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How to Negotiate Difficult Colonoscopy to Optimize Cecal Intubation Rate Cahyono, Suharjo B; Bayupurnama, Putut
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy VOLUME 14, NUMBER 2, August 2013
Publisher : The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy

Colonoscopy is the current standard method for evaluating colon. Cecal intubation rate is an important indicator of colonoscopy quality. In up to 10–20% colonoscopies, cecal intubation may be considered difficult.There are several consequences of low cecal intubation rate: it limits the efficacy of colonoscopy, increasing risk of complications and cost, and missing in detecting adenoma colorectal or other abnormal mucosa lesion.Failure to intubate the cecal can be a result of: (1) patients factors (female, older, diverticular disease, history of abdominal surgery, low body mass index, history of constipation, laxative use); (2) endoscopist factors (prior experience, the specific techniques and instrument used; (3) or some combination thereof. In an effort to solve these problems endoscopist should increase their technical manoeuvres (minimizing inflation and looping, using water–aided method, appropriate use of positional changes and abdominal pressure) and use various accessories methods (inserting a biopsy forceps through the biopsy channel, pediatric colonoscopy, variable stiffness colonoscopy).Keywords: cecal intubation rate, difficult colonoscopy, colonoscopy quality, water–aided colonoscopy

Gallstones and Choledocolithiasis with Severe Cholestatic Jaundice in beta-Thalasemia Intermedia Patient Cahyono, Suharjo B; Bayupurnama, Putut; Ratnasari, Neneng; Nurdjanah, Siti
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy Vol 15, No 2 (2014): VOLUME 15, NUMBER 2, August 2014
Publisher : The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy

Geographically, b-thalassemia can be found in many countries including in Indonesia. Thalassemia intermedia referred to patients as being ‘too haematologically severe to be called minor, but too mild to be called major’. Patients with thalassemia intermedia usually present themselves to medical attention in later childhood or even adulthood and are sustainable without the need for regular transfusion therapy. Three main factors are responsible for the clinical sequele of thalassemia intermedia: chronic anemia, ineffective erythropoiesis, and iron overload.There are many complications related to b-thalassemia intermedia such as gastroentero-hepatology diseases (splenomegaly, gallstones, choledocolithiasis, predispose patients to liver fibrosis and cirrhosis), vascular, endocrine and bone diseases. About 55-63% thalassemia intermedia patients suffer from gallstone with 68–85% of these patients undergo cholecystectomy, and 67-90% patients undergo splenectomy. Therefore, ultrasound examination is required to be performed regularly during illness and before patient underwent surgery or splenectomy to detect the presence of gall stones. In this case report a patient with gallstones and choledocholithiasis was reported. Severe cholestatic jaundice in b-thalassemia intermedia was diagnosed six months before hospitalization. The patient underwent open cholecystectomy and exploration common bile duct stones. Keywords: beta-thalassemia intermedia, gallstones, choledocolithiasis, iron overload

Ultrasound-Diagnosed Non-Alcoholic Fatty Liver Disease among Medical Check Up Patients Cahyono, Suharjo B; Bayupurnama, Putut; Ratnasari, Neneng; Maduseno, Sutanto; Nurdjanah, Siti
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy VOLUME 14, NUMBER 3, December 2013
Publisher : The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy

Background: Non-alcoholic fatty liver disease (NAFLD) is recognised as one of the most important causes of chronic liver disease and has become an important health issue in many countries. The aim of the study wasto evaluate the prevalence and risk factors of NAFLD patients based on ultrasound diagnosed in medical check up setting.Method: In this study, of 2,105 patients undergoing medical check up in Charitas Hospital, Palembang between January 2011 to August 2013, 115 NAFLD patients and 113 non-NAFLD patients as controls were included. Diagnosis of NAFLD was based on ultrasound appearance, patients did not consume alcohol, with negative HBsAg and hepatitis C virus antibodies.Results: The prevalence of NAFLD in medical check up patients was 7.9% whereas 39% patients had normal body mass index (BMI) (< 25 kg/m2). Patients with NAFLD compared with non-NAFLD patients had higher values of BMI (p < 0.001), triglycerides (p = 0.001), aspartate aminostransferase (AST) (p < 0.001), alanine aminotransferase (ALT) (p < 0.001), fasting glucose (p = 0.002), and lower HDL cholesterol (p = 0.001). Obesity was the strongest associated factor for NAFLD (95% CI = 1.87-7.85; OR = 3.83; p < 0.001), followed by high glucose levels (95% CI = 1.38 - 8.31; OR = 3.83; p = 0.008) and hypertriglyceridemia (95% CI = 1.38 - 4.11;OR = 2.38; p = 0.002).Conclusion: About 7.9% patients suffered from NAFLD. Approximately 39% medical check up patients had NAFLD with normal BMI. Obesity, hypertriglyceridemia and high glucose levels were the risk factors for NAFLD.Keywords: non-alcoholic liver disease, body mass index, prevalence, metabolic syndrome

Tuberculosis Peritonitis Patient with Septic Shock caused by Extended–Spectrum Beta Lactamases Producing Pseudomonas Aeruginosa Cahyono, Suharjo B; Ratnasari, Neneng; Bayupurnama, Putut; Triwikatmani, Catharina; Nurdjanah, Siti
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy Vol 15, No 3 (2014): VOLUME 15, NUMBER 3, December 2014
Publisher : The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy

According to World Health Organization (WHO), tuberculosis (TB) is a worldwide pandemic. Up to 5% of patients with TB may have abdominal disease and 25-60% may have peritoneal involvement. Diagnosis of TB peritonitis is still challenging, and symptoms are usually insidious. The sensitivity of acid fast bacilli (AFB) is very low, ranging from 0-6%. Conventional mycobacterial culture takes up to 8 weeks to achieve results. Laparoscopic or laparotomy biopsy is uncomfortable for patient. The consequence of these problems is missing and delays in diagnosing TB peritonitis. In the end, it can results in significant morbidity and mortality. This case described a 20 year old female patient with TB peritonitis that suffered from septic shock caused by extended-spectrum beta lactamases (ESBL) producing Pseudomonas aeruginosa. In this case, TB peritonitis was diagnosed based on clinical features, high levels of adenosine deaminase (ADA) and a positive rapid DNA test with Xpert MTB/RIF. Keywords: tuberculosis peritonitis, extended-spectrum beta lactamases producing bacilli, adenosine deaminase, XpertMTB/RIF assay

Maximum Tolerated Volume and Plasma Acylated Ghrelin Levels after Drink Tests in Patients with Functional Dyspepsia Cahyono, Suharjo B; Ratnasari, Neneng; Bayupurnama, Putut; S, Nurdjanah
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy Vol 16, No 1 (2015): VOLUME 16, NUMBER 1, April 2015
Publisher : The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy

Background: Impaired gastric accommodation and visceral hypersensitivity are major pathophysiological mechanism in functional dyspepsia (FD). Ghrelin, as gut hormone, may play a pathophysiological role in functional dyspepsia. Nutrient drink test was developed to assess impaired gastric accommodation in FD patients. The aims of this study are to compare maximum tolerated volume, postprandial symptoms and acylated ghrelin levels between dyspepsia functional patients and healthy subjects as controls.Method: A cross sectional study was conducted from July 2014 to November 2014, at Sardjito General Hospital, Yogyakarta. Twenties functional dyspepsia patients and 20 healthy subjects ingested nutrient drink tests (Ultra Milk contain 0.6 kcal/mL). The maximum tolerated volume was recorded. After ingested maximal tolerated volume, nausea, bloating and pain were rated using visual analogue scales (VAS) with 100 mm lines. The levels of acylated ghrelin was recorded before and 30 minutes after maximal drinking.Results: The demographic characteristics (age, sex, and body mass index) between dyspepsia patients and healthy subjects were compared. Patients with functional dyspepsia ingested 600 (350–1000) mL and healthy subjects ingested 1375 (1000–1900) mL (p < 0.001). The total symptom scores were higher in dyspepsia patients compared healthy subjects; 215 (110–350) vs. 75 (50–120) (p < 0,001). The fasting plasma levels of acylated ghrelin (20.65 : 2 – 31.37 pg/mL) in FD patients were significantly lower than healthy subjects (30.61 : 2 – 251.19 pg/mL) ( p = 0.012). Conclusion: Patients with functional dyspepsia ingested significantly lower volume and significantly have higher score symptoms than healthy subjects. The fasting plasma levels of acylated ghrelin in functional dyspepsia patients were significantly lower than healthy subjects.

Factors that Influence Cecal Intubation Rate in Unsedated Patients during Colonoscopy Cahyono, Suharjo B; Bayupurnama, Putut; Ratnasari, Neneng; Triwikatmani, Catharina; Indrarti, Fahmi; Maduseno, Sutanto; Nurdjanah, Siti
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy Vol 15, No 1 (2014): VOLUME 15, NUMBER 1, April 2014
Publisher : The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy

Background: Successful cecal intubation is a primary quality indicator in colonoscopies and the mostimportant factor in detecting abnormal lesion in the colon. There are many factors that influence cecal intubationrate during colonoscopy procedure. The aim of this study is to evaluate the factors that influence cecal intubationrate in unsedated patients during colonoscopy. Method: A retrospective study of colonoscopy performed at Sardjito General Hospital, Jogjakarta, from January 2012 to August 2013. Age, sex, bowel preparation, indication for colonoscopy, colonoscopist, andreasons of incomplete colonoscopy from 564 colonoscopy reports were recorded and analysed. Results: Overall successful cecal intubation rate was 408 (72.34%). Causes of incomplete colonoscopywere patients discomfort or pain 41.66%, looping/redundant 28.85%, poor bowel preparation 18.59%, fixation/adhesion 6.41%, and bleeding risk 4.49%. Female was more unsuccessful in cecal intubation than male (31.50%vs. 24.05%; p = 0.048). The successful cecal intubation rates for gastroenterologists compared to gastroenterology(GI) fellows were 77.92% vs. 49.55%; p < 0.001, and poor bowel preparation was more difficult to reach cecalthan good preparation (57.58% vs. 23.69%; p < 0.001). Multivariate logistic regression analysis demonstratedthat female and poor bowel preparation were independently associated with lower cecal intubation rate, andgastroenterologists were independently associated less unsuccessful to reach cecal. Conclusion: The overall successful cecal intubation rate was still below the set standard. Several identifiedfactors that may predict lower of cecal intubation rate: the skill and experience of colonoscopists (GI fellows),poor bowel preparation and female.Keywords: cecal intubation rate, colonoscopy, unsedated colonoscopy

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