Get That Cow Milk Away

From Me, Please...!!

Tutor: dr. Julius Chandra Y.

Kelompok 9
Nama

NIM

Posisi

Yuliana Starsia

405070021

Ketua

Saskia Prathana

405070088

Sekretaris

Rendy Christian
M.

405070159

Anggota

Aditya Nagatama

405070064

Anggota

Frans Welly

405070059

Anggota

David Santoso

405070074

Anggota

Puspita Permata
Sari

405070150

Anggota

Lusia Christina

405070073

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Jessica
Purnamasari

405070165

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Fracella Putri

405070160

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Ronald Yulianto

405070110

Anggota

Case 1B
You receive a call from Mrs. Melati, mother of Rosa, a
previously healthy 2-month-old girl. For the past 3 days,
Rosa developed an occult bleeding and mucous in the
stool accompanied by a moderate degree of emesis.
However, her temperature hasnt increased, no
abdominal cramping or colic, but today she seems a bit
pale and more irritable.
Unfortunately Mrs. Melati didnt breastfeed Rosa about a
week ago, and give her regular cow milk formula.
While you are discussing her family history, Mrs. Melati
reports that Rosas brother and sister are having food
allergy, her 6-year-old brother is asthmatic as well as his
father. The mother assumed that he has the same dairy
product allergy like his 3-year-old sister.
You tell her to bring him for further diagnostic investigation
and call the lactation clinic for a counseling appointment
in order to return to exclusive breastfeeding.

Foreign Terminology
Occult blood in the stool:
Small quantities of blood in the stool,
that can only be detected with
chemical testing or microscopical
analysis (Dorland)

Emesis:
Forceful expulsion through the mouth of
the contents of the stomach as a
response to irritation

GI Tract Anatomy

GI Tract Physiology
The six processes of digestion involve:
(1) the movement of food and liquids
(2) the lubrication of food with bodily secretions
(3) the mechanical breakdown of
carbohydrates , fats, and proteins
(4) the reabsorption of nutrientsespecially
water
(5) the production of nutrients such as vitamin K
and biotin by friendly bacteria
(6) the excretion of waste products

Comparison of Breastmilk and

Formula
-

Protein
Whey
Casein

HUMAN

1.1

COW

3.3

0.7

0.6

0.4

2.7

FORMULA

1.6
0.9 0.96
0.6 0.64

Carbohydrate

6.9

4.7

7.0

Fat

4.4

3.3

1.1

Water

87.5

88.0

80

Calories (kcal)

70

61

60

GI BLEEDING AND OCCULT

BLOOD

1.

Gastrointestinal
Bleeding
UpperGI bleeding: esophagus, stomach, or
duodenum (first part of the intestine).
Bleeding can come from ingestion of caustic
poisons or stomach cancer.
Peptic ulcers
Gastritis
Esophageal varices

2. LowerGI bleeding:
the digestive system-the segment of the small intestine
farther from the stomach, large intestine, rectum, and
anus.
Diverticular disease, angiodysplasia, polyps, hemorrhoids,
and anal fissures most commonly cause the bleeding.
Blood in the stool can result from cancers, inflammatory
bowel disease, and infectious diarrhea.

GI Bleeding Symptoms

Acute GI bleeding first will appear as vomiting of blood

Fatigue
Weakness
Shortness of breath
Abdominal pain
Pale appearance
Vomiting of blood usually originates from an upper GI
source.
Bright red or maroon stool can be from either a
lower GI source or from brisk bleeding at an upper
GI source.
Long-term GI bleeding may go unnoticed or may cause
fatigue, anemia, black stools, or a positive test for
microscopic blood.

Occult Bleeding
Definition
Occult gastrointestinal bleeding refers to a
slow loss of blood into the upper or lower
gastrointestinal tract that does not cause
changes in the color of the stool or result in
visible bright red blood.
Occult bleeding has many of the same causes as
rectal bleeding and may result in the same
symptoms as rectal bleeding.
It is often associated with anemia that is due to loss
of iron along with the blood (iron deficiency
anemia).

Occult Bleeding
Cause and site of rectal bleeding
determined
History and physical examination
Anoscopy
Flexible sigmoidoscopy
Colonoscopy
Radionuclide scans
Visceral angiogram
Blood tests

Occult Bleeding
Rectal bleeding treated
Correcting low blood volume and anemia
Intravenous fluids or blood transfusions and oral
iron supplements (tablets).
Determining the cause and site of bleeding
Colonoscopy is the most widely used procedure
in the diagnosis and treatment of rectal bleeding
Stopping bleeding and preventing
rebleeding
Colonoscopy also be used to stop bleeding by
removing (snaring) bleeding polyps, by
cauterizing (sealing with electrical current)
bleeding angiodysplasias or postpolypectomy
ulcers and, occasionally

EMESIS

Emesis
Definition
Vomiting is emitting stomach contents
from the mouth. This is not the same as
regurgitation, which refers to emitting
already swallowed food, and must be
distinguished correctly. Vomiting is often
related to or preceded by nausea, but both
nausea-without-vomiting and vomitingwithout-nausea are possible. Any nausea
or vomiting symptom needs prompt
professional medical investigation.

Emesis
Patophysiology
Receptors are stimulated which contribute impulses to the vomiting center in
the brain

Sensory impulse stream from receptors reach the vomiting center and initiate a
number of motor responses.

The diaphragm and the skeletal muscles of the abdominal wall contract

Increase the intra-abdominal pressure

The cardiac sphincter relaxes and soft palate rise to close off the nasal passage

The stomach (or intestinal) contents are then forced upward through the
esophagus, pharynx and out the mouth

Emesis or Vomiting

Emesis
The vomiting center has inputs mainly
from:
Stretch or irritant receptors in the stomach
(responds to excessive gastric distention or
ingestion irritants or emetics)
Chemoreceptor trigger zones in the floor of
the fourth cerebral ventricle (responds to
increases in ICP)
Mechanical receptors in the throat
Vestibular apparatus (responsible for the
travel/motion sickness)

Emesis
Causes
These are possible causes of vomiting in infants (0 - 6 months):
1. Congenital pyloric stenosis, a constriction in the outlet from
the stomach (the infant vomits forcefully after each feeding
but otherwise appears to be healthy)
2. Food allergies or milk intolerance
3. Gastroenteritis (infection of the digestive tract that usually
causes vomiting with diarrhea)
4. Gastroesophageal reflux
5. An inborn error of metabolism
6. Hole in the bottle nipple may be wrong size, leading to
overfeeding
7. Infection, often accompanied by fever or runny nose
8. Intestinal obstruction, evidenced by recurring attacks of
vomiting and crying or screaming as if in great pain
9. Accidentally ingesting a drug or poison

Diagnosing Causes of
Emesis
The history and physical examination
should include:
duration of vomiting,
the presence of blood in the vomitus,
the presence of abdominal pain or
distension,
the character of the stool
the presence of the fever.

Diagnosing Causes of
Emesis

Blood and urine analysis

Plain Abdominal X-ray
USG
Intravenous Pyelography
Endoscopy
Monitoring oesophageal pH

Complications of Emesis
Excessive or repeated vomiting can cause
dehydration and may lead to severe disturbances in
the electrolyte and acid-base balance in the body.
Dehydration due to loss of water from the GI
tract.
Hypokalaemia due to loss of the potassium ions
in GI secretions
Hypochloremia due to loss of chloride ions in the
vomitus
Alkalosis - due to loss of H+ ions in the vomitus
Aspiration syndrome
Malnutrition and failure to thrive
Peptic oesophagitis

Therapy
Causal treatment
Antiemetic medication

ADVERSE REACTIONS TO
MILK

Lactose Intolerance
Definiton
Lactose intolerance is the inability or insufficient ability
to digest lactose, a sugar found in milk and milk
products
Lactose intolerance is caused by a deficiency of the enzyme
lactase, produced by the cells lining the small intestine
Lactase breaks down lactose into two simpler forms of sugar
called glucose and galactose, which are then absorbed into
the bloodstream
People sometimes confuse lactose intolerance with cow milk
allergy
Milk allergy: by the bodys immune system to one or more
milk proteins and can be life threatening when just a small
amount of milk or milk product is consumed
Milk allergy most commonly appears in the first year of life,
while lactose intolerance occurs more often in adulthood

Epidemiology
More than 50 million Americans are lactose intolerant.
Nearly twothirds of the world's adult population has some degree of
difficulty
with digestion of milk sugar because of a lactase deficiency:
97-100% of African Blacks
90-100% of Asians
70-75% of North American Blacks
70-80% of Mexicans
60-90% of Mediterraneans
60-80% of Jewish descent
10-12% of Middle Europeans
7-15% of North American Caucasians
1-5% of Northern Europeans.

Etiology of lactose
malabsorption
Primary lactose
malabsorption

Secondary lactose
malabsorption

Developmental
lactase deficiency
Congenital lactase
deficiency

Bacterial
overgrowth/stasis
Mucosal injury of GIT
that causes villus
flattening

Developmental lactase
deficiency
Low lactase levels as a consequence
of prematurity
Lactase activity in the fetus
increases late in gestation
Premature infants born at 28-32
weeks of gestation have a reduced
lactase activity

Congenital lactase
deficiency
Characterized by the absence of
lactase activity in the small
intestine, with normal histologic
findings
A gene located on the same
chromosome of the lactase gene, is
responsible for CLD
Affected infants have diarrhea from birth,
hypercalcemia and nephrocalcinosis

Secondary lactose
malabsorption
Mucosal injury
Villus flattening or damage to the
intestinal epithelium

Celiac disease
Crohns disease
Radiation enteritis, chemotherapy
HIV enteropathy
Whipples disease

Lactose Intolerance
Patophysiology
Lactose ingested into small intestine

Unabsorbed lactose into colon.

Normal bacterium split the lactose and use the resulting glucose and
galactose for its own purposes

The bacteria also release hydrogen gas

the gas is absorbed from the colon and into the body
then expelled by the lungs in the breath

Most of the hydrogen is used up in the colon by other types of bacteria.

A small proportion of the hydrogen is responsible for the increased flatus

(passing gas)

Bacteria changes the hydrogen gas into methane gas, and these people
will excrete it in their breath and flatus.

Lactose Intolerance
Not all of the lactose that reaches
the colon is split and used by colonic
bacteria. The unsplit lactose in the
colon draws water into the colon (by
osmosis). This leads to loose,
diarrheal stools.

Clinical manifestations
Abdominal pain crampy, localized to
periumbilical area, or lower quadrant
Bloating
Flatulence
Diarrhea
Vomiting
Stools are usually bulky, frothy and
watery

Differential diagnosis

Irritable bowel disease

Inflammatory bowel disease
Cystic fibrosis
Diverticulitis
Celiac sprue
Acute gastroenteritis
Giardiasis

Diagnosing Lactose
Intolerance
Hydrogen Breath Test
The person drinks a lactose-loaded beverage and
then the breath is analyzed at regular intervals to
measure the amount of hydrogen. Normally, very little
hydrogen is detectable in the breath, but undigested
lactose produces high levels of hydrogen. Smoking
and some foods and medications may affect the accuracy
of the results. People should check with their doctor about
foods and medications that may interfere with test results.

Stool Acidity Test

The stool acidity test is used for infants and young
children to measure the amount of acid in the stool.
Undigested lactose creates lactic acid and other
fatty acids that can be detected in a stool sample.
Glucose may also be present in the stool as a result
of undigested lactose.

Lactose Intolerance Treated

1. Dietary changes
The most obvious means of treating lactose
intolerance is by reducing the amount of lactose
in the diet.
Food products that may contain lactose include:
Bread and other baked goods
Processed breakfast cereals
Instant potatoes, soups, and breakfast drinks
Margarine
Lunch meats (except those that are kosher)
Salad dressings
Candies and other snacks
Mixes for pancakes, biscuits, and cookies

Lactose Intolerance
2. Lactase enzyme
Caplets or tablets of lactase are available to take with
milk-containing foods.
3.Adaptation
Some people can slowly increasing the amount of
milk or milk-containing products in their diets they
are able to tolerate larger amounts of lactose
without developing symptoms. This adaptation to
increasing amounts of milk is not due to increases in
lactase in the intestine. Adaptation probably results
from alterations to the bacteria in the colon.
Increasing amounts of lactose entering the colon change
the colonic environment, for example, by increasing the
acidity of the colon. These changes alter the way in which
the colonic bacteria handle lactose. For example, the
bacteria produce less gas. There also may be a reduction
in the secretion of water and, therefore, less diarrhea.

Lactose Intolerance
4.Calcium and vitamin D supplements
Milk and milk-containing products are the
best sources of dietary calcium and
vitamin D .Its a good idea for lactoseintolerant persons to take
supplemental calcium and vitamin
D to prevent calcium and vitamin D
deficiency.

MILK PROTEIN ALLERGY

Milk Protein Allergy

Definition
An abnormal response to a food
triggered by the body's immune system
Can cause serious illness or death
Problem foods for children: eggs, milk
(especially in infants and young children)
and peanuts
A reaction to food can also be food
intolerance, which is not an allergic
reaction, but may present like one.

Epidemiology
Cow's milk allergy (CMA) affects about 27.5% of infants.
In CMA patients, 50% will develop an
allergy to other food proteins (egg, soya,
peanut) and 50-80% will develop an
allergy against one or more inhalant
allergens (grass pollens, house dust mite,
cat) before puberty.
There is also a higher risk of developing
other allergic diseases such as asthma or
eczema.

Clinical Types of Milk Allergic

Reactions
Type 1: Early Reaction
Appears 45 minutes after milk ingestion
Colic, diarrhea, vomiting, skin rash, eczema,
occasionally wheezing or sneezing

Type 2: Intermediate Reaction

Appears 45 minutes to 20 hours after milk
ingestion
Vomiting and diarrhea

Type 3: Late Reaction

Appears after 24 hours of milk ingestion
Diarrhea, vomiting, wheezing and coughing

Symptoms that could

indicate a possible milk
allergy

excessive colic
recurrent
diarrhoea
Vomiting
abdominal pain
excoriated buttocks
rash, hives and
eczema
chronic runny nose
nasal stuffiness

recurrent bronchitis
recurrent "colds,"
sinusitis
ear infections
fluid behind ears
wet and wheezy
chest
coughing
irritability
failure to thrive

Diagnosis
Only the immediate milk reactions that
develop after a few minutes are most
likely to give a positive blood or skin
test, as these detect IgE that is
involved in the immediate type
reaction
Nearly 60% of milk reactions in the young
child are the delayed type (intolerant)
and therefore unlikely to give positive
results with the blood and skin tests

Milk Protein Allergy

Milk Protein Allergy Treatment
Avoid allergens while maintaining a
balanced, nutritious diet for infants
and mothers.
Breastfeeding can be continued if
allergens are avoided.

Prognosis
Most children will outgrow their Cow
Milk Allergy, +60% at 4 years and
+80% at 6 years
Some patients retain the allergy throughout
life
If the milk is strictly excluded from the diet
for + 2-3 years, the child then has an 80%
chance of tolerating the milk in small
amounts again
CMA may be acquired later in life

Conclusion and
Recommendation
Based on Rosas symptoms (occult
bleeding, mucous in stool, and emesis)
and her given family history, it is possible
that she suffers adverse reactions to foods,
specifically milk, in the form of lactose
intolerance or milk protein allergy.
It recommended that she undergoes
further diagnostic investigation to identify
the underlying cause and also avoid dairy
products for the time being

References
http://www.foodallergysolutions.com/lactoseintolerance.html
http://www.medicinenet.com/lactose_intoleran
ce/discussion-106.html
http://digestive.niddk.nih.gov/ddiseases/pubs/l
actoseintolerance
http://pedsinreview.aappublications.org/cgi/co
ntent/full/29/2/39
http://www.allergyadvisor.com/Educational
http://www.saanendoah.com/compare.html