Case Presentation 26 NOVEMBER 2020

CASE PRESENTATION
26 NOVEMBER 2020
Yosua Butar Butar, dr / Dr.

Hartono Kahar, dr, Sp.PK (K), MQIH
MS. A S , 30 YO
MC : Epigastric pain
HI : - 2 days before admitance she complain pain in her
stomach , go to ER RSUD Soetomo, given Gastritis drug and
sent home.
- 1 days before admitance She still suffering from abdominal
pain . The pain was sharp,persistent and accompanied with
nausea and vomiting. Loss appetite +. Bowel habit and
micturation were normal.
HPI: Abdominal Pain in 4 month, HT (-), DM (-)
General Status: weak
GCS: 4 – 5 – 6
BP: 100/70 mmHg
HR: 110 x/min
RR: 25 x/min
Tax: 36,8oC
Sa02 : 97%
Physical Examination
H/N : A (-) / I (-) / C (-) / D (-)
Chest : Heart: S1 S2 single, m (-), g (-)
Lung : ves/ves, rh -/-, wh -/-
Abd : epigastric palpation pain (+),
abdomen soepel, bowel sound (+), Liver &
Spleen unpalpable, ascites (-)
Extr : warm, oedema (-)
16/11/2020 Reference
Hematology ER Interval
Result
WBC x 103/µL 4.49 3.37-10.0
% Neu 53,6 39.8-70.5
% Lym 35,4 23.1-49.9
% Mono 9,6 4.3-10.0
% Eos 0,7 0.6-5.4
% Baso 0,7 0.3-1.4
RBC x 106/µL 4.71 3.69-5.46
Hb g/dL 13.1 11-14.7
Hct % 40.1 35.2-46.7
MCV fL 85.1 86.7-102.3
MCH pg 27,8 27.1-32.4
MCHC g/dL 32.7 29.7-33.1
RDW % 13.2 12.2-14.8
Plt x 103/µL 255 150-450

PERIPHERAL BLOOD SMEAR
(16/11/2021)
E : Normochromic normocytic, polychromatophilic cell (-),
normoblast (-)
L : Seems to be normal in number, dominated by segmented
neutrophil, immature granulocyte (-), atypical lymphocytes (-) blast
(-)
T : Seems to be normal in number, giant platelet (+)
Conclusion : morphology eritrocyte normochromic normocytic

Clinical 16/11/21 23/11/21 Refference
Chemistry IRD IRJ Range
7-18
BUN (mg/dL) 7
Serum Creatinin 0.6-1.3
(mg/dL) 0.69
Direct Bilirubin <0.20
(mg/dL) 0.76 0.16
Total Bilirubin 0.2-1
(mg/dL) 1.32 0.27
RBG (mg/dL) 90 83 40-121
0 – 50
AST (U/L) 547 19.2
0 – 50
ALT (U/L) 582 120.2
135-145
Sodium (mol/L) 141
3.5-5.1
Pottasium (mol/L) 3,9
Cloride (mol/L) 106 98-107
CRP 3.85 0-1
Albumin (g/dL) 3.97 3.4-5.0

17/11/21 23/11/21
Clinical Chemistry Refference Range
GDC IRJ
25-115
71
Amilase U/L 223
73-393
Lipase U/L 874 199
00-200
Total Cholesterol 128
40-60
HDL 43
30-150
LDL 62
00-99
Trigliserida 60
BGA IRD Reference
(16/11/2021) Range
pH 7.44 7.35-7.45
pCO2 36 35-45
(mmHg)
pO2 106 80-100
(mmHg)
HCO3 24.5 22.0-26.0
(mmol/L)
TCO2 25.8 23-30
BE-ecf 0.3 -2.00-2.00
(mmol/L)
SaO2 (%) 98 94-98
AaDO2 32
FiO2 21%
Temp (0C) 37.0
Coagulation Result
(17/11/2020) Result Reference
Range
PPT 10.2 9-12 s
APTT 13.1 23-33 s
Immunology Result
(16/11/2020) Result Reference
Range
HBSAg Non Reactive -
HIV Non Reactive -
Rapid test Non Reactive -
Antigen
Covid
Radiology Result
USG (RSUD Soetomo 17/11/21)
- Liver : normal size. the intensity of echoparenchyma appears to increase
- Lien : normal size
- GB : hyperechoic lesion 1.5 cm x 0.9 cm with sludge GB
- Pancreas : normal size , the intensity of echoparenchyma appears to increase
- Conclusion: Parenchimal liver disease , Cholelithiasis,
Pancreatitis
Thorax photo (RSUD Soetomo 16/11/21)
There is no abnormalities of cor and pulmo
Diagnosis : Acute pancreatitis + cholelithiasis
Therapy :
Soft Diet HK, Low Fat 2100 kkal/day
IVFD Nacl 0,9% 500 ml/ 24 hr
Ursodeosikolat acid 250 mg/ 3x1
Inj. Antrain 1 gr/ 8 hr
Inj. Ranitidin 50 mg/ 12 hr
Inj. Metocloperamide 1 amp / 8 hr
Resume
• Anamnesis : Abdominal pain (+), fever (+)
• HPI : Abdominal paint (+)
• Physical examination : epigastric palpation pain (+)
• Laboratory finding :
Amilase ↑, Lipase ↑ , Direct bilirubin↑, Total bilirubin ↑, AST
↑, ALT ↑.
USG Abdomen : parenchimal liver disease , Cholelithiasis,
Pancreatitis
Acute pancreatitis + Cholelithiasis

PROBLEM LIST
1. How to diagnose acute pancreatitis?

2. What is the cause increament AST
and ALT ?
3. What about prognosis in this
patient ?
THANK YOU
PPDS PEMBIMBING
Yosua Butar Butar, dr. Dr. Hartono Kahar, dr, Sp.PK (K),
MQIH
1. HOW TO DIAGNOSE ACUTE PANCREATITIS
?
Clinical 17/11/21 Refference
This Patient : Abdominal Chemistry GDC Range
25-115
pain & increase of Amilase U/L 223
pancreatic enzyymes Lipase U/L 874
73-393
Priyadarshan Konar, 2016

CLASSIFICATION OF ACUTE PANCREATITIS—2012: REVISION OF THE ATLANTA
CLASSIFICATION AND DEFINITIONS BY INTERNATIONAL CONSENSUS, 2012
What is the cause increament of AST
and ALT?
TRANSAMINASE SERUM
 SGOT : Serum Glutamic Oxaloacetic Transaminase
atau
AST : ASpartate amino Transferase
Terdapat pada mitokondria dan sitoplasma
Terutama pada : jantung, hati, otot skelet, ginjal,
pankreas
 SGPT : Serum Glutamic Pyruvic Transaminase.
atau
ALT : Alanine amino Transferase
Terutama pada sitoplasma:
hati, jantung, ginjal,
otot skelet.
Kuliah dr.Leonita Sp.PK, 2010
 Kerusakan sel hati ringan → terutama

ALT meningkat.
® Kerusakan sel hati berat/nekrosis →
terutama AST meningkat.
* Aminotransferase
enzim yang mengkatalisis perpindahan
reversibel satu gugusan amino dari asam
amino ke asam alfa-keto.
AST DAN ALT

Dalam sitoplasma hepatosit:
- AST 1,5 – 2 x ALT
Waktu paruh : - AST ~ 18 jam
- ALT ~ 48 jam
 awal hepatitis akut AST > ALT
> 48 jam kmd ALT > AST
KERUSAKAN SEL HATI
 Hepatitis virus  transaminase 

 Nekrosis oleh karena toksin 
transaminase 
 Cholestasis, sirosis  transaminase 
Pancreatic enzyme
Role of Biomarkers in Diagnosis and Prognostic Evaluation of Acute
Pancreatitis, 2015
Gallstones
GALLSTONES
Gallstones are solid stones that are produced in the
gallbladder when there’s an imbalance in the
composition of bile. The main types of gallstones are
cholesterol stones, bilirubin stones
Cholelithiasis involves the presence of gallstones,
which are concretions that form in the biliary tract,
usually in the gallbladder.
Choledocholithiasis refers to the presence of one or
more gallstones in the common bile duct (CBD).
Treatment of gallstones depends on the stage of disease
ALP
ALKALI PHOSPHATASE
( ALP )
 Tdpt dlm sel : TULANG, USUS HALUS,
HATI, PLASENTA
( TLG  40 – 70% DLM SERUM)
PADA ANAK 2 – 3 X DEWASA.

 INDIKATOR YANG PEKA
. KOLESTASIS - INTRA HEPATIK
- EXTRA HEPATIK
. PENY HATI INFILTRATIF

- TUMOR/ GRANULOMA
KOLESTASIS BIASANYA > 3 x BATAS ATAS NORMAL.
 ALP MENINGKAT PADA :
PENYAKIT PAGET,
METASTASIS TUMOR- TULANG,
HODGKIN STAD. I & II,
PYELONEPHRITIS AKUT,
ENTERITIS REGIONALIS,
KEHAMILAN,
FRAKTUR
URINE AMYLASE
PEMERIKSAAN URINE
AMILASE
Sampel : urine 24 jam.
Urine amilase tetap meningkat selama beberapa hari
setelah serum amilase mejadi normal.
UAMY/24HR = Urine Amylase (U/L) x mL urine / 24 HR

1000
Nilai rujukan : 59-401 U/24 jam
Referat dr. Erik, 2020

RASIO AMYLASE URINARY CLEARANCE-
CREATININE CLEARANCE
Rasioamylase urinary clearance- creatinine clearance
dapat digunakan dalam diagnosis pankreatitis akut.
AMY/CREA Clearance Ratio = x 100
Nilai rujukan : 1,3% - 4,3%

TG INDUCE PANCREATITIS
TRIGLISERIDA
Trigliserida > 1000 mg / dL akan memicu pankreatitis. Berawal
ketika lipase bekerja pada keadaan kadar trigliserida dalam serum
tinggi akan memicu terbentuknya asam lemak bebas yang toksin.
Hal ini akan membuat endotel dari kapiler atau pembuluh darah
memicu trombosis yang akan menginduksi pankreatitis.

DELTA BILIRUBIN
4. What is the cause anemia?
ISTILAH

Case Presentation 26 NOVEMBER 2020

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CASE PRESENTATION

Yosua Butar Butar, dr / Dr.

WBC x 103/µL 4.49 3.37-10.0

% Neu 53,6 39.8-70.5

% Lym 35,4 23.1-49.9

% Mono 9,6 4.3-10.0

% Eos 0,7 0.6-5.4

% Baso 0,7 0.3-1.4

RBC x 106/µL 4.71 3.69-5.46

Hb g/dL 13.1 11-14.7

Hct % 40.1 35.2-46.7

MCV fL 85.1 86.7-102.3

MCH pg 27,8 27.1-32.4

MCHC g/dL 32.7 29.7-33.1

RDW % 13.2 12.2-14.8

Plt x 103/µL 255 150-450

Conclusion : morphology eritrocyte normochromic normocytic

CRP 3.85 0-1

Albumin (g/dL) 3.97 3.4-5.0

Acute pancreatitis + Cholelithiasis

1. How to diagnose acute pancreatitis?

Priyadarshan Konar, 2016

 Kerusakan sel hati ringan → terutama

AST DAN ALT

KERUSAKAN SEL HATI

 Hepatitis virus  transaminase 

PADA ANAK 2 – 3 X DEWASA.

. PENY HATI INFILTRATIF

UAMY/24HR = Urine Amylase (U/L) x mL urine / 24 HR

Nilai rujukan : 59-401 U/24 jam

Referat dr. Erik, 2020

AMY/CREA Clearance Ratio = x 100

Nilai rujukan : 1,3% - 4,3%

Referat dr. Erik, 2020

Referat dr. Erik, 2020

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