batu kandung empedu dan ikterik obstruktif

7/25/2019 Batu Kandung Empedu Dan Ikterik Obstruktif

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BATU KANDUNG EMPEDU

DAN IKTERIK OBSTRUKTIF



ANATOMI



ANATOMI

• Common bile duct (CBD) memn!n" #e b"in in$e%io%menu!u &&ill o$ 'te% di#oon"#n #e duodenum

• Pn!n" CBD *+, cm

• Ditl CBD be%tu den"n &nc%etic duct tu bi !u"

mu# #e duodenum mellui lubn" -n" be%bed• Gllbldde%

– &e% .&ed %ee'oi%/ &n!n" 0+12 cm/ dimete% 3+* cm/#&it 32+42 ml

– Be%d di &e%mu#n in$e%io% li'e% dn eb"in di elubun"in

&e%itoneum5 – Te%di%i d%i $undu/ bod-/ nec# 5 B"in nec# dn c-tic duct d

&i%l mucol $old ('l'e o$ .eite%) mence". #elu%n-"lltone/ mence". diteni tu #ol& d%i "llblde%



ANATOMI

• 6#ul% bili%- t%ee

– Ditl d%i A5 "t%oduodenl/ A5%et%oduodenl/ A5 &ote%ou&e%io%

&nc%etoduodenl – P%o#imlA5 .e&ti# de7t%/ A5 c-ticu

• 6#ul% "llblde% in"le c-tic %te%-(d&t be%l d%i A5 8e&tic init%/ A5

8e&tic communi/ A5 Meente%icu&e%io%)

• Clot9 t%in"le



FISIO:OGI

• Du#tu bili%i/ "llbldde%/ dn ;n"te%oddi be%$un"i untu# me%ub./ men-im&ndn me%e"uli em&edu

• Ti& .%i li'e% mem&%odu#i em&edu *22+1222 ml

• Se#%ei di timuli neu%o"enic/ '"l/c.emicl – 6"l menin"#t#n e#%ei

– S&lncn.ic ne%'e menu%un#n e#%ei

– GI .o%mone



FISIO:OGI

• Ii em&edu i%/ ele#t%olit/ "%m em&edu/ li&id/ &%otein/&i"men em&edu

• G%m em&edu &%ime% diintei di li'e% ole. #olet%ol5

G%m em&edu die#%ei #e em&edu ole. .e&toit dn

membntu &en-e%&n lem# di uu5• ,*< #n di#embli#n #e .e&% mellui 'en &o%t

.e&tic dn *< die#%ei#n #e $ee5

• S;n"te% oddi t%u#tu% #om&le# -" inde&enden d%i otot

duodenum5 Be%$un"i men"tu% mu#n- em&edu dn

pancreatic juice #e duodenum5 Memili#i te#nn -" tin""ie.in"" mence". %e"u%"iti & -" d di duodenum5Di&en"%u.i ole. .o%mon &ence%nn m#nn

mu#%el7bile #elu%



Ge!l Sim&tomti#

• Pin

• Bili%- colic n-e%i menet& di RU= 1 !m tu lebi. etel.m#n dn bin- #%en #ont%#i "llbldde% -n" di&icuole. e#%ei CCK5 Keti# lumen "llbldde% tid# bi di#oon"#n#%en obt%u#i ole. btu m# 'ice%l ;be% &in di#ti$#n

e.in"" menimbul#n n-e%i &d e&i"t%ium tu RU=• Fe'e% muncul #%en in$e#i tu in>mi

• ?undice diebb#n #%en &enin"#tn e%um bili%ubin -n"bi dili.t d%i #le%/ $%enulum lid. tu #ulit5 Se%um bili%ubin@5* m"dl d&t diidenti;#i mellui #le% -" i#te%i#5 ?i# @*

m"dl m# mni$etin- di #ulit5• C.%cot9 TRIAS $e'e%/ RU= &in/ !undice u"eti$

&en-umbtn e#%ei bilie% d%i li'e% bu#n .n- d%i"llbldde%



T%nbdominl Sono"%&.-



8IDA



CT Scn



MRI



ERCP



CA:CU:OUS BI:IARDISEASE



EPIDEMIO:OGI

• Btu em&edu &lin" e%in" te%!di&d &ien -" di%t den"n#elu.n GIT5

• F#to% Rii#o nit/ obeit/#e.miln/ e%in" men"#onumim#nn be%lem#/ c.%on9 diee/

te%minl ilel %eection/ $e%oitoi.e%edite%/ ic#le cell diee/t.lemi



PATOGENESIS

• K%en #etid#mm&un mem&e%t.n#n ci%nem&edu (#olet%ol/ "%m #lium)

• ?eni btu em&edu – btu #olet%ol

– btu &i"men (.itm tu co#lt)• Bili%- lud"e cm&u%n #%itl #olet%ol/ "%nul #lium

bili%ubin dn muin "el mt%i75 Al d%i "lltone5

c.olet%ol "lltone &to"enei

• 15 u&e%tu%i #olet%ol &d em&edu

• 5 nu#lei #%itl

• 35 &embentu#n btu



PATOGENESIS

• Mu#o "llbldde% mem&e%t.n#n #olet%ol dimuli d%i&embentu#n micelle (bile lt+$o$oli&id+#olet%ol com&le7)dn 'ei#el #olet%ol5

• P%odu#i #olet%ol tin""i m# 'ei#el te%ebut !u"menin"#t#n #&bilit untu# ment%n&o%t #olet%ol menimbul#n #%itl5

• Btu &i"men

– Btu .itm men"ndun" #olet%ol 2</ dn be%%n "el& #%nmen"ndun" clcium bili%ubinte5 U#u%n #ecil dn be%.ubun"nden"n #ondii .emoliti# e&e%ti $e%oitoi .e%edite%/ i%oi/ tu

ic#le cell diee – Btu co#lt memili#i #oniteni -n" lun#/ dn men"ndun"

#olet%ol dn #lium &lmitt5 Be%d di dlm bile duct dnbe%.ubun"n den"n in$e#i dn #elinn motilit bilie%5• E5coli mene#%ei Bet+"lu#o%onide -n" men-ebb#n .id%olii d%i

con!u"ted bili%ubin "luco%inde -n" men".il#n bili%ubin beb dn

end&n #lium



8ISTOR

• Bin- im&tomti#/ nmun d&t men!diim&tomti# #eti# btu men"obt%u#idu#tu iti#u dn menimbul#n #oli#5

•

Kom&li#i -n" d&t timbul #oleititi/#oledo#olitii den"n tu tn& #oln"iti/"lltone ileu/ "llbldde% c%cinom5

• Btu em&edu bin- ditemu#n ec%

tid# en"! #eti# l&%otomi tu USG/ CTcn5



C8RONIC CA:CU:OUS

C8O:ECSTITIS

• De;nii &%oe in>mi den"n e&iode%e#u%en d%i #oli# bilie% (n-e%i #ibt obt%u#i)5

• 8itolo"i &enin"#tn el ube&itelil/ ;b%oiube%ol dn in;lt%i el mononu#el%5

• MK

– #oli# bilie%/ n-e%i -" menet& 1+* !m &e% .%i5 ?i#n-e%i lebi. d% !m b%%ti lebi. #emun"#inn #ut#oleititi5

– Mul/ munt./ blotin"/ n-e%i UR=5

– Pd e&iode tid# n-e%i/ PF dn li'e% tet no%ml5



C8RONIC CA:CU:OUS

C8O:ECSTITIS

• Di"noi – d%i MK dn &eme%i#n %diolo"i

– USG "old tnd%d &eme%i#n

"lltone5 – Nmun te%#dn" &d &ien den"n

#elu.n #oli# tid# ditemu#n btu &dUSG/ t&i .n- ditemu#n lud"e5

– ?i# n-e%i dn lud"e ditemu#n &d @#e!din m# d&t diindi#i#n untu##oleite#tomi



C8RONIC CA:CU:OUS

C8O:ECSTITIS

• Tt :#n – Idel electi'e l&%oco&ic

c.olec-tectom-5

– Diet tn& lem# dn &o%i -" edi#itelm menun""u o&e%i5

– Hnit .mil den"n #elu.nim&tomti# "lltone dn #elu.n tid#menu%un etel. modi;#i diet d&tmen!lni #oleite#tomi &d t%imete%#ediu5



INDIKASI KO:ESISTEKTOMI

• URGENT (dlm +0 !m)

+cute c.olec-titi

+em&.-emtou c.olec-titi

+em&-em o$ t.e "llbldde%

+&e%$o%tion o$ t.e "llbldde%

+&%e'iou c.oledocoliti.ii it. endoco&ic duct

cle%nce

•

E:ECTI6E+bili%- d-#inei

+c.%onic c.olec-titi

+-m&tomtic c.olelit.ii



ACUTE CA:CU:OUS C8O:ECSTITIS

• Pto;iolo"i – Pd ,*< #u be%.ubun"n den"n btu em&edu5

– Obt%u#i c-tic duct -n" memicu #oli# bilie%

– ?i# c-tic duct tet& obt%u#i diteni "llbldde% dindin" edem dn in>mi5

– Ditndi den"n &%oe in>mi• &enebln dn .i&e%emi dindin" den"n &e%d%.n

ube%ol

• mu#o .i&e%emi dn &tc.- nec%oi5

• Pd #ebn-#n #u !i# umbtn dile&#n m#in>mi ec% be%t.& #n .iln"5

• Acute "n"%enou c.olec-titi te%bentu# #%en dn- betu em&iem di "llbldde%5



ACUTE CA:CU:OUSC8O:ECSTITIS

• MK – N-e%i RU=

– Demm/ mul/ munt./ !undice

– PF RU= tende%ne/ !i# &e%itoniti m# tende%neelu%u. l&n" bomen5

– ?i# te%b m be%%ti ud. d.ei #e omentum

– D&t !u" mu%&.- i"n (J)

– :b

• mild leu#oc-toi (15222+15222mm3)• mild ele'tion o$ bili%ubin (@m"dl)

• mild ele'tion l#line $o$te/ t%nmine/ dnmile



ACUTE CA:CU:OUSC8O:ECSTITIS

• Di"noi USG dl. Modlit- o$ C.oice untu# cutec.olec-titi5 Penebln dindin" @mm/ &e%ic.olec-tic >uid/diteni "llbldde%5

• Tt l#n ntibioti# "%m ne"ti$ e%ob dn ne%ob/ I6 >uid/nl"ei5

• De;niti'e t%etment – #oleite#tomi +3 .%i etel. #elu.n tu 4+12 min""u etel. initil

mediction5

– :&%oco&ic c.olec-tectom- lebi. bi# dibndin"#n o&enc.olec-tectom-5 Nmun bin- o&en c.olec-tectom- dil#u#n untu#mem&e%timbn"#n bebe%& $#to% e&e%ti ASA -" menin""i d%

ebelumn-/ obeit/ ui tu t&i tid# di%n#n5 – ?i# &ien tid# bi di l&%otomi bi den"n &%ecutneou

t%n.e&tic c.olec-tectom- den"n netei lo#l untu# d%in"llbldde%/ nmun %ii#o in$e#i lebi. tin""i5

• Kom&li#i em&-em "llbldde%/ em&.-emtou "llbldde%



C8O:EDOCO:IT8IASIS

• Btu &d common bile duct (CBD)

• Be%mul di "llbldde% llu mi"%i #e c-ticduct dn #emudin #e CBD5

• Btu di#t#n menet& !i# mi. d t.un &ot #oleite#tomi

• Btu di#t#n %e#u%en !i# lebi. d% t.un&ot #oleite#tomi

• Btu e#unde% bin- b%on tone di CBD/btu &%ime% be%.ubun"n den"n bili%-ti dn in$e#i



C8O:EDOCO:IT8IASIS

• MK – im&tomti#/ lb tet no%ml/ bin- ditemu#n ec%

inidentl

– im&tomti# #oli# bilie%/ !undice/ %n $ee &uct/ u%inbe%%n "el&5

– Demm #dn" d

– Se%um bili%ubin (@3 m"d:)/ e%um minot%n$e%e/ l#lin$o$te menin"#t t&i tnd te%ebut tid# &ei;#mennd#n dn- btu CBD 5

• D7 – USG dilti BD @ mm/ bili%- &in/ !undice5

– ERCP (endoco&ic %et%o"%de c.oln"i&nc%eto"%&.-)me%u&#n MOC dn untu# di"noti# dn te%&euti# CBDtone5



C8O:EDOCO:IT8IASIS

• Tt :#n – endoco&ic c.oln"io"%&.- untu# di"noti# dn

;n"te%e#tomi ebelum l&%o#o&i# #oleite#tomi

– Indi#i c.oln"iti -" membu%u#/ m&ull%- tone

im&ction/ billi%- &nc%etiti/ i%oi5 Setel.endoco&i &.incte%ectom- dn tone e7t%ction/&ien mi. be%ii#o untu# men"lmi bili%-com&liction5

– :&%oco&ic CBD e7&lo%tion int%o&e%ti'e

c.oln"io"%m t #oleite#tomi5 – O&en common bile duct e7&lo%tion !%n" di&#i5

Bi di"un#n !i# tone im&cted di m&ull/ !diulit men""un#n endoco&ic5



SURGER FOR CA:CU:OUS BI:IAR

DISEASE

:&%oco&ic c.olec-tectom-

• Kont%indi#i co"ulo&t.-/ e'e%e co&d/ endt"e li'e% diee/ C8F5

•

T.&n – Pien u&ine/ o&e%to% di ebel. #i%i

– Pneumo&e%itoneum dibut den"n " den"n COtu den"n o&en tec.niLue tu cloed+needletec.niLue

– :&%oco&e dn #me% dimu#n 'i umbilicl&o%t die#i m&e te%li.t c-tic duct dn c-tic%te%- te%li.tli"i c-tic %te%- di ditl dn&%o#imldie#i "llbldde%



SURGER FOR CA:CU:OUS BI:IAR

DISEASE

Int%o&e%ti'e c.oln"io"%mUlt%ound

• ?i# &ien memili#i bno%ml li'e% $unction tet/ du#tu-" be%/ dn btu -" #ecil/ dilti CBD/ &%eo&e%ti'eendoco&ic c.oln"io"%&.- belum dil#u#n5

O&en c.olec-tectom-• B"i &ien den"n &oo% &ulmon%-c%dic %ee%'e/

u&ected "llbldde% cnce%/ i%oi.i&e%teni &o%tl/#e.miln t%imete% 35

CBD e7&lo%tion

• Pd &ien den"n btu -" bn-# dn be% tudilti CBD dn te%&i den"n endo#o&i ""l5 ?i#""l/ indi#i untu# o&en u%"e%- llu !i# mi. ""lERCP5

batu kandung empedu dan ikterik obstruktif

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