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CASE REPORT

DYSPEPSIA

PRECEPTOR:
dr. Hj. Ihsanil Husna, Sp.PD

ARRANGED BY:
Ayu Devita Ashari
2013730128

DEPARTMENT OF INTERNIST
JAKARTA ISLAMIC HOSPITAL CEMPAKA PUTIH
FACULTY OF MEDICINE
MUHAMMADIYAH JAKARTA UNIVERSITY
2018
KATA PENGANTAR

AssalamualaikumWr. Wb.

Alhamdulillah, Puji syukur penyusun panjatkan kehadiran ALLAH SWT atas


terselesaikannya tugas Laporan Kasus “Dyspepsia”.

Makalah Laporan Kasus ini disusun dalam rangka untuk dapat lebih mendalami
dan memahami mengenai “Dyspepsia”. Tujuan khususnya adalah sebagai pemenuhan
tugas kepaniteraan Stase Ilmu Penyakit Dalam.

Semoga dengan adanya laporan kasus ini dapat menambah khasanah ilmu
pengetahuan dan berguna bagi penyusun maupun peserta didik lainnya.

Penyusun menyadari bahwa laporan kasus ini masih jauh dari kesempurnaan, oleh
karena itu penyusun sangat membutuhkan saran dan kritik untuk membangun laporan
kasus yang lebih baik di masa yang akan datang.

Terimakasih.

WassalamualaikumWr. Wb

Jakarta, Maret 2018

Penulis
CHAPTER I
PATIENT’S IDENTITY

A. PATIENT’S IDENTITY
• Name : Ms. A

• Age : 20 years old

• Address : Kemayoran

• Marital Status : Not married

• Religion : Moslem

• Date of Admission : March 16th 2018

• MR Number : 00 92 18 43

B. ANAMNESIS (AUTOANAMNESIS)
• a. Chief Complaint :

Epigastric pain since 1 week before entering the hospital.

Another Complaint :
Nausea (+), Vomit (+), Fever (+), Cough (+).

• b. History of Present Illness

Patient came to Cempaka Putih Islamic Hospital with epigastric pain since
a week before admission. The pain decreases at rest, but reappear when patient
doing some activity. The pain feels like being stabbed and there is a burning
sensation in the epigastric area. Patient said the epigastric pain was felt after
consuming spicy foods. Patient also complained fever since approximately two
days before admission. Fever is felt throughout the day. Since one month, patient
coughs but not often. The patient has felt nausea and vomit but not much. Patient
doesn’t have problem with her appetite and also doesn’t have problem with
urinating and defecating.

• c. History of Past Illness

Previously patients has experienced the same complaint about three months ago.
No history of hypertension
No history of cardiovascular disease
No history of asthma
No history of allergic
No history of hematologic disease

• d. History of Family

Patient’s father has history of hypertension


Patient’s father has history of DM
No history of allergic
No history of hematologic disease

 e. History of Allergy
Patient has no allergy to food, drugs and weather

• f. History of Treatment

Patient has already consumed polysilane for her epigastric pain.

• g. Habits

Patient have a smoking habit about 4 to 5 packs per day. But has begun to be
reduced.

Patient had a habit of drinking alcohol but it has stopped a few years ago.

Patient has a habit of consuming spicy foods.


C. PHYSICAL EXAMINATION
• Generalis Status : Moderate ill

• Conciusness : Composmentis

• Vital Sign

- Blood Pressure : 120/80 mmHg

- Heart Rate : 100 x/minute

- Respiratory Rate : 18 x/minute

- Temperature : 38 ° C

• Anthropometric Status

- Body weight : 67 kg

- Body high : 160 cm

- BMI : 26,17 (Obese 1)

GENERAL PHYSICAL EXAMINATION


• Head : Normocephal, Deformity (-)

• Eyes : Anemic Conjungtiva (-/-), Icteric Sclera (-/-)

• Nose : Epistaksis (-/-), Secret (-/-), Deviasi Septum (-/-),

• Mouth : The Oral Mucosa Moist, Edentulous

• Neck : Palpable Mass (-), Lymphadenopathy (-)

• Thorax

• Inspection : The movement of the chest symmetrical


• Palpation : Same vocal fremitus in dextra and sinistra

• Percussion : Sonor

• Auscultacion : Vesicular breath sounds + / +, Ronkhi -/-, Wheezing - / -

Heart
• Inspection : Ictus cordis not seen

• Palpation : Ictus cordis not palpable

• Percussion : Right heart margin: Sternalis line sinistra ICS-V

Left heart margin: Midclavicula line sinistra ICS-V.

• Auscultation : Regular 1st & 2nd heart sounds, Murmur (-), Gallop (-)

Abdomen

 Inspection : Looked flat


 Auscultation : Bowel (+) sounds 7x/minutes
 Palpation : Pressure epigastric pain (+), ascites (-)
 Percussion : Timpani, shifting dullness (-)

Extremities
• Superior : Edema (- / -), Warm akral (+ / +), RCT <2 seconds (+ / +)

• Inferior : Edema (-/ -), Warm akral (+ / +), RCT <2 seconds (+ / +)

Laboratory Examination
16 March 2018

EXAMINATION VALUE UNITS NORMAL

Hemoglobin 12,6 g/dL 11,7 – 15,5

Leukosit 9.27 103/uL 3,60 - 11


Hematokrit 36 % 35 - 47

Trombosit 253 103/uL 150 - 440

Eritrosit 4,48 103/uL 3,80 – 5,20

MCV 81 fL 80-100

MCH 28 pg 26-34

MCHC 35 g/dl 32-36

Resume
• Ms. A, 20 years old, came to Cempaka Putih Islamic Hospital with epigastric pain
since a week before admission. The pain decreases at rest, but reappear when
patient doing some activity. The pain feels like being stabbed and there is a
burning sensation in the epigastric area. Patient said the epigastric pain was felt
after consuming spicy foods.

• Patient also complained fever, cough, nausea and vomit but not much.

• Patient had a history of the same complaint about three months ago

• Patient had a habit of smoking, drinking alcohol and consuming spicy foods.

Physical examination :
• BP: 120/80 mmHg

• HR: 100 x/minute

• RR: 18 x/minute

• Temp: 38° C

General Physical examination:

Pressure epigastric pain (+)


Laboratory examination:

• Normal

Problem List
• Dyspepsia

• Bronchitis

Assessment

 Dyspepsia

S : Epigastic pain, burning sensation in the epigastric area, nausea, vomit

Habit of smoking, drinking alcohol, and consuming spicy foods.

O : BP: 120/80 mmHg, HR: 100 x/minute, RR: 18 x/minute, Temp : 38° C.

Pressure epigastric pain (+)

A : Dyspepsia

P : Planning diagnostic:

Endoscopy

Planning therapy

Healthy life style (by reducing smoke, alcohol and spicy foods)

Domperidon 3x10 mg

Ranitidine injection 2x25 mg


 Upper Respiratory Tract Infections

S : cough, fever

O : BP: 120/80 mmHg, HR: 100 x/minute, RR: 18 x/minute, Temp : 38° C.

A : Upper Respiratory Tract Infections

P : Planning diagnostic:

Sputum for tuberculosis

Planning therapy

Paracetamol 3x500 mg

Acetylcysteine 2x200 mg
Follow Up

DATE SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

17 Epigastric - BP: 110/80 Dyspepsia - Paracetamol


March pain (+) URTI 3x500 mg
2018 Nausea (+) - HR: 90x
Cough (+) - Domperidon 3x10
- RR: 20x mg
- Temp: - Ranitidin inj 2x25
36,50C mg
- Pressure - Acetylcysteine
epigastric 2x200 mg
pain (+)

18 Epigastric - BP: 110/70 Dyspepsia - Paracetamol


March pain (+) URTI 3x500 mg
2018 Nausea (+) - HR: 88x
Cough (+) - Domperidon 3x10
- RR: 20x mg
- Temp: 36,0C - Ranitidin inj 2x25
- Pressure mg
epigastric - Acetylcysteine
pain (+) 2x200 mg

19 Epigastric - BP: 120/80 Dyspepsia - Domperidon 3x10


March pain (+) mg
2018 - HR: 88x
- Ranitidin inj 2x25
- RR: 20x mg
- Temp:
36,30C

- Pressure
Epigastric
Pain (+)
20 Epigastric - BP: 110/70 Dyspepsia - Domperidon 3x10
March pain (+) mg
2018 - HR: 84x
- Ranitidin inj 2x25
- RR: 19x mg
- Temp:
36,10C
CHAPTER II
LITERATURE REVIEW
DYSPEPSIA

Globally there are about 15-40% people with dyspepsia. Every year a nuisance it's
about 25% of the world's population. Prevalence dyspepsia in Asia ranges from 8-30%.
Modern lifestyle (fatty foods, cigarettes, NSAIDs, less physical activity) may contribute.
Dyspepsia is a complex disorder, referring to the collection of symptoms such as painful
or uncomfortable sensations in the upper abdomen, burning, nausea, vomiting, full and
bloated. A variety of mechanisms may underlie cover interference intestinal motility,
hypersensitivity, infection, or psychosocial factors. Although not fatal, this disorder can
degrade the quality of life and become a social burden of society.

DEFINITION
The British Society of Gastroenterology (BSG) states that the term 'dyspepsia' is
not a diagnosis, but rather a collection of symptoms that lead to upper gastrointestinal
diseases / disorders. The definition of dyspepsia is upper gastrointestinal tract infections
include pain or discomfort in the gastro-duodenal (epigastric) area, burning, fullness, full
satiation, nausea or vomiting.

CLASSIFICATION
Dyspepsia is classified into two, organic (structural) and functional (nonorganic).
In organic dyspepsia there is an underlying cause, such as peptic ulcer disease (PUD),
GERD (GastroEsophageal Reflux Disease), cancer, alcohol use or chronic drugs. Non-
organic (functional) is characterized by pain or discomfort in the upper abdomen chronic
or recurrent, with no abnormalities on physical examination and endoscopy.

EPIDEMIOLOGY
It is estimated that about 15-40% of the world's population have complaints of
chronic or recurrent dyspepsia; half of which is organic (structural) dyspepsia. The
highest etiology of organic dyspepsia is gastric / duodenal peptic ulcer, gastroesophageal
reflux disease, and gastric cancer. However, most of the etiology of dyspepsia is
unknown (functional).

ETIOLOGY
Idiopathic / functional dyspepsia (50-70%)
Peptic ulcer (10%)
Gastroesophageal reflux disease (GERD) (5-20%)
Gastric cancer (2%)
Helicobacter pylori infection
Non-steroidal anti-inflammatory drugs (NSAIDs)

Dietary factors (burnt food, fast food, fatty, spicy, coffee, tea) and lifestyle (smoking,
alcohol, NSAID / aspirin drugs, lack of exercise) are believed to contribute to dyspepsia.
Cigarettes are thought to decrease the protective effect of gastric mucosa, while alcohol
and anti-inflammatory drugs play a role in increasing stomach acid production.
Study in India in people with dyspepsia with an average age of 20 years,
significantly related to lifestyle factors such as the consumption of fatty foods, cigarettes,
NSAIDs, and low physical activity. Studies in Arabic analyzed the relationship between
lifestyle and diet in dyspepsia. Approximately 77 (43.8%) of 176 students with a mean
age of 20 years suffered from dyspepsia, and there was a significant correlation of
dyspepsia with smoking, sleep deprivation, stress, academic factors (p <0.05), while
alcohol, fast food, salty food, spicy food, coffee, and the level of physical activity has no
significant relationship with dyspepsia.
Risk factors for organic dyspepsia include age> 50 years, family history of gastric cancer,
history of peptic ulcer, treatment failure, history of gastrointestinal bleeding, anemia,
weight loss, persistent vomiting, changes in bowel habits, high or long-term use of
NSAIDs , and alcohol consumption. Study in Taiwan in 2,062 people with Chinese
dyspepsia obtained normal endoscopic results of 1174 (56.9%), gastritis 215 (10.4%),
gastric ulcer 254 (12.3%), duodenal ulcer 194 (9, 4%), reflux esophagitis as much as 182
(8.8%), and esophageal / gastric cancer as much as 43 (2.1%). Organic dyspepsia patients
in the study tended to be found at older age, more likely to be infected with H. pylori, and
drug users (aspirin, NSAIDs) than functional dyspepsia.

DIAGNOSTIC
Characteristics of dyspepsia generally include full post-eating, full satiety, burning in the
epigastrium (associated with GERD), epigastric pain, non-cardiac chest pain, and less
specific symptoms such as nausea, vomiting, bloating, belching, abdominal distension.
Functional dyspepsia patients usually experience intermittent symptoms in the long-term
interspersed with remission periods.

Distinguishing organic dyspepsia by function requires an accurate history and physical


examination. Investigations such as blood tests, endoscopy, and radiology are required in
certain cases. Indication of endoscopy when there are symptoms or alarm signs. Age> 55
years is one indication due to age of onset of stomach cancer in Southeast Asian
countries. When in upper gastrointestinal endoscopy and hepatobiliary ultrasound (if
indicated) there is no organic lesion called functional dyspepsia. H. pylori infection
detection may use non-invasive methods such as urea breath test, stool antigen, or
serology.
Symptoms and alarm signs
 Age> 55 years
 Gastrointestinal haemorrhage (hematemesis, melena)
 Anemia
 Quickly full / full
 Dysphagia (difficult to swallow) or odinofagia (painful swallowing)
 Weight loss (> 10% normal weight)
 Vomiting over and over
 Lymphadenopathy
 Family history of stomach / esophageal cancer
 Palpable abdominal mass
According to Rome III Criteria, the definition of functional dyspepsia is the presence of
symptoms that are thought to originate in the upper gastrointestinal tract, in the absence
of organic, systemic, or metabolic diseases.
* Diagnostic criteria should include
One or more of the following:
 a disruptive post-meal feeling
 fast satiety
 epigastric pain
 burning sensation in the epigastrium
There is no evidence of structural disease (from endoscopy) that may explain the
symptoms.
(*) Criteria are met the last 3 months with atset at least 6 months before diagnosis

Initially functional dyspepsia is divided into 3 types of dominant symptoms, namely


'ulcer-like', 'reflux-like', and 'dysmotility-like'. Considering more symptoms induced by
food consumption (± 80%), it is currently divided into two subtypes: Epigastric Pain
Syndrome (epigastric pain or burning) and Postprandial Distress Syndrome (full post-
meal and full satiety).

Functional dyspepsia criteria of epigastric pain type.


The diagnosis should include all of the following:
 Pain / burn in epigastrium, minimal intensity, at least once a week
 Pain should not be generalized to the abdominal or chest area, or in other
abdominal areas.
 Pain is not lost with bowel movements or flatus
 Pain does not meet the criteria of gallbladder pain or the Oddi sphincter.

Functional dyspepsia criteria of postprandial distress type.


One of:
 Full taste of post-meal in regular portions, several times a week
 Quickly satied so that the usual portion of food reduced, several times a week
MANAGEMENT OF DYSPEPSIA
Functional dyspepsia therapy needs to be differentiated for the subtype of pain or
postprandial distress. In the epigastric pain type, first-line therapy aims to suppress
stomach acid (H2-blocker, PPI). In the postprandial type of distress, the first line with
prokinetics, such as metoclopramide / domperidone (dopamine antagonists), acotiamide
(acetylcholinesterase inhibitors), cisapride, tegaserod, buspiron. If the first line fails, PPI
may be used for postprandial and prokinetic types of pain for the type of pain. The
combination of gastric acid and prokinetic acid is useful in some patients. There is no
effective therapy for all patients; various therapies may be used sequentially or in
combination.
In cases not responding to these drugs, antidepressants are used. Tricyclic
antidepressants (amitriptyline 50 mg / day, nortriptyline 10 mg / day, imipramin 50 mg /
day) for 8-12 weeks are effective for functional dyspepsia therapy, SSRI or SNRI no
more effective than placebo. Although still controversial, H. pylori can be tested in cases
of functional dyspepsia since the infection is generally asymptomatic. Therapy of
psychological conditions such as anxiety or depression may be helpful in cases of
difficult / resistant dyspepsia. Psychological therapy, acupuncture, herbal supplements,
psychological probiotics in functional dyspepsia have not been proven. Patient education
is important to avoid precipitating factors such as reducing stress / anxiety, start eating
fewer regular meals and avoid triggering foods.
GERD therapy aims to reduce the amount of stomach acid that enters the distal
esophagus by neutralizing gastric acid, reducing production, and increasing gastric
emptying into the duodenum, and relieving discomfort from burning. The preferred
therapy, ie PPI or H2-blocker, may be supported by administration of antacids, 5-HT4
agonists, or prostaglandin analogues (sucralfat, misoprostol). Patient education to reduce
dyspepsia (spicy, fatty acid, coffee, and alcohol) triggers eating a small portion of
frequent frequent frequencies, indirectly lying down after meals, upper body elevation
during sleep and weight loss is recommended.
H. pylori ulcer therapy aims to eradicate germs and cure ulcers, through 3
regimens, namely: PPI (omeprazole 2x20-40 mg) or H2-blocker (co-ranitidine 2x150 mg
or 300 mg before bed), plus the following two antibiotics: clarithomycin 2x500 mg, 2x1 g
amoxicillin, or metronidazole 2x400-500 mg for 7-14 days. If allergic to penicillin, given
4 kinds of therapy, namely: PPI (omeprazole 2x20-40 mg), bismuth 4x120 mg,
metronidazole 4x250 mg, and tetracycline 4x500 mg for 10-14 days. H. pylori
eradication needs to be verified by non-invasive tests (urea breath test, stool antigen test)
4 weeks after completion of therapy.
NSAID-related peptic ulcer therapy is by discontinuing the use of NSAIDs or
replacing with selective COX-2 antagonist inhibitors. Treatment with PPIs is quite
effective in NSAID-related ulcers (superior to H2-blockers). Continuous 72-hour PPI
infusion is recommended in cases of severe peptic ulcer bleeding, to maintain gastric pH>
6.
The pathogenesis of multifactorial functional dyspepsia. Several pharmacologic
treatments are recommended according to pathogenesis, namely: (1) gastric acid
suppression controls gastric hypersentivity, (2) prokinetics improves gastric motility
disorders, (3) antidepressants overcomes psychological disorders, accelerates gastric
emptying and manipulates pain perception. The efficacy of acid suppressant drugs (H2-
blockers, PPIs) in functional dyspepsia is moderate. Antacids, bismuths, and sucralfates
are not effective in functional dyspepsia. Prokinetics are more effective than placebo.

PROGNOSIS
Most patients with chronic and recurrent functional dyspepsia, with asymptomatic
periods followed by episodes of relapse. Based on population study of functional
dyspepsia patients, 15-20% had persistent symptoms, 50% had symptom improvement,
and 30-35% had fluctuating symptoms. Although functional dyspepsia is chronic and
affects the quality of life, it is not proven to decrease life expectancy.

CONCLUSION
Dyspepsia many experienced and disrupt the quality of life of patients. Classification
based on the presence or absence of organic lesions from physical and supporting
examinations (laboratory, endoscopy). Consideration of possible non-gastrointestinal
causes should be considered. Recommended avoidance of risk factors for triggers and
pharmacological therapy.
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