) vs 44.6 (6.5-310.3) respectively (p <0.05). Statistically significant difference was observed in visualization of intrahepatic ductal branches (p<0,05), discordance >50%) with increase in visualization of right duct anterior segment in 66% observation, right duct posterior segment in 58% observation, and 70% observation in left intrahepatic bile duct. Conclusion: Use of pineapple juice as negative oral contrast significantly reduce gastric and duodenal signal in MRCP also affect visualization of the intrahepatic biliary duct branches."

"Purpose

The association between the preoperative absolute neutrophil count (NC), lymphocyte count (LC), and monocyte count (MC) in the peripheral blood and the prognosis of gastric cancer (GC) patients has not been investigated widely.

Methods

We enrolled 445 patients who underwent surgery for GC between January, 2005 and April, 2013 to analyze the correlations among NC, LC, and MC and their prognoses.

Results

Based on cut-off values calculated by ROC analysis, patients were sub grouped as having: NC ≥ 4477 (NCHigh), NC < 4477 (NCLow); and as LC ≥ 1447 (LCHigh), LC < 1447 (LCLow); and as MC ≥ 658,5 (MCHigh), MC < 658,5 (MCLow). Each group was assigned as follows; NCHigh group = 1, NCLow group = 0, LCHigh group = 0, LCLow group = 1, MCHigh group = 1, MCLow group = 0, and the sum of each score was defined as the lymphocyte-monocyte-neutrophil score (LMN score). The overall 5-year survival rates were 89%, 74%, 57,8%, and 53,3% for LMN scores of 0, 1, 2, and 3, respectively (P = 0,0004). Multivariate analysis indicated that the LMN score was an independent prognostic indicator.

Conclusions

The combination of preoperative NC, LC, and MC appears to be a useful indicator of GC prognosis."

"Meningitis tuberkulosis (MeTB) merupakan manifestasi klinis berat dari infeksi TB yang menyerang sistem saraf pusat (SSP) dan menyebabkan pasien mengalami penurunan asupan nutrisi karena menurunnya kemampuan makan dan selera makan. Asam amino rantai cabang (AARC) diketahui memiliki efek meningkatkan selera makan dan protektif terhadap massa otot. Pemenuhan kebutuhan AARC berpotensi memperbaiki kapasitas fungsional pasien sehingga menurunkan morbiditas dan mortalitas pasien MeTB. Empat pasien MeTB dipantau selama perawatan di Rumah Sakit Cipto Mangunkusumo (RSCM). Pencatatan asupan makanan pasien dilakukan dengan metode FFQ semi kuatitatif dan 24h dietary recall. Selama masa perawatan diberikan terapi medik gizi sesuai kondisi klinis pasien, dilakukan pemantauan harian termasuk penilaian kapasitas fungsional pasien hingga pasien selesai perawatan. Semua pasien menunjukkan tanda malnutrisi berdasarkan kriteria klinis menurut American Society of Parenteral and Enteral Nutrition (ASPEN). Belum ada rekomendasi terapi medik gizi khusus MeTB yang dapat digunakan, namun pada pasien dengan masalah infeksi disertai masalah neurologis rekomendasi tatalaksana TB paru dan stroke dapat menjadi acuan untuk tatalaksana pasien. Pemberian asupan kalori 35-40 kkal pada pasien dengan protein minimal 1,5 g/kgBB berpotensi meningkatkan kapasitas fungsional pasien dan mencegah perburukan penyakit. Tiga pasien mendapatkan asupan AARC diatas rekomendasi dan didapatkan peningkatan kapasitas fungsional dengan menggunakan indeks Barthel. Terapi medik gizi dengan pemberian protein dan AARC yang lebih tinggi dari rekomendasi IOM pada pasien MeTB dapat meningkatkan kapasitas fungsional pasien.

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Tuberculous Meningitis (TBM) has been the most severe manifestation of Tuberculosis infection attacking central nervous system (CNS) and causes the risk of malnutrition in patients due to decrease the ability of eating and loss appetite. Branched chain amino acid (BCAA) has been known having effects in appetite and protection of muscle mass. Fulfilling BCAA requirement is potential to improve patient functional capacity, furthermore lowering the morbidity and mortality of TBM patient. Four TBM patients has been observed during hospitality in Cipto Mangunkusumo Hospital (RSCM). Patient’s dietary intake was collected using semiquantitative FFQ and 24h dietary recall. During hospitality, medical nutrition therapy was administered based on patient clinical condition, daily observation including patient functional capacity was done until patient was discharged. All patients showed malnutrition signs based on clinical criteria according to American Society of Parenteral and Enteral Nutrition (ASPEN). Recommendation of nutrition therapy on TBM patient still not exist, however in patient with infection and neurological problem, guideline of nutrition therapy in TB infection and stroke can be used. Intake of 35-40 kcal/kgBW calories and 1,5 g/kgBW of protein can be potential to increase patient functional capacity and prevent further morbidity. Three patient can fulfill their BCAA beyond the requirement and there were increase in patient functional capacity using Barthel Index. Medical nutrition therapy using protein and BCAA administration above the IOM recomendation in TBM patient can improve functional capacity."

"Latar Belakang: Kolestasis adalah hambatan atau supresi sekresi empedu. Kolelitiasis dan obstruksi bilier akibat keganasan merupakan kasus kolestasis yang sering ditemui. Kolestasis dapat menyebabkan gangguan nutrisi dan berbagai komplikasi. Selain pembedahan, terapi nutrisi adalah pendekatan tata laksana pada pasien kolestasis untuk mempertahankan status nutrisi dan kapasitas fungsional. Kasus: Pasien dalam serial kasus ini terdiri atas tiga pasien laki-laki dan satu perempuan, berusia 36-55 tahun dengan diagnosis kolestasis akibat keganasan dan postcholecystectomy syndrome (PCS) dengan riwayat kolelitiasis. Satu pasien dengan keganasan dan dua pasien dengan PCS menjalani operasi bypass biliodigestif dan rekonstruksi, sedangkan satu pasien menjalani perbaikan kondisi klinis sebelum pembedahan. Terapi nutrisi yang diberikan meliputi diet tinggi protein dan rendah lemak dengan nutrien spesifik berupa MCT dan BCAA. Pada kasus pertama terapi nutrisi diberikan pascabedah. Selama perawatan ada kecurigaan leakage anastomosis, tetapi keluaran klinis membaik. Pasien kedua mendapat terapi nutrisi prabedah dan mengalami perbaikan kondisi klinis. Kedua pasien tidak mencapai target nutrisi walaupun toleransi makanan cair baik. Kasus ketiga dan keempat mendapat terapi nutrisi pra dan pascabedah dan pada akhir masa pemantauan, dapat mempertahankan status nutrisi. Pada keempat pasien, kapasitas fungsional dapat dipertahankan, bahkan mengalami perbaikan.Kesimpulan: Terapi nutrisi yang optimal dapat memberikan keluaran klinis yang baik pada pasien kolestasis. Pemberian nutrien spesifik berupa MCT dan BCAA diperlukan untuk meningkatkan toleransi asupan, mempertahankan status nutrisi, dan memperbaiki kapasitas fungsional pasien kolestasis.

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Background: Cholestatis is obstruction or suppression of bile secretion. Cholestasis may cause nutritional disturbance and other complication. Besides surgery, nutritional therapy is needed in cholestasis patient for maintaining nutritional status and functional capacity.

Cases: Four cases (three male and one female) of cholestasis with range of age between 36-55 years old are included in this case series. They were diagnosed with cholestasis because of cancer and post-cholecystectomy syndrome (PCS) with cholelithiasis history. One patient with cancer and two patients with PCS had the biliodigestive bypass surgery and reconstruction, while one patient was restoring her clinical condition before surgery. All patients were given high protein and low fat diet, with specific nutrient such as MCT and BCAA. The first patient received nutrition therapy during postoperative phase. During monitoring, he was suspected with leakage anastomosis, but in the end the outcome was good. Second patient got nutritional therapy in preoperative phase and got better clinical condition. Both patients couldnt reach the nutritional target although their tolerance of ONS was good. The third and the fourth patient got nutritional therapy in pre and postoperative phase and had maintained their nutritional status. In all patients, the functional capacity could be maintained and improved.

Conclusion: Optimal nutritional therapy is needed in cholestasis patients to get better clinical outcomes. Specific nutrients such as MCT and BCAA improve the nutritional tolerance, maintain the nutritional status, and improve the functional capacity."

"Penyakit lambung merupakan penyakit yang terjadi di lambung atau bersumber dari lambung. Terdapat beberapa macam penyakit lambung, seperti Gastroesophageal Reflux Disease (GERD), tukak lambung, dan dispepsia. Golongan obat Antagonis Reseptor Histamin H2 atau Antagonis H2, adalah golongan obat penekan asam lambung yang sering digunakan dalam berbagai kondisi penyakit lambung. Clinical pathway atau alur klinis merupakan suatu alat yang digunakan untuk memandu perawatan kesehatan untuk pasien. Pembuatan clinical pathway harus dikembangkan berdasarkan bukti yang tersedia, seperti pedoman praktik klinis yang memuat tatalaksana penyakit, tindakan, dan terapi yang akan diberikan kepada pasien. Peran farmasis dalam clinical pathway adalah dalam manajemen terapi obat, kebutuhan obat pasien, edukasi obat kepada pasien berserta keluarga pasien dan juga tenaga kesehatan, merevisi dan menetapkan protokol pengobatan, dan evaluasi hasil pengobatan. Oleh karena itu, clinical pathway terapi penyakit lambung perlu diketahui untuk memberikan informasi serta rekomendasi terkait pengobatan dan penanganan pasien kepada tenaga kesehatan demi tercapainya hasil pengobatan yang diharapkan dan sebagai manajemen terkait kualitas, biaya, kepuasan pasien dan efisiensi. Metode pelaksanaan tugas khusus ini adalah dengan cara studi literatur untuk pencarian clinical pathway penyakit lambung dengan obat golongan Antagonis H2 dengan mencari sumber atau referensi dan melakukan penelusuran pustaka terkait penatalaksaan atau algoritma penyakit lambung. Berdasarkan hasil studi literatur yang dilakukan, golongan obat Antagonis H2 dapat dijadikan sebagai pilihan terapi untuk GERD ringan, dapat menjadi pilihan untuk mengobati dispepsia tanpa alarm symptoms, baik untuk pasien yang sebelumnya mengonsumsi obat-obatan NSAID ataupun tidak, dan dapat menjadi terapi pilihan untuk penyakit lambung dengan dosis yang berbeda-beda sesuai dengan penyakitnya.

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Gastric disease is a disease that occurs in the stomach or originates from the stomach. There are several kinds of gastric diseases, such as Gastroesophageal Reflux Disease (GERD), peptic ulcers, and dyspepsia. The H2 Histamine Receptor Antagonist drug class or H2 antagonists, is a class of drugs that suppress stomach acid which is often used in various conditions of gastric disease. Clinical pathway is a tool used to guide health care for patients. Making a clinical pathway must be developed based on available evidence, such as clinical practice guidelines that contain disease management, actions, and therapies to be given to patients. The role of pharmacists in clinical pathways is in drug therapy management, patient drug needs, drug education for patients and their families as well as health workers, revising and establishing treatment protocols, and evaluating treatment results. Therefore, it is necessary to know the clinical pathway for gastric disease therapy to provide information and recommendations related to treatment and patient care to health workers in order to achieve the expected treatment results and as management related to quality, cost, patient satisfaction and efficiency. The method of carrying out this special assignment is by means of a literature study to search for clinical pathways for gastric disease with H2 antagonist class drugs by finding sources or references and conducting literature searches related to gastric disease management or algorithms. Based on the results of a literature study conducted, the H2 antagonist drug class can be used as a therapeutic option for mild GERD, can be an option for treating dyspepsia without alarm symptoms, both for patients who have previously taken NSAID drugs or not, and can be the therapy of choice for chronic kidney disease. stomach with different doses according to the disease."

"Background: Esophagitis implies an organic damage of the esophagus due to several pathophysiologic factors, predominantly: (1) degree of gastric acid secretion (gastric pH), whereabouts are rapidly or slowly to be mucosal breaks onto esophagus were under the influe nced by: (a) gastric pH 54 and (b) the contact of gastric acid into esophageal mucosal. (2) Lower esophageal sphincter (LES) as a important lactor lor antifetlux mechanisms, which antireflux mechanism cannot senre as a barrier system whenever tone of LES comes down until 510 mml-lg that causes feeble resting LES pressure. Esophageal injuries are recognized endoscopicaliy by the presence of the Savary-Millers classification (1985), but there are not definitely which ones principally to pathophysiologic factor. Methods: This was a consecutive non-random sampling cross sectional study Thirty subject from 127 patients with dyspepsia undergoing elective upper-endoscopic examination with collecting of the gastric juice and biopsies of tower esophageal mucosal, also esophageal manometric examination. Before that, clinical inclusive and exclusive criterias until laboratory examination were performed. Significant interval was 95%. Analyzing data with Fisher?s Exact Test One-Tail to correlate between gastric pH and hypotonic LES into esophagitis. Results: Esophagilis prevalence was 22. 8%. Fisher's Exact Test One-Tail to correlate esophagitis with gastric pH E 4 was significant (p=0.013798), but with hypotonic LES (tones of LES S 10 mmHg) was not (p=0.60269). The combined roles or' gastric pH and tones of LES into esophagitis are included: (1) Frequency of roles of pH E 4 and hypotonic LES are 48.2% (2) Frequency of role of pH < 4 without hypotonic of LES are 33.3%. (3) Frequency of role of hypotonic LES without pH S4 are 11. 1% and (4) Frequency of esophagitis without roles of pH $4 and hypotonic ol LES are 7.4%. Conclusions: The sum of gastric pH 5 4 and hypotonic of LES together are more than each separate factor. Onto statistically was significant between esophagitis and gastric pH, but there is no correlation with tones ol LES. So, gastric pH plays a more important role than LES."

"Non-steroid anti-inflammatory drugs (NSAID) can cause gastropathy and gastric mucosa, especially the mucous may play an important prevention role. This cross-sectional, single group study was conducted to evaluated the difference of mucous thickness in antrum or corpus mucosa and the correlation of gastric mucous thickness to gastropathy. Patients who received NSAID from the rheumatology clinic were studied. Healthy subjects of 14 - 65 years old who never received NSAID were included as normal controls. Piroxicam 20 mg daily was given to the patients for 7 days, then gastroscopy and gastric mucosa biopsy with frozen section were performed. Specimens were stained with haematoxyline eosin and thickness of the mucous layer was measured using ocular micrometer. Thirty-two out of 70 patients participated in the study. All cases had hyperemia on gastroscopy with erosions and ulcer in 32 and 9 cases, respectively. The mean thickness of mucosa in distal antrum, proximal antrum and corpus was 28.5 ± 9, 37.4 ± 13.1 and 43.3 ± 13.1 microns, respectively. There was significant relationship between gastric mucosa mucous thickness with gastroscopic findings. In conclusion, this study confirmed that thickness of gastric mucosa mucous has an important role in preventing NSAID gastropathy and dyspeptic complaints in this kind of patients does not suggest abnormalities of gastric mucosa."