translate jurnal pancretitis

8/18/2019 Translate Jurnal Pancretitis

1/29

KUMPULAN PANDUAN GASTROENTEROLOGI AMERIKA : PENANGANAN PANKREATITIS

AKUT

Scott Tenner , MD, MPH, FACG 1, John B!""!e , MB, ChB, FRCP, FACG # , J o h n D e $ ! t t , M

D , F A C G % n & S n t h ! S ' r o o ( ) e * e , M D , F A C G +

Pe&on !n! en-.!/n re/oen&0! nt/ (enn*nn (0!en &en*n (n/ret!t!0 /t

2AP34 Se" &e/&e ter/h!r, te"h & (ehn 5r &n (er/e5n*n &" &!*no0!0,

et!o"o*!, &n (enn*nn '" &n /h!r &r! (en-/!t !n!4 Kren &!*no0!0 AP ("!n* 0er!n*

&!te*//n &en*n *e." /"!n!0 &n h0!" te0 "5ortor!, contrast-enhanced computed tomography

2CECT3 &n 6 t magnetic resonance imaging 2MRI3 &r! (n/re0 hr0 &!0e&!/n nt/ (0!en

-n* &!*no0!0n- t!&/ .e"0 t -n* **" &" (er5!/n 0ecr /"!n!04 Stt0 heo&!n!/

hr0 &!n!"! 0e*er 0ete"h &!*no0!0 te"h &!te*//n &n "n*/h7"n*/h re00!t0! "!&!(er"/n4 P0!en &en*n /e**"n or*n &n 6 t 0!n&ro re0(on !n8"0! 0!0te!/ 2SIRS3 hr0

&!r't &! n!t (er'tn !nten0!8 2ICU3 t (en*trn (er'tn (erntr6 5n*0" 5!"

en*/!n/n4 h!&r0! *re0!8 hr0 &!5er!/n /e(& 0e (0!en, /ec"! /oor5!&!t0 .ntn*

&n 6 t *!n." &!/e"r/n4 H!&r0! !ntr9en *re0!8 0ecr &!n! ("!n* 5ern8t &" .n*/

'/t 1#7#+ ., &n n*/!n e!"!/! /entn*n -n* .h 0e&!/!t4 P0!en &en*n AP &n

5er0n &en*n /o"n*!t!0 /t hr0 en."n! endoskopi retrograde cholangiopancreatography

2ERCP3 &" '/t #+ . 0ete"h 0/ rh 0/!t4 Stent &/t0 (n/re0 &n 6 t non0tero!&"

nt!7!n8"tor- 2OAINS3 0(o0!tor! (0c(ro0e&r hr0 &!n8t/n nt/ enrn/n re0!/o

/e(rhn (n/ret!t!0 (0c7ERCP (& (0!en -n* 5er!0!/o t!n**!4 Pen**nn rt!n nt!5!ot!/

(ro8!"/0!0 (& (0!en &en*n AP 5ert &n 6 t ne/ro0!0 0ter!" t!&/ &!n.r/n4 P& (0!en

&en*n ne/ro0!0 ter!n8e/0!, nt!5!ot!/ -n* &!/en" nt/ ene50 6 5er(entr0! /e ne/ro0!0

(n/re0 n*/!n 5er*n &" enn& (e5er!n !nter9en0!, 0eh!n** enrn/n or5!&!t0

&n ort"!t04 D" /00 AP -n* r!n*n, (e5er!n /nn 0ecr or" &(t 0e*er &!"!

.!/ t!&/ & " &n nth4 D" /00 AP -n* 5ert, ntr!0! enter" &!re/oen&0!/n nt/

ence*h /o("!/0! !n8e/0!, 0e&n*/n ntr!0! (renter" hr0 &!h!n&r!4 Pn/re0 tn( *e." &n

6 t &en*n ne/ro0!0 e/0trhe(t!/ &n 6 t (0e&o/!0t t!&/ en.!n &n- !nter9en0! ter"e(0

&r! /rn, "o/0!, &n 6 t e/0ten0!4 P& (0!en 0t5!" &en*n ne/ro0!0 ter!n8e/0!, (e5e&hn,

r&!o"o*!0, &n 6 t &r!n0e en&o0/o(! hr0 &!tn&, 0e5!/n- 0e" + !n**, nt/

en*/!n/n (en*e5n*n &!n&!n* &! 0e/!tr ne/ro0!04


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Pen&h"n

Pn/ret!t!0 /t 2AP3 &"h 0"h 0t (en-/!t -n* ("!n* &r! 0"rn (encernn,

-n* en-e55/n 5e5n eo0!on", 8!0!/, &n 5e5n /en*n -n* "r 5!0 21,#34 D! Aer!/

Ser!/t, (& thn #;, AP &"h &!*no0!0 *0troentero"o*! ("!n* &en*n (en*e"rn 5!- #,< !"!r &o"r 2#34 Pene"!t!n ter5r enn.//n /e.&!n AP 5er9r!0! ntr +,; &n =%,+

/00 (er 14 &! 0e"rh &n! 2%,+34 Pen!n*/tn /e.&!n thnn nt/ AP te"h &!t! &!

0e5*!n 5e0r 0t&! ter5r4 U"0n &t e(!&e!o"o*! &r! thn 1;>> 0(! #% (& National

Hospital Discharge Survey enn.//n 5h' (ener!n rh 0/!t nt/ /00 AP en!n*/t

&r! + (er 14 (& thn 1;;> en.&! = (er 14 (& thn ##4 Me0/!(n t!n*/t

/et!n /00 nt/ AP te"h enrn &r! '/t /e '/t, t!n*/t /et!n 0ecr /e0e"rhn

(o("0! AP tet( t!&/ 5er5h 2134

Te"h ter.&! (er5hn (ent!n* &" &e8!n!0! &n /"0!8!/0! AP 0e./ /"0!8!/0! Atlanta

&r! thn 1;;# 2?34 Se" &e/&e ter/h!r, 5e5er( /eter5t0n te"h &!/! -n* en-e55/n

/e"o(o/ /er. &n re9!0! /on0en00 5er50!0 'e5 2


3/29

Se5h (encr!n &r! MEDLINE e""! OVID interface en**n/n !0t!"h MESH

(n/ret!t!0 /t ter5t0 (& .! /"!n!0, "0n, (e&on, &n et7n"!0!0 nt/ thn 1;


4/29

-n* 0e0! &en*n (en-/!t, 2!!3 0er !"0e &n 6 t "!(0e en!n*/t "e5!h t!* /"!

&r! 5t0 t0 nor", &n 6 t 2!!!3 ten /r/ter!0t!/ &r! abdominal imaging

2re/oen&0! /t, /"!t0 5/t! o&ert34

#4 ontras-enhanced computed tomography 2CBCT3 &n 6 t magnetic resonance imaging

2MRI3 (& (n/re0 hr0 &!0e&!/n nt/ (0!en -n* &!*no0!0n- t!&/ .e"0 t -n*

**" &" (er5!/n 0ecr /"!n!0 &" '/t +>7=# . (ert 0ete"h 0/ rh

0/!t 2 re/oen&0! /t, ren&hn- /"!t0 5/t!34

Et!o"o*!

%4 USG trn05&o!n" hr0 &!"//n (& 0e (0!en &en*n (n/ret!t!0 /t

2re/oen&0! /t, ren&hn- /"!t0 5/t!34

+4 Den*n t!&/ &n- 5t e(e& &n 6 t r!'-t 0!*n!8/n &r! (en**nn "/oho",

0er tr!*"!0er!& hr0 &!(ero"eh &n &!n**( 0e5*! et!o"o*! .!/ 14 * 6 &"

2re/oen&0! 5er0-rt, /"!t0 5/t! o&ert34

?4 P& (0!en -n* "e5!h t &r! + thn, tor (n/re0 hr0 &!(ert!5n*/n 0e5*!

/en*/!nn (en-e55 (n/ret!t!0 /t 2re/oen&0! 5er0-rt, ren&hn- /"!t0 5/t!34


5/29

1?4 Ke5thn c!rn hr0 &!n!"! "n* (& !nter9" -n* 0er!n* &" '/t < . 0t 0/

/erh 0/!t &n nt/ 0e"n.tn- #+ 7 +> .4 T.n &r! h!&r0! *re0!8 hr0

enrn/n n!tro*en re &rh 2re/oen&0! /t, /"!t0 5/t! o&ert34

ERCP (& (n/ret!t!0 /t

14 Den*n t!&/ &n- /o"n*!t!0 &n 6 t .n&!ce, MRCP t USG en&o0/o(!/ 2EUS3 "e5!h

5!/ &r!(& &!*no0t!/ ERCP hr0 &!*n/n nt/ en-r!n* /o"e&o/o"!th!0!0 -n*

0n*t &!cr!*! 2re/oen&0! 5er0-rt, ren&hn- /"!t0 5/t!34

1;4 Stent &/t0 (n/re0 &n 6 t re/t" 0(o0!tor! non0tero!&" nt!7!n8"tor- 2OAINS3

(0c (ro0e&r hr0 &!n8t/n nt/ ence*h (n/ret!t!0 -n* 5ert (0c7ERCP

(& (0!en -n* 5er!0!/o t!n**! 2re/oen&0! 5er0-rt, /"!t0 5/t! o&ert34

Pern nt!5!ot!/ (& (n/ret!t!0 /t

#4 Ant!5!ot!/ hr0 &!5er!/n nt/ !n8e/0! e/0tr(n/re0, 0e(ert! /o"n*!t!0, !n8e/0! /teter

-n* &!&(t, 5/tere!, !n8e/0! 0"rn /e!h, (neon! 2re/oen&0! /t, /"!t0 6

5/t! -n* t!n**!34

#14 Pen**nn rt!n nt!5!ot!/ (ro8!"/0!0 (& (0!en &en*n (n/ret!t!0 /t 5ert t!&/

&!n.r/n 2re/oen&0! /t, /"!t0 5/t! o&ert3

##4 Pen**nn nt!5!ot!/ (& (0!en &en*n ne/ro0!0 0ter!" nt/ ence*h (er/e5n*n

ne/ro0!0 ter!n8e/0! t!&/ &!n.r/n 2re/oen&0! /t, /"!t0 5/t! o&ert34

#%4 Ne/ro0!0 ter!n8e/0! hr0 &!(ert!5n*/n (& (0!en &en*n ne/ro0!0 (n/re0 t

e/0tr(n/ret!/ -n* e5r/ t **" &" (er5!/n 0ete"h = 7 1 hr! r't !n(4

P& (0!en !n!, 2!3 0(!r0! .r h"0 &!(n& CT 0cn '" 2FNA3 nt/ (e'rnn &n

/"tr nt/ en& (en**nn nt!5!ot!/ -n* te(t t 2!!3 (en**nn e(!r!/

nt!5!ot!/ tn( CT FNA hr0 &!5er!/n 2re/oen&0! /t, /"!t0 ren&h 5/t!34

#+4 P& (0!en &en*n ne/ro0!0 ter!n8e/0!, nt!5!ot!/ -n* &!/en" nt/ ene506(enetr0!

ne/ro0!0 (n/re0, 0e(ert! cr5(ene0, /!no"on, &n etron!&o", n*/!n 5er*n &"

enn& t /&n*7/&n* &(t en*h!n&r! (e5er!n !nter9en0!, 0eh!n** enrn/n

or5!&!t0 &n ort"!t0 2re/oen&0! 5er0-rt, ren&hn- /"!t0 5/t!34

#?4 Pe5er!n rt!n *en nt!.r 5er0 &en*n nt!5!ot!/ (ro8!"/0!0 t ter(! t!&/

&!n.r/n 2re/oen&0! 5er0-rt, ren&hn- /"!t0 5/t!34

Ntr!0! (& (n/ret!t!0 /t

#4 D" AP 5ert, ntr!0! enter" &!re/oen&0!/n nt/ ence*h /o("!/0! !n8e/0!4 ntr!0!


6/29

(renter" hr0 &!h!n&r! /ec"! ."r enter" t!&/ ter0e&!, t!&/ &!to"ern0!, t t!&/

eenh! (er0-rtn /"or! 2re/oen&0! /t, /"!t0 5/t! -n* t!n**!34

#;4 M0/n- /nn e""! n0o*0tr!/ &n n0o.e.n" &r! /nn enter" nc"

0e5n&!n* &" n8t &n /e0e"tn 2re/oen&0! /t, /"!t0 5/t! o&ert3

Pern (e5e&hn (& (n/ret!t!0 /t%4 P& (0!en &en*n AP r!n*n, -n* &!te/n e!"!/! 5t e(e& (& /n&n*

e(e&, /o"e0!0te/to! hr0 &!"//n 0e5e" &!0chr*e2&!"e(0/n3 nt/ ence*h

/e/5hn AP 2re/oen&0! /t, /"!t0 5/t! o&ert34

%14 P& (0!en &en*n AP e(e& -n* ne/ro0!0 , nt/ ence*h !n8e/0!, /o"e0!0te/to!

&!tn& 0(! !n8"0! -n* /t!8 ere& &n (en(/n c!rn &!t0! t &!0t5!"/n

2re/oen&0! /t, /"!t0 5/t! o&ert3

%#4 A&n- (0e&o/!0t tn( *e." &n (n/re0 &n 6 t ne/ro0!0 e/0trhe(t!/ t!&/

en.!n &n- !nter9en0!, ter"e(0 &r! /rn, "o/0!, &n 6 t e/0ten0! 2re/oen&0!

/t, /"!t0 5/t! o&ert34%%4 P& (0!en 0t5!" &en*n ne/ro0!0 ter!n8e/0!, (e5e&hn, r&!o"o*!, &n 6 t &r!n0e

en&o0/o(! hr0 &!tn& 0e" "e5!h &r! + !n** nt/ en*/!n/n (enc!rn &n

ter.&!n- &!n&!n* 5er0ert &! 0e/!tr ne/ro0!0 2'""7o88 ne/ro0!03 2re/oen&0! /t ,

ren&hn- /"!t0 5/t!34

%+4 P& (0!en &en*n *e." ne/ro0!0 ter!n8e/0!, eto&e !n!" !n90!8 necro0ecto- "e5!h

5!/ nt/ necro0ecto- ter5/ 2re/oen&0! /t, ren&hn- /"!t0 5/t!3

D!*no0!0

14 D!*no0!0 AP ("!n* 0er!n* &!te*//n &en*n &n- # &r! % /r!ter! 5er!/t: 2!3 n-er!

(ert 0e0! &en*n (en-/!t, 2!!3 0er !"0e &n 6 t "!(0e "e5!h t!n**! &r! t!* /"!

5t0 t0 nor", &n 6 t 2!!!3 ten /r/ter!0t!/ &r! 5&o!n" !*!n* 2re/oen&0!

/t, /"!t0 5/t! o&ert34

#4 Contr07 enhnce& co(te& too*r(h- 2CBCT3 &n 6 t *net!c re0onnce !*!n*

2MRI3 (& (n/re0 hr0 &!0e&!/n nt/ (0!en -n* &!*no0!0n- t!&/ .e"0 t -n*

**" &" (er5!/n 0ecr /"!n!0 &" '/t +>7=# . (ert 0ete"h 0/ rh

0/!t t nt/ en*e9"0! /o("!/0! 2re/oen&0! /t, ren&hn- /"!t0 5/t!34

DIAGNOSIS: GAMBARAN KLINIS

P0!en &en*n AP -n* /h0 5!0n- &tn* &en*n n-er! e(!*0tr! t /&rn /!r! t04

R0 n-er! 5!0n- &!*5r/n 0e5*! n-er! -n* /on0tn &en*n (en."rn /e (n**n*, &&,

t (n**", t(! &e0/r!(0! !n! non 0(e0!8!/4 !nten0!t0 r0 n-er! 5!0n- (rh, t(! 5!0 5er9r!0!4

!nten0!t0 &n "o/0! &r! r0 n-er! t!&/ 5er/ore"0! &en*n t!n*/t /e(rhn4 N-er! &!*5r/n 5er0!8t t(", /o"!/, t ter"et/ &! &erh (ert 5*!n 5'h -n* t!&/ /on0!0ten &en*n AP


7/29

&n enn.//n et!o"o*! "tern!t84 A5&o!n" !*!n* &(t e5nt nt/ enent/n

&!*no0!0 AP (& (0!en &en*n *5rn /"!n!0 -n* t!&/ /h04

DIAGNOSIS : PARAMETER LABORATORIUM

Kren /eter5t0n &" 0en0!t!9!t0, 0(e0!8!0!t0, &n n!"! (re&!/0! (o0!t!8 &n ne*t!8, 0er

!"0e 0. t!&/ &(t &!*n/n nt/ en&!*no0!0 AP &n 0er "!(0e "e5!h &!(!"!h4 Ser

!"0e (& (0!en AP n- n!/ &" 5e5er( . 0ete"h t!5"n- *e." &n /e5"! /e

n!"! nor" &" '/t % 7 ? hr!@ Nn, h" !t n*/!n tet( &" /!0rn nor" (& 0t

0/ /erh 0/!t 0e5n-/ 0e(er"! &r! (0!en 21#,1%34 D!5n&!n*/n &en*n 0er "!(0e,

0er !"0e /e5"! "e5!h ce(t /e n!"! 5'h &r! 5t0 t0 nor"4 Kon0entr0! 0er !"0e

n*/!n nor" (& AP 2(n/ret!t!0 /t3 /!5t "/oho" &n h!(ertr!*"!0er!&e!4 Kon0entr0!

0er !"0e n*/!n t!n**! &en*n t!&/ &n- AP (& cro-"0e! 20!n&ro -n*

&!tn&! o"eh (e5ent/n /o("e/0 o"e/" 5e0r ntr !"0e &n !no*"o5"!n 5nor"3,

(& (0!en &en*n (enrnn ". 8!"tr0! *"oer"0, (en-/!t /e"en.r "!r, &n (& (en-/!t

e/0tr(n/ret!/ -n* 5erh5n*n &en*n (er&n*n, ter0/ 00 5nt /t, /o"e0!0t!t!0,

o50tr/0! 00 t !0/e!, "/0 (e(t!/, &n (en-/!t *!ne/o"o*!4

Ser "!(0e t(/n- "e5!h 0(e0!8!/ &n tet( t!n**! "e5!h " &r! !"0e 0ete"h nc"n-

(en-/!t4 Me0/!(n re/oen&0! &r! (ene"!t! 0e5e"n- 21+3 &n (e&on (enn*nn AP 21?3

-n* ene/n/n /entn*n &r! 0er "!(0e, 0"h -n* 0 &en*n n!"! (re&!/0! tet( (&

(o("0! (0!en tertent, ter0/ /e5er&n cro"!(0e!4 L!(0e .* &!te/n en!n*/t

(& 5er5*! (en-/!t non7(n/re0 , 0e(ert! (en-/!t *!n.", 00 5nt, /o"e0!0t!t!0, &n

0e5*!n-4 Se"!n !t, 5t0 t0 nor" "e5!h 5e0r &r! % 7 ? /"! n*/!n &!(er"/n (& (en&er!t

&!5ete0 -n* nc" nt/ e!"!/! "!(0e e&!n -n* "e5!h t!n**! &!5n&!n*/n &en*n (0!en

non7&!5ete0 nt/ "0n -n* t!&/ .e"0 2134 Te0 &r! 5n-/ en! (n/re0 "!nn- te"h &!n!"! 0e" 1? thn

ter/h!r, tet(! t(/n- t!&/ & n!"! &!*no0t!/ -n* "e5!h 5!/ 0e"!n 0er !"0e &n "!(0e

21;34 Me0/!(n /e5n-/n 0t&! enn.//n e8!/0! &!*no0t!/ "e5!h 5e0r &r! % 7 ? /"! 5t0 t0

nor", &o/ter hr0 e(ert!5n*/n /on&!0! /"!n!0 (0!en /et!/ en*e9"0! /et!n**!n

!"0e &n "!(0e4 Ket!/ /er*n en*en! &!*no0!0 AP ter.&!, 5&o!n" !*!n*, 0e(ert!

CECT, &!n.r/n4

DIAGNOSIS : ABDOMINAL IMAGING

A5&o!n" !*!n* 5er*n nt/ en*/on8!r0! &!*no0!0 &r! AP4 CECT e5er!/n

0en0!t!9!t0 "e5!h &r! ; &n 0(e0!8!0!t0 nt/ &!*no0!0 AP 2#34 Pen**nn rt!n &r! CECT

(& (0!en &en*n AP &"h t!&/ 5er"0n nt/ &!"//n, /ren &!*no0!0-n* .e"0 (&


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5n-/ (0!en &n 0e5*!n 5e0r e!"!/! /00 -n* r!n*n, tent 0. t!&/ r!t4 Nn, (&

(0!en -n* **" &" (er5!/n 0ete"h +>7=# 2!0"n-, n-er! (er0!0ten, &e, ", t!&/

&(t /n 0ecr or"3, CECT t MRI !*!n* &!n.r/n nt/ en!"! /o("!/0! "o/" 0e(ert!

ne/ro0!0 (n/re0 2#1 7 #%34 Co(te& too*r(h- 2CT3 &n MRI 0e5n&!n* &" (en!"!n '"

AP 2#+34 MRI, &en*n en**n/n *net!c re0onnce cho"n*!o(ncreto*r(h- 2MRCP3,

e!"!/! /entn*n en&ete/0! /o"e&o/o"!th!0!0 &en*n &!eter % &n *n**n 0"rn

(n/re0 05!" e5er!/n (enc!trn 5er/"!t0 t!n**! nt/ t.n &!*no0t!/ &n 6 t t!n*/t

/e(rhn4 MRI 0n*t e5nt (& (0!en -n* "er*! /ontr0 &n !n08!0!en0! *!n." &!n

*5rn !"-weighted tn( /ontr0 *&o"!n! &(t en&!*no0 ne/ro0!0 (n/re0 2#+34

ETIOLOGI

Re/oen&0!

14 USG trn05&o!n" hr0 &!"//n (& 0e (0!en &en*n AP 2re/oen&0! /t,

ren&hn- /"!t0 5/t!34

#4 Den*n t!&/ &n- 5t e(e& &n 6 t r!'-t 0e.rh -n* 0!*n!8!/n &r! (en**nn

"/oho", 0er tr!*"!0er!& hr0 &!(ero"eh &n &!n**( et!o"o*! .!/ 1 * 6 &"4

2Re/oen&0! 5er0-rt, /"!t0 5/t! o&ert34

%4 P& (0!en 0! + thn, tor (n/re0 hr0 &!(ert!5n*/n 0e5*! /en*/!nn

(en-e55 AP 2re/oen&0! 5er0-rt, ren&hn- /"!t0 5/t!3

+4 In9e0t!*0! en&o0/o(! (& 0e5h et!o"o*! -n* 0"!t &!(h! (& (0!en &en*n AP

hr0 &!5t0!, /ren re0!/o &n n8t &r! !n9e0t!*0! (& (0!en !n! t!&/ .e"0

2Re/oen&0! 5er0-rt, ren&hn- /"!t0 5/t!34

?4 P0!en &en*n AP -n* !&!o(t!/ 2IAP3 hr0 &!r./ /e (0t -n* "e5!h h"! 2re/oen&0!

5er0-rt, ren&hn- /"!t0 5/t!34

7 %34 I&ent!8!/0! 5t e(e& 0e5*! et!o"o*! hr0

0e*er &!"//n t!n&/n /o"e0!0te/to! nt/ ence*h 0ern*n 5er"n* &n (oten0! 0e(0!0 5!"!er

2#;,%34 Bt e(e& (n/ret!t!0 5!0n- /e.&!nn- /t &n en*h!"n* /et!/ 5t !t

&!n*/t t &!h!"n*/n 0ecr 0(ontn4


9/29

Pn/ret!t!0 -n* &!0e55/n /ren "/oho" 0er!n* 5ern!8e0t0! 0e5*! 0e5h 0(e/tr,

"! &r! e(!0o&e AP -n* 5er5e&75e& /e (er5hn !re9er0!5e" -n* /ron!04 D!*no0!0 t!&/

0ehr0n- &!""!/n /ec"! 0e0eorn* e!"!/! 0e.rh "e5!h &r! ? thn &" en*/on00!

"/oho" 5ert 2%134 Kon00! "/oho" -n* Bert n- ? * (er hr!, tet(! 0er!n* .h "e5!h

t!n**! &r! !t2%#34 Ter5/t! 0ecr /"!n!0 AP ter.&! (& ? &r! (e!n 5ert 2%%3@ &en*n

&e!/!n, & /en*/!nn 8/tor "!n !n&!9!& -n* 0en0!t!8 terh&( e8e/ "/oho", 0e(ert! 8/tor

*enet!/ &n (en**nn te5/ 2#=,%%,%+34

Etiologi Lain

Den*n t!&/ &n- "/oho" t 5t e(e&, (er!n*tn hr0 &!"//n /et!/

en*h5n*/n et!o"o*! -n* n*/!n 5*! AP nt/ *en t /on&!0! "!n4 O5t, *en !n8e/0!, &n

(en-e55 et5o"!/ 0e(ert! h!(er/"0e! &n h!(er(rt!ro!&!0e &"h (en-e55 -n* .rn*,

0er!n* 0"h &!!&ent!8!/0! 0e5*! (en-e55 AP 2%? 7 %=34 Me0/!(n 5e5er( o5t7o5tn 0e(ert!


10/29

(en-/!t (n/re0, -n* en-e&!/n "-nn en&o0/o(! cn**!h &n (en&e/tn *5n*n

"t!&!0!("!n4

Ano"! nto! &n 8!0!o"o*!0 (n/re0 ter.&! (& 1 7 1? &r! (o("0!, ter0/ (n/re0

&!9!0 &n &!08n*0! &r! 08!n*ter O&&! 2+>34 In! 0!h /ontro9er0!" .!/ *n**n !n! 0. -n*en.&! (en-e55 AP 2+;34 Mn*/!n & /o5!n0! 8/tor, ter0/ nto! &n *enet!/, -n*

e(en*rh! ter.&!n- AP (& !n&!9!& -n* rentn 2+>34 Ter(! en&o0/o(!, 5er8o/0 (&

(en*o5tn (n/re0 &!9!0 &n 6 t &!08n*0! 08!n*ter O&&!, e5' r!0!/o 0!*n!8!/n -n*

encet0/n ter.&!n- AP &n hr0 &!"//n hn- (& n!t /h00 2?,?134 Pen*rh &n-

&e8e/ *enet!/, 0e(ert! t0! /t!on!/ tr!(0!no*en, S(!n/, t t0! CFTR, &" en-e55/n

ter.&!n- AP 0e/!n &!/!4 De8e/ !n!, "e5!h .h "*!, n*/!n .* en!n*/t/n re0!/o

ter.!&n- AP (& (0!en &en*n no"! nto!, 0e(ert! (n/re0 &!9!0 2+>34 Nn, (ern

(en*.!n *enet!/ (& AP 5e" &!tent/n, tet(! n*/!n 5er*n (& (0!en &en*n "e5!h &r!

0t n**ot /e"r* &en*n (en-/!t (n/re0 2%+34 In&!9!& &en*n IAP &n r!'-t /e"r*

(en-/!t (n/re0 hr0 &!r./ nt/ /on0e"!n* *enet!/ -n* 8or"4

PENILAIAN AWAL DAN ESIKO STATI!IKASI

Re/oen&0!

14 Stt0 heo&!n!/ hr0 &!n!"! 0e*er 0ete"h &!*no0!0 &!te*//n &n e"! "n*/h7

"n*/h re00!t0! &!(er"/n 2re/oen&0! /t, /"!t0 5/t! o&ert34

#4 Pen!"!n re0!/o hr0 &!"//n nt/ 0trt!8!/0! (0!en /e &" /te*or! -n* 5ere0!/o

t!n**! &n 5er!0!/o ren&h nt/ e5nt tr!0e, 0e(ert! (er"n- 0/ /e (en*trn

(er'tn !nten0!8 2re/oen&0! 5er0-rt, /"!t0 5/t! ren&h 0(! o&ert34

%4 P0!en &en*n **" or*n hr0 &!r't &! n!t (er'tn !nten0!8 t (en*trn

(er'tn enen*h65n*0" 5!" en*/!n/n 2re/oen&0! /t, ren&hn- /"!t0

5/t!34

ANGKUMAN BUKTI

Defini"i AP #$an%reatiti" a%&t' (erat

Se5*!n 5e0r e(!0o&e AP 5er0!8t r!n*n &n 0e5h 0en&!r!, hn- e5th/n r't !n(

&en*n .n*/ '/t -n* 0!n*/t4 AP -n* r!n*n &!&e8!n!0!/n 0e5*! t!&/ &n- /e**"n

or*n &n 6 t ne/ro0!0 (n/re0 2?,


11/29

&n 80e /h!r4 Ko("!/0! "o/" ter0/ (en(/n c!rn (er!(n/ret!/ &n (n/re0 &n

ne/ro0!0 (er!(n/ret!/ 20ter!" t ter!n8e/0!34 Ke5n-/n (0!en &en*n (en-/!t 5ert 5er&

&!rn* *'t &rrt tn( /e**"n or*n t ne/ro0!0 (n/re0@ S-n*n-, !n! te"h

en-e55/n 5n-/ /e0"hn &" (enn*nn /"!n!0 (en-/!t !n! 2?#34 Ke0"hn !n! ter0/

/e**"n nt/ e5er!/n h!&r0! -n* e&!, /e**"n nt/ en&!*no0 &n en*o5t!

/o"n*!t!0, &n /e**"n nt/ en*o5t! /e**"n or*n 0ecr &!n!4 Unt/ "0n !n!, 0n*t

(ent!n* 5*! &o/ter nt/ en*en"! (ent!n*n- e5er! "5e" (0!en -n* 5enr &en*n (en-/!t

r!n*n &" +> . (ert 0t 0/ /erh 0/!t nt/ (en-/!t AP4

AP 2(n/ret!tt!0 /t3 5ert ter.&! (& 1? 7 # &r! (0!en 2?%34 AP -n* 5ert &!&e8!n!0!/n

&en*n &n- 2**" nt/ en-e"e0!/n &" '/t +> .3 /e**"n or*n -n* (er0!0ten

&n 6 t /et!n 2 .

P#


12/29

At"nt en&e8!n!0!/n /e**"n or*n 0e(ert! 0/or &r! # t "e5!h nt/ 0"h 0t 0!0te or*n

!n! en**n/n 0!0te 0cor!n* o&!8!/0! Mr0h""234 Pen"!0 er0 5h' &r!(&

en*h!tn* 0/or Mr0h" !n! 2-n* n*/!n /o("e/0 nt/ (r &o/ter -n* 0!5/3, /!t

5er*ntn* 0. (& &e8!n!0! At"nt -n* " -n* 0e(ert!n- /n 5er*n4 Pene"!t!n "e5!h "n.t

&!(er"/n nt/ e9"!&0! /e5thn nt/ en**n/n 0/or Mr0h"4

Ne/ro0!0 (n/re0 &!&e8!n!0!/n 0e5*! &erh -n* &!80 t 8o/" &r! (ren/! (n/re0

-n* r0/ % c t % &r! (n/re0 2?%34 Ne/ro0!0 (n/re0 5!0 0ter!" t ter!n8e/0!

2&!5h0 &! 5'h34 Den*n t!&/ &n- ne/ro0!0 (n/re0, (en-/!t r!n*n &r! e&e (n/re0

&!&e8!n!0!/n 0e5*! (n/ret!t!0 !nter0t!t!"4 Me0/!(n & 5e5er( /ore"0! ntr !n8e/0!, ne/ro0!0

(n/re0, "n- (er'tn &! rh 0/!t, &n /e**"n or*n, 5!/ (0!en &en*n ne/ro0!0

0ter!" &n ne/ro0!0 ter!n8e/0! &(t en*"! /e**"n or*n 2??,?


13/29

(rote!n 2CRP3, !n8"0! -n* ("!n* 5n-/ &!(e".r! 0e5*! (enn& AP, t!&/ (r/t!0 /ren

e5th/n =# . nt/ en.&! /rt 2?+34 Penc!trn &en*n CT &n 6 t MRI .* t!&/

&(t &!(erc- enent/n /e(rhn '" &n &(t ter.&! 0ete"h #+ 7 +> . 2#+,


14/29

2==,=>34 Me0/!(n &n- SIRS 0e" #+ . '" e!"!/! 0en0!t!9!t0 t!n**! nt/ e(re&!/0!

/e**"n or*n &n /et!n, &n- SIRS /rn* e!"!/! 0(e0!8!0!t0 nt/ (en-/!t -n* 5ert

2+134 Krn*n- 0(e0!8!0!t0 &"h /ren 8/t 5h' &n- SIRS t!&/ 0e(ent!n*

(er0!0ten0!n-4 Unt/ "0n !n!, (0!en &en*n SIRS -n* (er0!0ten, tert ere/ -n* t/!(ne

&n 6 t t/!/r&!, hr0 &!r't &! n!t (er'tn !nten0!8 t n!t 0er( nt/ h!&r0! !ntr9en

-n* *re0!8 &n (en&e/tn nt/ (entn4

PENANGANAN AWAL

Re/oen&0!

14 H!&r0! *re0!8, &!&e8!n!0!/n 0e5*! (e5er!n c!rn 0e5n-/ #?7? " (er . &en*n

"rtn /r!0t"o!& !0oton!/ hr0 &!0e&!/n nt/ 0e (0!en, /ec"! /r&!o90/"r,

*!n.", t 8/tor /oor5!&!t0 ter/!t "!nn- &4 h!&r0! !ntr9en *re0!8 '" ("!n*

en*ntn*/n 0e" (e5er!n 1#7#+ . (ert, &n n*/!n e!"!/! 0e&!/!t

/entn*n -n* "e5!h2re/oen&0! /t, /"!t0 5/t! o&ert34

#4 P& (0!en &en*n (enrnn 5ert 9o"e, -n* 5ern!8e0t0! 0e5*! h!(oten0! &n

t/!/r&!, (e5er!n c!rn -n* ce(t 25o"03 n*/!n &!(er"/n 2re/oen&0! 5er0-rt,

/"!t0 5/t! o&ert34

%4 Lrtn R!n*er "/tt "e5!h &!(!"!h 0e5*! c!rn (en**nt! &r! /r!0t"o!& !0oton!0

2re/oen&0! 5er0-rt, /"!t0 5/t! o&ert34

+4 Ke5thn c!rn hr0 &!n!"! "n* (& !nter9" -n* 0er!n* &" '/t < . 0t

0/n- /e rh 0/!t &n nt/ 0e"n.tn- #+ 7 +> .4 T.n h!&r0! *re0!8

0e5!/n- nt/ enrn/n BUN 2re/oen&0! /t, /"!t0 5/t! o&ert34

HIDASI INTAVENA AGESI! AWAL

Me0/!(n ("hn (erco5n c/, t!&/ & o5t -n* te"h ter5/t! e8e/t!8 &" en*o5t! AP

2%#,?%34 Nn, !nter9en0! -n* e8e/t!8 te"h &!.e"0/n &en*n 5!/: h!&r0! !ntr9en *re0!8 '"4

Re/oen&0! en*en! h!&r0! *re0!8 &!&0r/n (& (en&(t h"! 21,?#,?%3, (erco5n

"5ortor! 2=;,>3, 5/t! /"!n!0 -n* t!&/ "n*0n* 2#3, 0t&! e(!&e!o"o*! 2?;3, &n .!

/"!n!0 5!/ retro0(e/t!8 &n (ro0(e/t!8 2;,>%34

A"0n nt/ h!&r0! *re0!8 0ecr &!n! (& AP nc" &r! (en*tn &n- h!(o9o"e!

-n* 0er!n* -n* ter.&! &r! 5e5er( 8/tor -n* e(en*rh! (0!en &en*n AP, ter0/

nth, (en*rn*n 0(n or", .r/ /et!* c!rn, (en!n*/tn /eh!"n*n (ern(0n, &n

&!(hore0!04 Se"!n !t, (ene"!t! 5erh!(ote0!0 5h' /o5!n0! e8e/ !/ron*!o(t! &n e&e (&

(n/re0 -n* er&n* enrn/n "!rn &rh , -n* en-e55/n (en!n*/tn /et!n 0e",

ne/ro0!0, &n (e"e(0n 5er/e"n.tn &r! (en*/t!8n en! (n/re04 In8"0! .* en!n*/t/n (ere5!"!t0 (e5"h &rh, -n* en-e55/n (en!n*/tn rn* /et!* /eh!"n*n c!rn &n


15/29

e5r/n- h!(o(er80! (n/re0 -n* en-e55/n (en!n*/tn ne/ro0!0 (ren/! (n/re0 &n

/et!n 0e" 2>+34 Re00!t0! c!rn !ntr9en *re0!8 '" e5er!/n &/n*n 0!r/"0! !/ro

&n /ro nt/ ence*h /o("!/0! 0er!0 0e(ert! ne/ro0!0 (n/re0 213

Me0/!(n & &t (ro0(e/t!8 ter5t0 5h' h!&r0! !ntr9en *re0!8 &(t &!(nt &n 6 t

&!(n& o"eh (enn& "5ortor!, (en**nn heto/r!t 2=,>>34 Ten (ene"!t!n 9r!5e" !n! &(t 0e5*!n

&!.e"0/n o"eh (er5e&n (ent!n* &" &e0!n (ene"!t!n4 Me0/!(n 0t&! !n! en!n*/t/n

/e/h't!rn tentn* (en**nn ter0 ener0 h!&r0! *re0!8 "e5!h &r! +> ., (ern h!&r0! '"

2&" ;,;34 D" AP, & n8tteor!t!0 t5hn nt/ en**n/n "rtn R!n*er "/tt nt/ en-e!5n*/n PH nt/

re00!t0! c!rn &!5n&!n*/n &en*n nor" 0"!ne4 (H ren&h en*/t!8/n tr!(0!no*en, e5t

"el7"el acinar "e5!h rentn terh&( ce&er &n en!n*/t/n /e(rhn AP &" 0t&!

e/0(er!ent"4 Me0/!(n /e&n- 5!/ "rtn /r!0t"o!& !0oton!/, nor" 0"!ne &!5er!/n &"

9o"e 5e0r &(t en-e55/n ter.&!n- *( non7n!on, 0!&o0!0 et5o"!/ h!(er/"ore!/ 2>%3

H" !n! (ent!n* nt/ en*en"! 5h' h!&r0! *re0!8 '" hr0 &!5er!/n 0ecr ht!7ht!

nt/ /e"o(o/ (0!en tertent, 0e(ert! orn* t, t orn*7orn* &en*n r!'-t .ntn* &n 6 t

(en-/!t *!n." nt/ en*h!n&r! /o("!/0! 0e(ert! 9o"e -n* o9er"o&, e&e (r, &n

0!n&ro /o(rteen 5&oen 2;134 Pen*/rn te/nn 9en 0entr" e""! /teter &!te(t/n


16/29

ter(0t !n! ("!n* 0er!n* &!*n/n nt/ enent/n 0tt0 9o"e &" (en*trn !n!4 Nn,

&t enn.//n 5h' !n&e/0 9o"e &rh !ntrthor/0 n*/!n e!"!/! /ore"0! -n* "e5!h

5!/ &en*n !n&e/0 .ntn* &r! te/nn 9en 0entr"4 Pen*/rn !n&e/0 9o"e &rh !ntrthor/0

en*/!n/n (en!"!n -n* "e5!h /rt &r! 0tt0 9o"e (0!en nt/ (en*o5tn (0!en &! n!t

(er'tn !nten0!84 P0!en t!&/ 5ere0(on terh&( h!&r0! !ntr9en '" 2&" < 7 1# .3 t!&/

e!"!/! n8t &r! h!&r0! *re0!8 -n* 5er/e"n.tn4

E8P PADA AP

Pern ERCP (& AP ter/!t &en*n (enn*nn /o"e&o/o"!th!0!04 Me0/!(n ERCP &(t

&!*n/n nt/ en*!&ent!8!/0! *n**n &/t0 (n/re0 (& (0!en &en*n AP -n* 5ert,

/en*/!nn en-e55/n !nter9en0! -n* &!0e5t 0!n&ro &!0"o/0! 0"rn, /on0en00 t!&/

(ernh nc" 5h' ERCP hr0 &!"//n 0ecr rt!n nt/ t.n !n! 2?#3

Re/oen&0!

14 P0!en &en*n AP &n 5er0n &en*n /o"n*!t!0 /t hr0 en."n! ERCP &"

'/t #+ . &r! 0/n- /e rh 0/!t 2re/oen&0! /t, /"!t0 o&ert 5/t!34

#4 ERCP t!&/ &!(er"/n (& '/t '" (& /e5n-/n (0!en &en*n (n/ret!t!0 5t

e(e& -n* /e/rn*n 5/t! "5ortor! t 5/t! /"!n!0 &r! o50tr/0! 5!"!er -n* ter0

ener0 2re/oen&0! /t, /"!t0 5/t! o&ert34

%4 Den*n t!&/ &n- /o"n*!t!0 &n 6 t .n&!ce, MRCP t EUS "e5!h 5!/ &!*n/n

&r!(& &!*no0t!/ ERCP hr0 &!*n/n nt/ en0/r!n!n* /o"e&o/o"!th!0!0 -n*

0n*t &!cr!*! 2re/oen&0! 5er0-rt, /"!t0 5/t! o&ert34

+4 0tent &/t0 (n/re0 &n 6 t (0c (ro0e&r o5t nt!!n8"0! non 0tero!& 2NSAID3

0(o0!tor! hr0 &!n8t/n nt/ enrn/n re0!/o -n* 5ert (0c7ERCP

(n/ret!t!0 (& (0!en 5er!0!/o t!n**! 2re/oen&0! 5er0-rt, /"!t0 5/t! o&ert34

PEAN E8P PADA AP

Untn*n-, 0e5*!n 5e0r 5t e(e& -n* en-e55/n AP &h "o"o0 /e &o&en &n

h!"n* &" 8e0e0 2;#34 Nn (& 0e5*!n /ec!" (0!en, cho"e&ocho"!th!0!0 (er0!0ten &(ten-e55/n o50tr/0! 0"rn (n/re0 &n 6 t o50tr/0! 5!"!er ter0 ener0, en-e55/n AP

-n* 5ert &n 6 t /o"n*!t!04 Pen*n*/tn 5t e(e& -n* en*o50tr/0! &r! 0"rn 5!"!er

(& (0!en &en*n AP hr0 en*rn*! re0!/o ter.&!n- /o("!/0! !n!4

S&h & 5e5er( .! /"!n!0 &!"//n nt/ en.'5 (ertn-n: (/h ERCP '" 2&"

#+ 7 =# . 0ete"h on0et /e.&!n3 (& (n/ret!t!0 5!"!er /t en*rn*! r!0!/o ter.&!n- AP -n*

5ert 2/e**"n or*n &n 6 t ne/ro0!03 Neo(to"eo0 et "4 2;%3 e(e".r! 1#1 (0!en &en*n

/en*/!nn (n/ret!t!0 5!"!er /t, &!/e"o(o//n 0e0! t!n*/t /e(rhn &en*n /r!ter!

G"0*o' -n* &!o&!8!/0!4 Perco5n !t &!"//n &! (0t tn**" &! In**r!04 P0!en &en*n

(re&!/0! &n- AP -n* 5ert e!"!/! /o("!/0! -n* "e5!h 0e&!/!t .!/ ere/ en."n! ERCP


17/29

&" '/t =# . &r! '" 0/n- /e rh 0/!t 2#+ 90


18/29

&en*n en!n*/tn- (0!en -n* 5er!0!/o t!n**! &n (ro0e&r r!0!/o t!n**! &! n ERCP hr0

&!h!n&r! &n (ener(n !nter9en0! -n* te(t nt/ ence*h AP &n AP -n* 5ert 2?34

P0!en &en*n 0"rn e(e& &n ht! -n* nor" t en&e/t! nor" e!"!/!

/en*/!nn "e5!h ren&h &r! 0"rn 5t e(e& &n 6 t (to"o*! "!n 20tr!/tr, tor34 P&

(0!en !n!, &!*no0t! ERCP 0e5*!n 5e0r te"h &!*nt!/n o"eh EUS t MRCP 0e5*!

re0!/o (n/ret!t!0 (0c7ERCP "e5!h 5e0r (& (0!en &en*n -n* nor" 0"rn e(e&n- &n

5!"!r5!n nor" o&&0 r0!o %,+ (n/ret!t!0 (0c7ERCP3 &!5n&!n*/n &en*n (0!en -n* .n&!ce

&en*n r0!o &!"t0! &/t0 e(e& 2o&&0 ,# nt/ (n/ret!t!0 (0c ERCP3 2;;34 Se"n.tn-,

MRCP &n EUS 0e/rt &!*no0t!/ ERCP &n t!&/ en!5"/n re0!/o (n/ret!t!0 2;>34

Unt/ (0!en -n* en."n! ter(et!/ ERCP, t!* !nter9en0! &!(e".r! &en*n 5!/ nt/

en*rn*! re0!/o (n/ret!t!0 (0c7ERCP, tert (en-/!t -n* 5ert ter0/: 2!3 *!&e'!re

20e"n*3 /n"0!, 2!!3 0tent &/t0 (n/re0, &n 2!!!3 NSAID (er re/t"4 G!&e're 20e"n*3

/n"0! 2/n"0! &r! 0"rn e(e& &n 0"rn (n/re0 o"eh *!&e're 20e"n*3 &!0//n

e""! /teter3 en*rn*! re0!/o (n/ret!t!0 213 &en*n en*h!n&r! ce&er h!&ro0tt!/ (&

(n/re0 -n* n*/!n ter.&! &en*n (en**nn *en r&!o/ontr04 D" 0e5h (ene"!t!n

&r! + (0!en 5ertrt7trt 0ecr c/ nt/ /n"0! /ontr0 &n *!&e're 20e"n*3, t!&/ &

/00 AP (& /e"o(o/ *!&e're 20e"n*3 &!5n&!n*/n &en*n > /00 (& /e"o(o/ /ontr0 2P

,134 Se5h (ene"!t!n (ro0(e/t!8 c/ -n* "e5!h 5r (& % (0!en /n"0!

*!&e're20e"n*3 &!5n&!n*/n &en*n !n.e/0! /ontr0 /on9en0!on" .* ene/n (enrnn

(n/ret!t!0 (0c7ERCP (& /e"o(o/ *!&e're20e"n*3 21134 Nn, (enrnn (n/ret!t!0

(0c7ERCP n*/!n t!&/ 0e"rhn- ter/!t &en*n /n"0! 21#3 &n n*/!n te"h 5erh5n*n

&en*n /rn*n- /e(er"n nt/ (rect 0(h!ncteroto- (& (0!en -n* en."n! /n"0!

*!&e're20e"n*34 A((n, /n"0! *!&e're20e"n*3 &!5n&!n*/n &en*n /n"0! /ontr0

/on9en0!on" t(/n- en*rn*! re0!/oAP -n* 5ert (0c7ERCP 21%41+3

Pene(tn 0tent 0"rn (n/re0 en*rn*! re0!/o (n/ret!t!0 -n* 5ert (0c7ERCP (&

(0!en -n* 5er!0!/o t!n**!, 0e(ert! -n* en."n! (""ecto-, en&o0/o(! noetr- 08!n*ter

O&&!, t !nter9en0! (n/re0 0e" ERCP4 Se5h et7n"!0!0 (& thn #= -n*

&!ter5!t/n o"eh An&r!""! et "4 21?3, -n* en*e9"0! + (erco5n c/, (ro0(e/t!8 ter0/ # (0!en, enn.//n 5h' (ene(tn 0tent 0"rn (n/re0 e5er!/n & /"! "!(t &"

/e.&!n (n/ret!t!0 (0c7ERCP 2#+,1 90 1#@ P ,;@ o&&0 r0!o: 4++ , ;? con8!&ence

!nter9": ,#+7,>134 Me0/!(n 0t&! "e5!h "n.t &!(er"/n,3 0tent (n/re0 -n* t!&/ 5er*e"n*

"e5!h /ec!" % French 2Fr3 t(/n- enrn/n r!0!/o (n/ret!t!0 (0c7ERCP 2P ,+%3,

e""! 0ecr 0(ontn 2P ,13, &n en-e55/n (er5hn &/t0 (n/re0 290 #+ 4 >3

&!5n&!n*/n &en*n0tent -n* "e5!h 5e0r + Fr, ? Fr, t < Fr 21


19/29

"e5!h t!n**! &r! (n/ret!t!0 5ert te"h &!"(or/n (& (0!en &en*n /e**"n 0tent!n* &/t0

(n/re0 21>34 Stent!n* 0"rn (n/re0 t!&/ 0e"" "-/ 0ecr te/n!0, &en*n t!n*/t /e**"n

-n* &!"(or/n 5er/!0r ntr + 0(! 1 21>34 Se"!n !t, /o("!/0! .n*/ (n.n* &r!

0tent!n* 0"rn (n/re0, 0e(ert! (n/ret!t!0 /ron!0, &(t ter.&! &n 0t&! "e5!h "n.t &!(er"/n

2+;34

Me0/!(n 0e."h 5e0r !nter9en0! 8r/o"o*!0 nt/ (ro8!"/0!0 terh&( (n/ret!t!0 (o0t7

ERCP te"h &!(e".r! 2?3, h0!" (ene"!t!n te"h 5n-/ en*ece'/n4 Ke"o(o/ -n* ("!n*

en.n.!/n &r! o5t nt/ e"eh/n re0(on !n8"0! &r! AP &"h NSAID 21;41134 D .!

/"!n!0 te"h enn.//n 5h' 1 * 0(o0!tor! re/t" &!/"o8en/ en*rn*! !n0!&en (n/ret!t!0

(0c7ERCP 2111411#34 Se"!n !t, "t!center 5r75r !n!, .! co5 &o5"e75"!n&, c/ ("ce5o

ter/ontro" &r!


20/29

0ete"h e(ero"eh /"tr -n* &!(er"/n nt/ *en !n8e/0!0, tn( CT FNA, hr0n-

&!5er!/n 2re/oen&0! /t, 5/t! o&ert34

?4 P& (0!en &en*n ne/ro0!0 ter!n8e/0!, nt!5!ot!/ -n* &!/en" nt/ ene50 ne/ro0!0 (n/re0,

0e(ert! cr5(ene0, /!no"on, &n etron!&o", n*/!n 5er*n &" enn& t /&n*7

/&n* en*h!n&r! (e5er!n !nter9en0!, 0eh!n** enrn/n or5!&!t0 &n

ort"!t0 2re/oen&0! 5er0-rt, /"!t0 5/t! o&ert34


21/29

In! 0!h 5e" .e"0 (/h 05/e"o(o/ (0!en &en*n AP 5ert 20e(ert! ne/ro0!0 "0 &en*n

/e**"n or*n3 &(t en*5!" n8t &r! nt!5!ot!/, tet(! (ene"!t!n 5e0r &!(er"/n nt/

enent/nn8t ((n /n 0"!t nt/ &!t(!"/n4 Ber&0r/n "!tertr 0t !n!, (en**nn

nt!5!ot!/ (ro8!"/0!0 nt/ ence*h !n8e/0! (& (0!en &en*n ne/ro0!0 0ter!" 25h/n (re&!/0!

e5*! (en-/!t -n* 5ert3 t!&/ &!n.r/n4

Pence*hn !n8e/0! .r (& (0!en !n! .* t!&/ &!n.r/n4 Me0/!(n !t en-rn/n

5h' !n8e/0! .r &(t en.&! (en-e55 -n* "e5!h &r! /et!n (& AP, (ene"!t!n

"e5!h "n.t 5e" en*/on8!r0! ten !n! 21#=34 A& 0t (erco5n /"!n!0ter/ontro" 0ecr c/

-n* 0/0e0, -n* en**n/n &e/ont!n0! 0e"e/t!8 00, enr*et/n 5/ter! &n .r, nt/

ence*h ne/ro0!0 ter!n8e/0! 21#>34 Kren or5!&!t0 enrn &n ort"!t0 (& (erco5n !n!

(& (0!en &en*n AP -n* 5ert te"h en."n! &e/ont!n0! 0e"e/t!8, 0t&! "e5!h "n.t (& re

!n! &!(er"/n4 A/h!rn-, (ro5!ot!/ t!&/ 5o"eh &!5er!/n (& AP -n* 5ert4 Me0/!(n (erco5n

0e5e"n- en-rn/n n8t, 0n*t 5!/ &!"//n, .! /"!n!0 c/ ter/ontro" enn.//n

(en!n*/tn ort"!t0 21#;34 Krn*n- n8t .* te"h &!tn.//n &" et7n"!0!0 ter5r

21%34

Ne%ro"i" terinfe%"i

Unt/ ence*h !n8e/0!, (ern nt!5!ot!/ (& (0!en &en*n AP ne/ro0!0 0e/rn* nt/

en*o5t! ne/ro0!0 ter!n8e/0!4 Kon0e( en*en! ne/ro0!0 (n/re0 -n* ter!n8e/0! e5th/n

&e5r!&eent -n* ce(t .* te"h &!tntn* o"eh 5e5er( "(orn &n 0er! /00 -n* enn.//n

5h' nt!5!ot!/ 0. &(t en-e55/n re0o"0! !n8e/0! &n, (& (0!en tertent, en*h!n&r!

o(er0! 0 0e/"! 21%171%+34 Gr* et "4 21%+3 e"(or/n +=6> (0!en &en*n ne/ro0!0 ter!n8e/0!

0e" (er!o&e 17thn 5erh0!" &!o5t! 0ecr /on0er9t!8 &en*n nt!5!ot!/ 0. 21%+34 ort"!t0

(& /e"o(o/ /on0er9t!8 &"h #% &!5n&!n*/n &en*n ?+ (& /e"o(o/ (e5e&hn4

/e"o(o/ -n* 0 e(5"!/0!/n et7n"!0!0 &r! > (ene"!t!n -n* e"!5t/n +; (0!en

&en*n ne/ro0!0 ter!n8e/0! &! ntrn- %#+ -n* 5erh0!" &!o5t! &en*n nt!5!ot!/ 0. 21%?34 Secr

/e0e"rhn,


22/29

ter!n8e/0! &n ne/ro0!0 0ter!" n*/!n t(/ !r!( &en*n &n- "e/o0!to0!0, &e, &n

/e**"n or*n 21%=3, &"h 0th!" nt/ e!0h/n ent!t0 tn( 0(!r0! .r4 Secr

h!0tor!0, (en**nn nt!5!ot!/ -n* ter5!/ &!5er!/n (& (n/re0 ter5/t! 0ecr /"!n!0 t !n8e/0!

e/0trhe(t!/, &n /ren !t CT FNA hr0 &!(ert!5n*/n /et!/ !n8e/0! &!cr!*!4 Se5h

t!n.n "n*0n* &r! (e'rnn *r /n ene*//n &!*no0!04 Nn, n*/!n 5!./0n

nt/ e"! (e5er!n nt!5!ot!/ 05!" enn** /on8!r0! !/ro5!o"o*!4 J!/ "(orn /"tr

ne*t!8, nt!5!ot!/ &(t &!hent!/n4

A& 5e5er( /ontro9er0! en*en! (/h CT FNA &!(er"/n (& 0e (0!en 2G5r

134 P& 5n-/ (0!en, CAT FNA t!&/ /n e(en*rh! (enn*nn 21%>34 Pen!n*/tn

(en**nn (enn*nn /on0er9t!8 &n &r!n0e !n!" !n90!8

te"h enrn/n (en**nn FNA nt/ &!*no0!0 ne/ro0!0 ter!n8e/0! 2?+34 Bn-/ (0!en &en*n

ne/ro0!0 0ter!" t ter!n8e/0! en!n*/t ce(t t en.&! t!&/ 0t5!", &n /e(t0n !nter9en0!

e""! rte !n!" !n90!8 t!&/ /n &!(en*rh! &en*n h0!" 0(!r0!4 Se5h /on8eren0!

/on0en00 en-!("/n 5h' DNA hn- 5o"eh &!*n/n (& 0!t0! &! n t!&/ & re0(on

/"!n!0 terh&( nt!5!ot!/, 0e(ert! /et!/ !n8e/0! .r &!cr!*! 2?+34


23/29

Ne/ro0!0 (n/re0 : 00(e/ !n8e/0!

(e'rnn *r (o0!t!8

&n t /"tr

T!&/ 0t5!" 0ecr

/"!n!0

St5!" 0ecr /"!n!0

G5r 14 Penn*nn ne/ro0!0 (n/re0 /et!/ !n8e/0! &!cr!*!4 Ne/ro0!0 ter!n8e/0! hr0&!(ert!5n*/n (& (0!en &en*n ne/ro0!0 (n/re0 t e/0tr(n/ret!/ -n* e5r/ t

**" &" (er5!/n 0ete"h = 7 1 hr! &! r't !n(4 P& (0!en !n!, 5!/ 2!3 0(!r0! .r h"0

&!(n& CT 0cn 2CT FNA3 nt/ (e'rnn *r &n /"tr nt/ en& (en**nn nt!5!ot!/

-n* te(t t 2!!3 (en**nn e(!r!/ nt!5!ot!/ tn( CT FNA hr0 &!5er!/n4 P& (0!en

&en*n ne/ro0!0 ter!n8e/0!, nt!5!ot!/ -n* &!/en" 5er(entr0! ne/ro0!0 (n/re0 n*/!n 5er*n

&" enn& (e5er!n !nter9en0!, 0eh!n** enrn/n or5!&!t0 &n ort"!t04 P& (0!en

0t5!" &en*n ne/ro0!0 ter!n8e/0!, (e5e&hn, r&!o"o*!, &n 6 t &r!n0e en&o0/o(! hr0 &!tn&

"e5!h + !n** nt/ en*/!n/n ter.&!n- ne/ro0!0 &! 0e/!tr &!n&!n* 2wall-off nekrosis

(n/re034

Penggunaan empiris dari

antibiotik yang berpenetrasi

Perolehan 0(!r0! .r

h"0 &! n& CT 0cn

Pewarnaan gram dan kultur

negatif

Nekrosis terinfeksi

NEKROSIS STERIL

perawatan suportif

mempertimbangkan

pengulangan !N" setiap #$%

Pengobatan pembedahan

debridement

"ntibiotik lan&utan dan obser'asi(((

Penundaan pembedahan minimal

in'asif) endoskopi atau debdridement

radiologi( *ika asimptomatik

pertimbangkan tidak dilakukan


24/29

NUTISI PADA AP

Re/oen&0!

1 D" AP -n* r!n*n, (e5er!n /nn "e't or" &(t 0e*er &!"! .!/ t!&/ &

" &n nth, &n n-er! (ert te"h re& 2re/oen&0! 5er0-rt, /"!t0 5/t! o&ert34

# D" AP -n* r!n*n, "!n- (e5er!n /nn &en*n &!et ren&h "e/ (&t

enn.//n /enn &!et c!rn 5en!n* 2re/oen&0! 5er0-rt, /"!t0 5/t! o&ert34

%4 D" AP -n* 5ert, ntr!0! enter" &!re/oen&0!/n nt/ ence*h /o("!/0! !n8e/0!4

Ntr!0! (renter" hr0 &!h!n&r!, /ec"! rte enter" t!&/ ter0e&!, t!&/ &!to"ern0!, t

t!&/ eenh! (er0-rtn /"or! 2re/oen&0! /t, /"!t0 t!n**! 5/t!34+4 Pe5er!n /n e""! n0o*0tr!/ &n n0o.e.n" &r! /nn enter" nc"

0e5n&!n* &" e8!/0! &n /ennn- 2re/oen&0! /t, /"!t0 o&ert 5/t!34

RANGKUMAN BUKTI

Ntr!0! (& AP

Secr h!0tor!0, e0/!(n t!&/ & &t /"!n!0, (0!en &en*n AP &!.* &en*n NPO 2t!&/

e""! "t3 nt/ en*!0t!rht/n (n/re0 2%#34 Ke5n-/n (e&on &! 0 ""

ere/oen&0!/n NPO 0(! re0o"0! r0 n-er! &n 5e5er( &!0rn/n enn** nor"!00!

en! (n/re0 t 5h/n (enc!trn 5/t! re0o"0! !n8"0! 0e5e" e"n.t/n (e5er!n

/nn or" 2?%34 Ke5thn nt/ ene(t/n (n/re0 5er!0t!rht 0(! re0o"0! "en*/( &r!

AP t!&/ "*! ter"!ht (ent!n*4 A00! -n* " en-t/n 5h' (n/re0 -n* er&n*

eer"/n !0t!rht " &en*n 5er(0 t(/n- t!&/ &!&/n* o"eh "5ortor! &n

(en*tn /"!n!0 21%;34 St&! /"!n!0 &n e/0(er!ent" enn.//n 5h' !0t!rhtn- 00

&!/!t/n &en*n tro8! /o0 00 &n (en!n*/tn /o("!/0! !n8e/0! /ren trn0"o/0! 5/ter!

&r! 00 2*t34 Be5er( 0t&! te"h enn.//n 5h' (0!en -n* en&(t/n (e5er!n

/nn or" 0ecr &!n! (& (er."nn (en-/!t AP e!"!/! '/t t!n**" &! rh 0/!t "e5!h (en&e/, (enrnn /o("!/0! !n8e/0!, (enrnn or5!&!t0, &n (enrnn n*/ /et!n

211=41+ 7 1+%3

D" AP -n* r!n*n, 0(n or" 5!0n- &!("!h/n &en*n ce(t &n t!&/ &

!nter9en0! *!! -n* &!5th/n4 Me0/!(n '/t (e5er!n /nn /e5"! 0!h /ontro9er0!",

0t&! ter5r enn.//n 5h' (e5er!n /nn or" "n*0n* (& (0!en &en*n AP r!n*n

t(/n- n 21%;34 Se"!n !t, &!et (&t ren&h "e/ te"h ter5/t! n &!5n&!n*/n &en*n

c!rn 5en!n*, -n* en-e&!/n "e5!h 5n-/ /"or! 21++34 De!/!n (", &" (erco5n c/

"!nn-, (e5er!n /nn or" &en*n &!et "n/ te"h &!te/n n &!5n&!n*/n &en*n

c!rn 5en!n* &n e(er(en&e/ '/t nt/ t!n**" &! rh 0/!t 21+?41+


25/29

/e5"! 0ecr &!n! .* &(t e(er(en&e/ '/t t!n**" &! rh 0/!t4 Ber&0r/n 0t&!

ter0e5t, (en*en"n (e5er!n /nn or" (& AP r!n*n t!&/ (er" nt/ e"! &en*n

c!rn -n* .ern!h &n (en!n*/tn 0ecr 5erth(, tet(! n*/!n "! 0e5*! re0!& ren&h,

ren&h "e/, &!et "n/ /et!/ (0!en t(/n- e5!/4

Ntr!0! (renter" tot" hr0 &!h!n&r! (& (0!en &en*n AP r!n*n &n 5ert4 Te"h &

5e5er( (erco5n c/ -n* enn.//n 5h' ntr!0! (renter" tot" &!/!t/n &en*n !n8e/0!

&n /o("!/0! -n* 5er/!tn "!nn- 2?%34 Kren /nn enter" e(erthn/n 5rr!er

/o0 00, ence*h *n**n, &n ence*h trn0"o/0! 5/ter! -n* e5t ne/ro0!0

(n/re0, ntr!0! enter" &(t ence*h ne/ro0!0 ter!n8e/0! 21+#41+%34 Se5h et7n"!0!0 !n!

en**5r/n > .! /"!n!0 c/ ter/ontro" -n* e"!5t/n %>1 (0!en ene/n (enrnn

/o("!/0! !n8e/0!, /e**"n or*n, &n /et!n (& (0!en &en*n AP 5ert -n* &!5er!/n

ntr!0! enter" &!5n&!n*/n &en*n ntr!0! (renter" tot"21+%34 Me0/!(n 0t&! "e5!h "n.t

&!(er"/n, !n80 /ont!n- "e5!h 5!/ &r!(& (e5er!n 0!/"!/ t 5o"04

Me0/!(n (en**nn rte n0o.e.n" te"h 0ecr tr&!0!on" "e5!h 5!/ nt/ en*h!n&r!

80e 0t!"0! "5n* , ntr!0! enter" n0o*0tr!c &!n**( n4 Se5h t!n.n 0!0tet!0

en**5r/n ;# (0!en &r! + 0t&! tentn* (e5er!n /n e""! t5n* n0o*0tr!/

ene/n 5h' (e5er!n /n &en*n n0o*0tr!/ n &n &!to"ern0! &en*n 5!/ (&

(0!en -n* &!&* en*"! AP 5ert 211=34 A& 5e5er( "(orn &r! (e5er!n /nn

e""! n0o*0tr!/ 0e&!/!t en!n*/t/n re0!/o 0(!r0!4 Unt/ "0n !n!, (0!en &en*n AP

en."n! ntr!0! enter" hr0 &!te(t/n &" (o0!0! 5&n -n* "e5!h te*/ &n en-!(/n

0(!r0! 0e5*! t!n&/n (ence*hn4 Me0/!(n 0t&! "e5!h "n.t &!(er"/n, en*e9"0! 9o"e

&" (ert -n* en-!(n re0!&", t!&/ n*/!n e5nt4 D!5n&!n*/n &en*n (e5er!n

/nn e""! n0o.e.n", (ene(tn t5n* n0o*0tr!/ .h "e5!h &h, h" !n! (ent!n* (&

(0!en &en*n AP, tert &" (en*trn (er'tn !nten0!84 Pene(tn t5n* N0o.e.n"

e5th/n !nter9en0! r&!o"o*! t en&o0/o(! &n &en*n &e!/!n 5!0 h"4 Unt/ "0n !n!,

(e5er!n /nn e""! t5n* n0o*0tr!/ hr0 "e5!h &!(!"!h21+=34 Se5h (erco5n

"t!center 5e0r -n* &!0(on0or! o"eh National In"tit&te" of Healt9 2NIH3 0t !n! 0e&n*

e"//n (en-e"!&!/n (/h (e5er!n /nn 0ecr n0o*0tr!/ t n0o.e.n" "e5!h 5!/ (& (0!en !n! /ren e/0(er!en -n* 0!*n!8!/n &n 5e5er( 5/t! (& n0! &r! /en**"n

(e5er!n /nn .e.n &!0t" (& AP4

PEAN PEMBEDAHAN PADA AP


26/29

Re/oen&0!

14 P& (0!en &en*n AP r!n*n, -n* &!te/n e!"!/! 5t e(e& &! /n&n* e(e&,

/o"e0!0te/to! hr0 &!"//n 0e5e" /e"r rh 0/!t nt/ ence*h ter"n*n- AP

2re/oen&0! o&ert, /"!t0 5/t! o&ert34

#4 P& (0!en &en*n AP e(e& ne/ro0!0, nt/ ence*h !n8e/0!, /o"e0!0te/to! &!tn&

0(! (er&n*n /t!8 ere& &n (en(/n c!rn &!t0! t &!0t5!"/n

2re/oen&0! /t, 5/t! o&ert3

%4 (0e&o/!0t &n (n/re0 &n 6 t ne/ro0!0 e/0tr (n/re0 0!(tot!/ t!&/ en.!n

&n- !nter9en0! ter"e(0 &r! /rn, "o/0!, &n 6 t e/0ten0! 2re/oen&0! o&ert,

/"!t0 5/t! -n* t!n**!34

+4 P& (0!en 0t5!" &en*n ne/ro0!0 ter!n8e/0!, (e5e&hn, r&!o"o*!, &n 6 t &r!n0e

en&o0/o(! hr0 &!tn& 0e5!/n- 0e" "e5!h &r! + !n** nt/ en*/!n/n

(enc!rn &r! /onten ter0e5t &n (en*e5n*n &!n&!n* 5er0ert &!0e/!tr ne/ro0!0 2wall-

off nekrosis3 2re/oen&0! /t, ren&hn- /"!t0 5/t!34

?4 P& (0!en &en*n *e." ne/ro0!0 ter!n8e/0!, eto&e !n!" !n90!8 necro0ecto- "e5!h

&!(!"!h nt/ necro0ecto- tertt( 2re/oen&0! /t, ren&hn- /"!t0 5/t!34

ANGKUMAN BUKTI

Kole"i"te%to3i

P& (0!en &en*n (n/ret!t!0 5t e(e& r!n*n, /o"e0!0te/to! hr0 &!"//n 0e"

!n&e/0 r't !n(4 L!tertr 0t !n!, -n* enc/( > (ene"!t!n /ohort &n 0t .! co5 0ecr c/

en**5r/n ;;> (0!en -n* e!"!/! &n -n* t!&/ en*"! /o"e0!0te/to! nt/

(n/ret!t!0 5!"!er, ;? 21>3 -n* 0/ rh 0/!t /e5"! nt/ /e.&!n e(e& 5er"n* &"

'/t ; hr! &r! '/t /e"r &r! rh 0/!t 2 90 1>, P ,13, ter0/ (n/ret!t!0 5!"!er

5er"n* 2n +%, >3 21+>3 4 Be5er( /00 -n* &!te/n en.&! (rh4 Ber&0r/n

(en*"n !n!, & /e5thn nt/ &!"//n /o"e0!0te/to! 0ecr &!n! 0e" r't !n( -n*

0, .!/ 0ern*n r!n*n4 P0!en -n* e!"!/! AP 5ert, tert &en*n ne/ro0!0 (n/re0, /n

e5th/n (en*5!"n /e(t0n -n* /o("e/0 ntr h"! 5e&h &n *0troentero"*!04 P&

(0!en !n!, /o"e0!0te/to! 5!0n- &!tn& 0(! 2!3 /e&!n '/t t!n**" &! rh 0/!t

5!0n- 5er/e(n.n*n, 2!!3 0e5*! 5*!n &r! (en*e"o"n ne/ro0!0 (n/re0 .!/ &, t 2!!!3

0ete"h /e"r &r! rh 0/!t 21+>41+;34 Pe&on 0e5e"n- ere/oen&0!/n /o"e0!0te/to!

0ete"h # 0ern*n &r! IAP, &en*n n**(n 5h' 5n-/ /00 0e(ert! !t n*/!n /ren

!/ro"!t!0!04 Nn, 0e5h 0t&! 5er&0r/n (o("0! ene/n 5h' /o"e0!0te/to! &!"//n

nt/ AP -n* 0ern*nn- 5er"n* tn( 5t 6 sludge (& USG &n t!&/ & (en!n*/tn -n*

0!*n!8!/n &r! te0 ht! 0e" 0ern*n AP -n* &!/!t/n &en*n re/ren0! AP ? 21?34

P& 0e5*!n 5e0r (0!en &en*n (n/ret!t!0 5t e(e&, n- 5t e(e& "o"o0

/e &o&en4 ERCP rt!n t!&/ 0e0! /ec"! & /ecr!*n t!n**! &r! 5t 0"rn e(e&


27/29

(er0!0ten, &!n!8e0t0!/n o"eh (en!n*/tn 5!"!r5!n 21?134 P0!en &en*n AP r!n*n, &en*n

5!"!r5!n nor", &(t en."n! /o"e0!0te/to! "(ro0/o(! &en*n cholangiography !ntro(ert!8,

&n 0et!( 5t 0"rn e(e& -n* ter0!0 &(t &!tn*n! &en*n ERCP (0c o(er0! t

!ntro(ert!84 P& (0!en &en*n re0!/o ren&h 0(! 0e&n*, MRCP t EUS &(t &!*n/n

0e5e" o(er0!, tet(! (en**nn rt!n MRCP t!&/ &!(er"/n4 P& (0!en &en*n AP r!n*n

-n* t!&/ &(t en."n! o(er0!, 0e(ert! orn* t -n* "eh &n 6 t orn*7orn* &en*n

(en-/!t (en-ert -n* 5ert, 0(h!ncteroto- e(e& 0en&!r! n*/!n er(/n cr -n* e8e/t!8

nt/ en*rn*! 0ern*n "e5!h "n.t &r! AP, e0/!(n 0ern*n /o"e0!0t!t!0 0!h n*/!n

ter.&! 2?%34

DEBIDEMEN NEKOSIS

Secr h!0tor!0, necro0ecto- ter5/ 6 &e5r!&eent &"h (en*o5tn (!"!hn nt/

ne/ro0!0 ter!n8e/0! &n ne/ro0!0 0ter!" 0!(tot!/4 De/&e -n* "", (0!en &en*n ne/ro0!0 0ter!"

en."n! &e5r!&eent '" -n* en*/!5t/n (en!n*/tn ort"!t04 Unt/ "0n !n!,

&e5r!&eent ter5/ &!n! nt/ ne/ro0!0 0ter!" &!t!n**"/n 2%#34 Nn, &e5r!&eent nt/ ne/ro0!0

0ter!" &!n.r/n .!/ &!/!t/n &en*n o50tr/0! "5n* &n 6 t o50tr/0! 0"rn e(e&4 P&

(0!en &en*n ne/ro0!0 ter!n8e/0!, &"h /e(erc-n -n* 0"h 5h' /et!n ne/ro0!0 ter!n8e/0!

h(!r 1 .!/ &e5r!&eent t!&/ &!"//n 0e*er 2?%41?#34 D" re9!e' retro0(e/t!8

&r! ?% (0!en &en*n ne/ro0!0 ter!n8e/0! &!o5t! &en*n o(er0! 2'/t rt7rt nt/ o(er0! &r! #>

hr!3 n*/ /et!n trn en.&! ## 0t necro0ecto- ne/ro0!0 &!tn& 211>34 Sete"h en!n.

11 (ene"!t!n -n* e0//n 141%< (0!en, (en"!0 ene/n 5h' enn& necro0ecto-

(& (0!en 0t5!" -n* &!o5t! &en*n nt!5!ot!/ 0. 0(! % hr! 0ete"h 0/ rh 0/!t

&!/!t/n &en*n (enrnn ort"!t0 21%134

Kon0e( 5h' ne/ro0!0 (n/re0 ter!n8e/0! e5th/n &e5r!&eent -n* ce(t .* te"h

&!tntn* o"eh 5e5er( "(orn &n 0er! /00 -n* enn.//n 5h' nt!5!ot!/ 0. &(t

en-e55/n re0o"0! !n8e/0! &n, (& (0!en tertent, &(t en*h!n&r! o(er0! 0 0e/"! 2 (0!en -n* &!5er! nt!5!ot!/ nt/ (enn*nn ne/ro0!0 (n/re0

-n* ter!n8e/0!, 1< en*h!n&r! o(er0!4 A& & /et!n (& (0!en -n* en."n! o(er0! &n& /et!n (& (0!en -n* &!o5t! &en*n nt!5!ot!/ 0.4 &en*n &e!/!n, &" "(orn !n!,

"e5!h &r! 0eten*h (0!en 5erh0!" &!o5t! &en*n nt!5!ot!/ &n t!n*/t /et!n (& /e&

/e"o(o/ 5e&h &n non75e&h &"h 0er(4 Kon0e( 5h' o(er0! -n* en&e0/ &!(er"/n

(& (0!en -n* &!te/n te"h en*"! ne/ro0!0 ter!n8e/0! t!&/ "*! 5er"/4 Pn/re0 tn(

*e." &n 6 t ne/ro0!0 e/0tr(n/ret!/ t!&/ eer"/n !nter9en0! ter"e(0 &r! /rn, "o/0!,

&n e/0ten0!4 In! n*/!n /n ter0e"e0!/n &r! '/t /e '/t, 5h/n &" 5e5er( /00

ne/ro0!0 ter!n8e/0! 2?+34

Me0/!(n (0!en 0t5!" &en*n ne/ro0!0 ter!n8e/0! hr0 en."n! &e5r!&eent -n* r*en0!,

/on0en00 0t !n! en-t/n 5h' (enn*nn '" ne/ro0!0 ter!n8e/0! nt/ (0!en -n* 0t5!"


28/29

0ecr /"!n!0 hr0 en&(t/n nt!5!ot!/ 0e5e" !nter9en0! nt/ en*/!n/n re/0! !n8"0!

en.&! "e5!h teror*n!0!r 2?+3 J!/ (0!en tet( 0/!t &n ne/ro0!0 ter!n8e/0! 5e" &!0e5h/n,

!n!" !n90!8 necro0ecto- 0e(ert! en&o0/o(!/, r&!o"o*!0, retro(er!tone" -n* &!5nt &en*n

9!&eo, (en&e/tn "(ro0/o(!, t /o5!n0! /e&n-, t o(er0! ter5/ &!n.r/n 0e/"!

ne/ro0!0 !t walled-off 25er&!n&!n* te5" &n /o/oh3 2?+41?% 7 1?


29/29

hr0n- &! !n&!9!&"/n, e5th/n (ert!5n*n &r! 0e &t -n* ter0e&! 2/"!n!0,

r&!o"o*!0, "5ortor!3 &n en**n/n /eh"!n -n* ter0e&!4 R./n '" /e (0t -n*

"e5!h n**" &"h 0n*t (ent!n*, /ren enn& (e5er!n !nter9en0! &en*n (er'tn 0(ort!8

/0!" &n en**n/n (en&e/tn !n90!8 !n!" te"h ter5/t! en*rn*! or5!&!t0 &n

ort"!t04

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