3. penyakit hati kronik

7/27/2019 3. PENYAKIT HATI KRONIK

1/38

Kuliah Pengantar

Ilmu Gastroentero-Hepatologi

Penyakit Dalam

________________________

Dr. H. Syafruddin AR. Lelosutan, Sp.PD

Departemen Penyakait Dalam RSPAD GS


2/38

ANATOMI SISTIM DIGESTIVUS (The alimentary tract.)

Parotid gland

Salivary glands


3/38

HATI


4/38

SIRRHOSIS HEPATIS

Berat hati : 1,21,5 kg

Faal hati : metabolisma,

sintesis,

detoksifikasi,

regulasi endokrin,sistim RES,

sistim koagulasi


5/38


6/38

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 beracun3. Autoimun

4. Fibrosis kistik

5.Penyakit Wilson : deposit Cu berlebihan dalam hati


7/38

Viral Hepatitis

Source of

virus

Route oftransmission

Chronic

infectionPrevention

Feces

Fecal-oral

No

Vaccine,immuneglobulin

A

Type of Hepatitis

Blood/body fluids

Yes

Vaccine,immuneglobulin,

Childbirth,needles,

sex,transfusion

B

Blood/body fluids

Yes

Blood donorscreening,

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 HBVco-infection)

D

HBV vaccine

CDC fact sheets, available at www.cdc.gov


8/38


9/38

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 Lancet2003


10/38

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 diCalifornia 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


11/38

Prevalence of HBV and Incidence of

Hepatocellular Carcinoma (HCC)

World prevalence of HBV carriers

HBsAg carriersprevalence

8%

Poorly documented

Annual incidence of primary HCC

Cases/100,000 population

13

310

10150

Poorly documented

WHO 1999


12/38

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


13/38

PATOGENESIS

HEPATITIS VIRAL

Averett DR and Mason WS.Viral Hep. Rev. 1995; 1:12942

Clinical hepatitis

HBV or HCV-infected

hepatocytes

Inflammationand cell death

HBV or HCV

production

Hepatocyteregeneration

Uninfectedhepatocytes

Infection

Immuneresponse

Re-infection

Alcohol,co-infection

etc.


14/38

Viral replication

Transplantor

Death

Immuneresponse

Tissuedamage

Scarring

HCC

Cirrhosis

Evidence of disease

PATOGENESIS

HEPATITIS VIRAL KRONIK

Adapted from Dr Z Goodman, Armed Forces Institute of Pathology, Washington, DC

Host andenvironmental factors(e.g. alcohol, co-infection)


15/38

Perjalanan Klinis HEPATITIS :

Penyakit Hepatitis akut kronikFAILURE 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


16/38

Faktor risiko dan Gejala


17/38

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 : fam ily, travel, eating, l iving5. Resipien : - transfusi darah sblm th. 1990,

- transplantasi organ

6. AIDS

7. Bayi dengan ibu pengidap Hepatitis B atau C8. Pekerja Kesehatan, Dentis ts and Dental Hygienists


18/38

PENATALAKSANAAN.

Diagnostik :

Klinis, Laboratoris dan Biopsi Hati.

Terapeutik :

Pencegahan.

Pengobatan / medikamentosa.

Edukasi :


19/38

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.


20/38

Importance of Serum Markers


21/38

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]


22/38

Assessing Predicting

Length Response SustainedMethod 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 Xassay

HCV genotype X

NIDDK. Chronic hepatitis C: current disease management.

Utility of Diagnostic Tests

*No longer widely used.


23/38

Role of Liver

Biopsy in HCV

Infection

Confirm clinicaldiagnosis

Assess severity of

fibrosis and

necroinflammation1,2

Evaluate possible

concomitant disease

processes (eg,alcoholic liver disease,

NASH)1,2

Assess

therapeutic

intervention1

1. NIH Consensus Statement Online. Management of hepatitis C.2. British Liver Trust Information Service. A guide to liver function tests.


24/38

Terapi Pencegahan :

Menjaga dan meningkatkan Daya TahanTubuh.

Menghindari :

- pemakaian jarum suntik berulang-ulang.

- seks bebas

- transfusi darah sembaranganMemelihara higiene-sanitasi.

Imunisasi / Vaksinasi (untuk HBV).


25/38

Terapi Medikamentosa :

Averett DR and Mason WS. Viral Hep.Rev. 1995; 1:12942

Block HBV or HCVproduction and/or re-

infectionwith antiviral

therapy

Clinical hepatitis

HBV or HCV-infected

hepatocytes

Inflammationand cell death

HBV or HCVproduction

Stimulate immune responsewith interferon

Hepatocyteregeneration

Uninfectedhepatocytes

Infection

Lysis of infected hepatocytesand regulation

of viral replication

Immuneresponse Alcohol,

co-infectionetc.

CAM

with Hepatoprotektor/stimulator


26/38

Pilihan Obat :

INTERFERON : IFN Standar

Peg-IFN

ANTIVIRAL : Ribavirin

NUKLEOSIDAANALOGUE : Lamivudine

Adevofir dipivoxil

IMMUNE SUPPORT : Glicirrhizine

Thymosin HEPATOPROTEKTOR :

FLEBOTOMI : LIT DI RSPAD GS


27/38

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 (-)


28/38

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


29/38

SIRRHOSIS HEPATIS


30/38

Drug Induced

Hepatitis

Viral Hepatitis

Fatty Liver/

Steato Hepatitis

Nodul-nodul


31/38

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/coklatmarun (melena), kesadaran

berkabut

(encefalopati) LABORATORIUM :

Hiperglobulinemia (rasio Alb/Glob terbalik)

Trombositopenia


32/38

KLASIFIKASI KLINIS

SIROSIS HATI

LATEN/TERKOMPENSASI

SIROSIS HATI DEKOMPENSATA


33/38

Klasifikasi CHILDs-PUGHSKOR 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 : 79

Childs C : > 9 the poorest prognostic group,

is less than 12 months

Hayes, et al. Churchills Pocketbook of Medicine, 3rdEdition. China, 2002.


34/38

KOMPLIKASI SIROSIS HATI

HEMETEMESIS MELENA

ASITES

SINDROMA HEPATORENALHEPATOMA

KOMA HEPATIKUM


35/38


36/38

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


37/38

Gejala dan Tanda:

Bervariasi

Berlangsung perlahan-lahan

ikterusNyeri epigastrium

Rasa tidak enak pada perut kanan atas

BB menurunAsites hemorrhagik


38/38

Diagnosis :

Laboratorium : AFP (alfa feto protein)

USG :

CT-scanAngiografi

Biopsi hati

3. penyakit hati kronik

Documents