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Abstract :
Upper Gastrointestinal Malignancy among Dyspepsia Patients
in Cipto Mangunkusumo Hospital Jakarta

Ali Imron Yusuf*, Ari Fahrial Syam**, Murdani Abdullah**,
Dadang Makmun**, Marcellus Simadibrata**, Chudahman Manan**, Abdul Aziz Rani**

* Division of Gastroentero-hepatology, Department of Internal Medicine, Faculty of Medicine
University of Lampung/Dr. Abdul Moeloek Hospital, Bandar Lampung
** Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine
University of Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta

ABSTRACT
Background: Upper gastrointestinal (GI) malignancy was still a health problem in all over the world. The prevalence of the upper GI Malignancy vary among Asian Country. From Indonesia itself, did not much report about upper GI malignancy. The aim of this study is to know how much upper gastrointestinal malignancy among dyspepsia that had been done esophagoduodenoscopy (EGD) procedure.
Methods: This is a retrospectives study from subject with dyspepsia that had been upper gastrointestinal endoscopy in Department of Internal Medicine Cipto Mangunkusumo hospital from January 2005 to December 2007 completely with data from medical report and histopathology appearance.
Results: Of 2,116 subjects with dyspepsia that had been endoscopic procedure, we found upper gastrointestinal malignancy in 110 subjects (5.19 %). This upper GI malignancy consist of gastric cancer 63 (2.97%), esophageal cancer 32 (1.51%) and duodenal cancer 15 (0.71%). The mean ages of the subjects is 53.36 ± 10.97 years, age less than 45 years is 20 subjects (18.2%), more than 45 years is 90 (81.18%), male 71 subjects (64.50%), female 39 (35.50%). Most of them had alarm signs 96 (87.30%). From histopathology appearance founded adenocarcinoma in 75 (68.20%), signet ring cell carcinoma in 14 (12.70%), squamous cell carcinoma in 8 (7.30%), others in 13 (11.80%). Base on EGD, location of gastric malignancy is 48 (76.20%) in lower gaster, 11 (17.50%) in upper gaster, and 4 (6.30%) in diffuse. By the ethnics founded Java 37 subjects (33.60%), Betawinese is 22 (20%) and Sundanese is 12 subjects (10.90%) and Bataknese 13 (11.80%).
Conclusions: Upper gastrointestinal malignancy found in five percents of dyspepsia subjects with distribution gastric carcinoma, esophageal carcinoma, and duodenal carcinoma respectively. Most of them were gastric carcinoma in the lower gaster with adenocarcinoma.

Keywords: upper gastrointestinal malignancy, dyspepsia, endoscopy, alarm sign, histopathology

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Abstract :
Vasoactive Intestinal Peptide-Secreting Tumor

Femmy Nurul Akbar*, Dadang Makmun**

* Faculty of Medicine and Health Science
Islamic State University of Syarif Hidayatullah, Jakarta
** Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine
University of Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta


ABSTRACT
Vasoactive Intestinal Peptide-Secreting Tumor (VIPoma) is one of rare tumors which cause the “watery diarrhea, hypokalemia, hypochlorhydria and acidosis syndrome” (WDHHA syndrome). These tumor due to non-insulin-secreting pancreatic islet tumor that associated with elevated plasma level Vasoactive Intestinal Polypeptide (VIP). VIP is a potent stimulator of gut cyclic adenosine monophosphate (cAMP) production, which leads to massive secretion of water and electrolytes mainly potassium. Over expression of VIP causes diarrhea and cancerous growth. The other clinical features of VIPomas such as hypercalcemia, abdominal discomfort, tetany, facial flushing are associated with the actions of VIP, which stimulate intestinal secretion, inhibit gastric acid secretion. VIP also regulates the synthesis, secretion, and action of neuroendocrine hormones such as secretin, glucagon, prostaglandin E, somatostatin and pentagastrin as well as cytokines and chemokines. Diagnosis is based on clinical, laboratory test show elevation VIP level, electrolyte and acid base imbalance also imaging such as CT scan or Magnetic Resonance Imaging (MRI) that show primary tumor in the pancreas and metastasis especially in the liver. Somatostatin receptor scintigraphy may be useful in identifying extrapancreatic VIPomas, i.e the sympathetic chain, colon, bronchus and occult or distant metastases. Initial treatment is to correct volume, electrolyte, and acid-base abnormalities with intravenous normal saline, potassium chloride, and, sodium bicarbonate. Somatostatin or long acting ocreotide is effective in reducing serum VIP levels and promptly controlling diarrhea. Interferon alpha and glucocorticoid may be useful for reducing symptoms. Surgical resection depends on staging of pancreatic tumor.

Keywords: VIPoma, WDHHA syndrome, VIP, non insulin secreting pancreatic islet tumor

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Abstract :
Tuberculous Peritonitis Presenting Acute Recurrent Pancreatitis

Birry Karim*, Afifah Is*, Ikhwan Rinaldi**, Ari Fahrial Syam***,
Murdani Abdullah***, Ceva Wicaksono Pitoyo****

* Department of Internal Medicine, Faculty of Medicine,
University of Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta
** Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine
University of Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta
*** Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine
University of Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta
**** Division of Pulmonology, Department of Internal Medicine, Faculty of Medicine
University of Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta

ABSTRACT
Tuberculosis (TB), one of the oldest diseases known to affect humans, is a major cause of death worldwide. TB is still a major problem in Indonesia. This disease, which is caused by bacteria of the Mycobacterium tuberculosis complex, usually affects the lungs, although other organs are involved in up to one-third of cases. Approximately 95% cases of TB and 98% death because of TB occur in developing country. Gastrointestinal tuberculosis is uncommon, making up 3.5% of extrapulmonary cases in the United States. This kind of TB may involve gastrointestinal tract, peritoneal, lymph nodes, or solid intraabdominal organs (viscera).
A 17 years old male admitted to hospital with TB peritonitis presenting unusual clinical manifestation. At the first admission patients was diagnosed with acute pancreatitis based on elevation of amylase and lipase level up to 285 and 2,046 U/L and after finishing further examination, patients suffered from tuberculous peritonitis which based on literature manifested some gastrointestinal disorders.
Diagnostic confirmation was accomplished by conducting serum-ascites albumin gradient (SAAG) of < 1.1 g/dL, peritoneal thickening and the presence of ascites with fine mobile septations on ultrasound, positive polymerase chain reaction (PCR) TB from ascitic fluid. Patients received conventional antitubercular therapy for 12 months of rifampicin, isoniazid, pyrazinamide, and ethambutol. The addition of corticosteroids for the first two or three months of treatment may reduce the incidence of late complications arising from adhesive disease, such as small bowel obstruction.

Keywords: mycobacterium tuberculosis, tuberculous peritonitis, PCR, serum-ascites albumin gradient

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Abstract :
Serial Cases of Combining ESWL and ERCP Procedures
in Management Chronic Pancreatitis and Difficult Bile Duct Stones

Achmad Fauzi*, Nur Rasyid**, Ari Fahrial Syam*, Murdani Abdullah*, Dadang Makmun*,
Marcellus Simadibrata*, Chudahman Manan*, Abdul Aziz Rani*, Daldiyono*

*Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine
University of Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta
**Department of Urology, Faculty of Medicine, University of Indonesia/
Dr. Cipto Mangunkusumo General National Hospital, Jakarta


ABSTRACT
Extracorporeal Shock Wave Lithotripsy (ESWL) has an established role in the management of pancreatic ductal calculi and as further treatment modality for large or difficult complicated Common Bile Duct (CBD) stones. Combined with minimally invasive endoscopic procedure such as Endoscopic Retrograde Cholangio-pancreatography (ERCP), it has replaced open surgery as the initial form of therapy. ESWL has also proved to be an effective therapy in treating intrahepatic stones that are refractory to routine endoscopic extraction. In these serial cases we present three cases which using combined ESWL and ERCP procedures to treat chronic pancreatitis pain and giant CBD stone that presenting good results on follow up without any complication.

Keywords: ESWL, ERCP, chronic pancreatitis, CBD stone