SESI 9 DISEASES of the DIGESTIVE SYSTEM (PENYAKIT SISTEM PENCERNAAN) BAB XI Disusun oleh: Dr Mayang Anggraini Naga

DESKRIPSI Pembahasan tentang gangguan/penyakit terkait kerongkongan (esophagus), lambung (stomach. Gaster), usus (intestine) hati (liver = hepar)) dan vesica felea (gallbladder = kantung empedu); struktur dan kekhususan isi Bab XI Diseases of The Digestive System disertai pelatihan pengkodean diagnosis gangguan sistem pencernaan.

TUJUAN INSTRUKSIONAL UMUM Memahami definisi istilah gangguan pencernaan dan menentukan nomor kodenya dengan benar.

TUJUAN INSTRUKSIONAL KHUSUS Menjelaskan: - Isi topic bacaan Reading 2. - Struktur dan kekhususan serta peraturan yang berlaku bagi pemilihan nomor kode gangguan sistem pencernaan - Cara memilih nomor kode diagnosis dengan akurat.

POKOK & SUBPOKOK BAHASAN ”Disorders of Digestive System” Struktur dan kekhususan Bab XI Pelatihan pencarian kode gangguan sistem pencernaan melalui ICD-10 volume 3 dan Volume 1

READING 2 DISORDER of the DIGESTIVE SYSTEM Disorder Of The Esophagus Despite its apparently simple structure, the esophagus is prone to a number of disorders, most of which lead to difficulty, or completely prevent swallowing and/or cause a pain in the chest. Congenital Defects Esophageal atresia is an absence from birth of a section of the esophagus, with the remaining sections ending in dead ends. It requires urgent surgical correction. Rarely, babies are born with web-like constructions of the esophagus. These are rarely, serious enough to require treatment, but may, if necessary, but broken down with a rubber dilator.

DISORDER of the DIGESTIVE SYSTEM (Cont.-1) Infection & Inflammation Infections of the esophagus are uncommon, but can occur in severity immunosuppressed patients whose defenses against infection are weakened, The most common infections are herpes simplex infection or candidiasis (thrush) extending downward from the mouth. Both cause pain on swallowing. Esophagitis is usually due to reflux of the contents of the stomach causing heartburn. A more severe form – corrosive esophagitis – can occur a result of swallowing caustic chemicals. Either of these types of esophagitis may lead to formation of an esophageal stricture.

DISORDER of the DIGESTIVE SYSTEM (Cont.-2) Injury Apart from the damaging effects of swallowing corrosive chemicals, the most common cause of injury to the esophagus is severe vomiting and stretching, which occasionally tear the esophageal lining or extreme causes lead to rupture. A hard swallowed foreign body can also cause injury and sometime perforation if it lodges the esophageal wall. Tumors Tumors of the esophagus are not rare about 90% are malignant, the remainder are benign. With both types the initial symptom is usually difficult swallowing.

DISORDER of the DIGESTIVE SYSTEM (Cont.-3) Other Disorderws An esophageal diverticulum is an outwardly protruding sac, formed usually at the top end of the esophagus in which food may collect and cause halitosis and sometime difficulty swallowing. Esophageal spasm consist of uncoordinated and uncontrollable contractions of the esophagus, which may make swallowing difficult. In achalasia, the spincter muscle at the junction between esophagus and the stomach falls to relax to allow the passage of food, causing pain on swallowing and sometimes regurgitation of food.

DISORDER of the DIGESTIVE SYSTEM (Cont.-4) Investigation Esophageal disorders are investigated by: - barium swallow and by - endoscopy (esophagoscopy). Occasionally, a biopsy (tissue sample), may be taken for pathologic examination.

DISORDER of the STOMACH Disorders of the stomach have a variety of causes, because the stomach is a reservoir, disorders in the process of emptying the stomach relate to the stomach’s role in the preparation of ingestion food for digestion. Infection The large amount of hydrochloric acid secreted by the stomach protects the stomach from some infections by destroying many of the bacteria, viruses, and fungi that are taken in with food and drink. When the protective power is insufficient, a variety of gastrointestinal infections may occur.

DISORDER of the STOMACH (Cont.-1) Tumors Stomach cancer causes about 15.000 deaths annually in the U.S. Each symptoms are often mistaken for indigestion and diagnosis is often delayed until it is too late for a cure. Any change in the customary functioning of the digestive system is important, especially after fifty. A persistent feeling of fullness, or pain before or after meals, should never be ignored. Unexplained loss of appetite or frequent nausea should always be reported.

DISORDER of the STOMACH (Cont.-2) A tumor in the upper part of the stomach, near the opening of the esophagus can cause obstruction and difficulty in swallowing. Sometime a stomach tumor remains “silent” and the first signs are due to the appearance of secondary growths elsewhere in the body. Benign (non-cancerous) polyps can also develop in the stomach. Ulceration The acid and other digestive juices secreted by the stomach sometimes attack the stomach lining.

The healthy stomach is prevented from digesting itself Ulceration (Cont.) The healthy stomach is prevented from digesting itself mainly by the protective layer of mucus secreted by the lining and by the speed with which damaged surface cells are replaced by the deeper layers. Many influents can upset this delicate balance. One of the most important is excessive acid secretion. The resulting peptic ulcers are probably the most common serious stomach disorder. Peptic ulcers are sometimes caused by stress, or by severe injury, such as major burns, accidents, and after surgery and severe infections, often they occur for no apparent reason. The stomach lining can be damaged by large amounts of aspirin or alcohol sometime causing gastritis. This may lead to ulceration of the stomach lining.

DISORDER of the STOMACH (Cont.-3) Autoimmune disorders Pernicious anemia is caused by the failure of the stomach lining to produce intrinsic factor, a substance whose role is to facilitate the absorption of vitamin B12. Failure to produce the intrinsic factor occurs if there is atrophy of the stomach lining, which also causes failure of acid production, Tests that determine a person’s ability to absorb vitamin B12 are important in the investigation of this condition. Pernicious anemia is usually due to an autoimmune disorder.

DISORDER of the STOMACH (Cont.-4) Other disorders Enlargement of the stomach may be caused when scarring from a chronic peptic ulcer occurs at the stomach outlet. It may also be complication of pyloric stenosis, a rare but serious condition caused by narrowing of the stomach outlet. Rarely the stomach may become twisted and obstructed, a condition called volvulus. Investigation Stomach disorders are investigated primarily by - barium X-ray examinations and/or - gastroscopy. Occasionally, a biopsy is performed.

DISORDER of INTESTINE The intestine is subject to various structural abnormalities and to the effects of many infective organism and parasite; it may also be affected by: - tumors, - impaired blood supply, and - other disorders. Congenital defects - atresia, - stenosis, - volvulus or - blockage by meconium. Early surgery may be required.

DISORDER of the INTESTINE (Cont.-1) Infection and Inflammation The general term for inflammation of the stomach and intestines is gastroenteritis. This is caused most commonly by viral or bacterial infections, which can range from the trivial to the life threatening. They ecompass many causes of food poisoning and travelers diarrhea as well as serious diseases such as typhoid fever and cholera. Protozoal infections includes gardiasis and amebiasis. Intestinal worm infestations are exceedingly common worldwide (round worms, tapeworms), includes pinworm are prevalent.

DISORDER of the INTESTINE (Cont.-2) Two important inflammatory conditions of the intestine, not caused by infection are ulcerative colitis and Crohn’s disease. Sometimes, inflammation is confined to a localized area, such as: - appendicitis and - diverticulitis disease.

Tumors of the small intestine are rare, but lymphomas, carcinoid tumors and benign growth occur. By contrast tumors of the large intestine (colon) are very common. Certain forms of familial polyposis may progress to cancer. Impaired blood supply The intestine is dependent on an adequate blood supply. Ischaemia may result from several causes. Causes includes partial or complete obstruction of the arteries in the abdominal wall, or from the blood vessels being compressed or tapped as in volvulus, intussusception, or hernias. Loss of blood supply to a segment o intestine may caused gangrene requiring immediate surgery.

Intestine obstruction may be caused by pressure from the outside, disease of the intestinal wall, or internal blockage. One of the most common causes is paralytic ileus, in which intestinal contractions cease and the intestinal contents are no longer transported. Oher disorders Peptic ulcer of the duodenum is a very common disorder, thought to affect 10% of the population. Ulceration of the small intestine occurs in typhoid and Crohn’s disease and may cause bleeding into the intestine or even perforation. Ulceration of the large intestine occurs in amebiasis and in ulcerative colitis.

DISORDER of the INTESTINE (Cont.-3) Diverticula Diverticula are small outpouchings from the inside of the bowel. They are usually harmless, but, in diverticular disease, become inflamed. Malabsorption and celiac sprue result from changes to the intestinal lining. Finally irritable bowel syndrome is associated with persistent abdominal pain and either constipation or diarrhea (or both), and is the most common intestinal disorder.

DISORDER of the INTESTINE (Cont.-4) Investigation Intestinal disorders are investigated by physical examination, and by techniques such as: - barium X-ray examination, - sigmoidoscopy or - possibly coloscopy, and by - laboratory examination of the feces or of a - biopsy specimen taken from the intestinal lining.

DISORDER of the LIVER By far the ost common cause of liver disease in the US and other developed countries is excessive consumption of alcohol. In part of Africa and Asia, up to 20% of the population are carriers of the hepatitis B virus, the most important liver disorders are virus-induced cirrhosis and primary liver cancer. Congenital defects Choledochal cyst, a malformation of the hepatic duct (union of the small bile ducts in the liver) may obstruct the flow of bile in infants  jaundice. In Billiary atresi, the bile duct are absent  jaundice.

DISORDER of the LIVER (Cont.-1) Infection and inflammation Hepatitis may be caused by viruses (A, B, and non-A and non-B viruses). Bacteria may spread up the billiary system toward the liver to cause cholangitis or liver abscess. Parasitic diseases that may affect the liver includes schistosomiasis. Liver fluke, and the hydatid disease, and amebiasis.

DISORDER of the LIVER (Cont.-2) Poisoning and drugs Many drugs and toxins are broken down by the liver, damaging lever cell in the process. Suicidal overdoses with the painkilling drug acetaminophen causes severe liver damage, which may not be obvious until up to two days after the overdose. Some medications, even in normal doses, can cause acute or chronic hepatitis by a direct toxic effect or through drug allergy. Poisoning by certain types of mushrooms can cause acute liver failure.

DISORDER of the LIVER (Cont.-3) Autoimmune disorders Liver cells and bile ducts can be targets for autoimmune reactions. A gradual destruction of liver is the main problem in autoimmune chronic active hepatitis. The slowly progressive bile duct damage that occurs in primary billiary cirrhosis and sclerosing cholangitis possibly also has an autoimmune basis. Metabolic disorders The two main metabolic disorders affecting the liver are hemochromatosis (too much iron in the body) and Wilson’s disease (too much copper)

DISORDER of the LIVER (Cont.-4) Tumor The liver is common site of malignant tumors that have spread from cancers of the stomach, pancreas, or large intestine. Enlargement of the liver and spleen is a common feature of: - leukaemias and - lymphomas. Primary tumors of the liver (hepatoma) are much less common.

DISORDER of the LIVER (Cont.-5) Other disorders In Budd-Chiari syndrome, the veins draining the liver become blocked by blood clots, causing painful swelling of the liver and severe ascites. Obstruction of the portal vein is one cause of portal hypertension, which can lead to esophageal varices, and ascites. Portal hypertension is also one of the usual complications of cirrhosis. Investigation Disorders of the liver may be investigates by: - physical examination tests, - ultrasound scanning and - CT scanning.

DISORDER of GALLBLADDER The gallbladder rarely causes problems in childhood or early adulthood, but, from middle age onward, the increasing occurrence of gallstones can sometimes give rise to symptoms Because the digestive system can function normally without a gallbladder, its removal has little known long term effect. Congenital and Genetic Defects Abnormalities present from birth may includes no gallbladder; an oversized gallbladder; or two gallbladders; these defects rarely cause problems

Metabolic Disorders The principal disorder of the gallbladder, with which most other problems are associated, is the formation of gallstones. Gallstones are common, but only about 20% of people with gallstones have symptoms requiring cholecystectomy. Attempts by the gallbladder to expel the stone or stones can cause severe biliary colic (abdominal pain). There are three main types of gallstones, cholesterol gallstones, pigment gallstones and mixed gallstones. The great majority are cholesterol of mixed gallstones, and women are affected four times as often as men. Every year about 1 million Americans develop gallstones. Many people carry “silent” gallstones, which produces no symptoms.

Infection and Inflammation If a gallstone becomes stuck in the outlet from the gallbladder, the trapped bile may irritate and inflame the gallbladder walls and the bile itself may become infected. The first symptom may be biliary colic, which is followed by fever and abdominal tenderness. Repeated attacks of biliary colic and acute cholecystitis can lead to chronic cholecystitis, in which the gallbladder becomes schrunken and thick-walled and ceases to function. Rarely, the gallbladder may become inflamed without the presence of gallstones – a condition that is called acalculous cholecystitis. Occasionally, cholecystitis proceeds to a condition in which the gallbladder fills with pus, called empyema of the gallbladder. This can cause a high fever and severe abdominal pain.

Gallbladders harboring gallbladder cancer usually Tumors Gallbladders harboring gallbladder cancer usually contain gallstones. However the cancer is extremely uncommon compared to the high prevalence of gallstones. Other Disorders In rare cases where a gallbladder is empty when a stone obstructs its outlet, it may filt with mucus secreted by the gallbladder walls, resulting in a distended, mucus- filled gallbladder known as mucocele. Investigation Physical examination, ultrasound scanning or radionucleid scaning, and blood tests may also be carried out.

KEKHUSUSAN BAB XI DIESASES OF THE DIGESTIVE SYSTEM (PENYAKIT SISTEM PENCERNAAN) (K00 – K93) [Hal.549-596] Perhatikan Excludes di bawah judul. Bab ini terbagi dalam 10 blok. K00-K14 Peny. rongga mulut, kelenjar air liur dan rahang K20-K31 Peny. esofagus, lambung dan usus duabelas jari K35-K38 Peny. Appendix (usus buntu) K40-K46 Hernia K50-K52 Enteritis dan colitis non-infeksi

KEKHUSUSAN BAB XI (Lanjutan-1) K55-K63 Peny. lain-lain terkait usus K65-K67 Peny. peritoneum (selaput pembungkus perut) K70-K77 Peny. hati K80-K87 Gangguan kantung empedu, sal. empedu & pankreas K90-K93 Penyakit-2 lain terkait sistem digestif. Ada 5 kategori bertanda-baca * yakni: K23* K67* K77* K87* K93*

KEKHUSUSAN BAB XI (Lanjutan-2) Ada Excludes yang harus diperhatikan. Contoh pada kategori: K00.2 Ukuran dan bentuk gigi abnormal [Hal. 550] Excludes: … K00.3 Mottled teeth [Hal. 550] K00.4 Distrurbance in tooth formation [Hal. 551] K01 Embeded and impacted teeth [Hal. 551] K03 Peny. Lain jaringan padat gigi [Hal. 552] Excludes: ... Dan seterusnya mengikuti nomor code lain-lian.

KEKHUSUSAN BAB XI (Lanjutan-3) Ada Use additional external code (Chapter XX) … Contoh ada pada: K03.8 Peny.-2 khusus lain terkait jaringan keras gigi [Hal. 553] K06.2 Gangg.-2 lain gusi dan tonjolan alveoler gigi [Hal. 556] K10.2 Kondisi peradangan rahang bawah [Hal. 559] K20 Oesophagitis [Hal. 564] K22.1 Ulkus (tukak) esofagus [Hal. 565] Dan seterusnya pada nomor code lain-lain.

Perhatian khusus bagi K25-K28 [Hal. 566-567] Disediakan subdivisi dengan digit-ke-4 yang harus mengikuti code K25-K28: .0 perdarahan akut .1 perforasi (luka tembus) akut .2 perdarahan dan perforasi akut .3 tanpa perdarahan ataupun perforasi .4 kronik atau tidak dirinci dengan perdarahan .5 kronik atau tidak dirinci dengan perforasi .6 kronik atau tidak dirinci disertai perdarahan dan perforasi .7 kronik tanpa perdarahan dan perforasi .9 tidak dirinci apakah kronik atau akut, tanpa perdarahan atau perforasi.

Gastruc ulcer & Appendicitis Contoh: perdarahan tukak lambung kronik: K25.4 perforasi tukak lambung : K25.5 perdarahan dan perforasi tukak lambung (kronik): K25.6 Perbedaan ada di digit ke-4. Perhatian khusus untuk Appendicitis [569-570] Diseases of appendix (K35-K38) Di sini jelas bahwa penyakit radang usus buntu memilki sebanyak 4 variasi, dari nomor code K35, K36, K37 dan K38. Oleh karenanya diagnose appendicitis hendaknya rinci terutama apabila pasien dicito operasi atau dirawat di ICU.

Hernia Perhatikan Note: … di bawah Hernia (K40-K46) [Hal. 570-574] Hernia dengan gangrene dan obstruksi diklasifikasi ke hernia with (dengan) gangrene. Hernia inguinal (K40), hernia femoral (K41) juga harus dirinci apakah unilateral atau bilateral, dengan atau tanpa obstruksi atau gangrene. Apakah kanan atau kiri tidak mempengaruhi code terpilih? K42, K43, K44, K45, K46 hanya di satu site, tidak ada kanan atau kiri.

Noninfective enteritis & colitis (K50-K52)[574-576] Perhatikan Excludes dan Includes yang ada di bawah grup ataupun pada masing-2 kategori. [Hal. 575]: K52.1 Toxic gastroenteritis and colitis Use additional …  untuk menjelaskan agen penyebab keracunan tersebut. [Hal. 576] K52.9 Noninfective gastroenteritis and colitis, unspecified. Perhatikan perbedaan penggunaannya dengan A09. A09 adalah untuk …. [lihat hal. 112] K52.9 adalah untuk … P78.3 adalah untuk …

Other diseases of Intestine (K55-K63) [Hal.576-582] Excludes: … K56 Paralytic ileus and intestinal obstruction without hernia K57 Diverticulitis disease of intestine Perhatikan Includes dan Excludes yang ada. K59.3 Megacolon, NEC Use additional external cause code …

Diseases of Peritoneum (K65-K67) [Hal. 583-585) K65 Peritonitis Excludes: … K65.0 Acute peritonitis Use additional code (B95-B97) … Diseases of liver (K70-K77) [Hal. 585 – 590] Perhatikan: Excludes: haemochromatosis (E83.1) jaundice NOS (R17) Reye’s syndrome (G93.7) viral hepatitis (B15-B19) Wilson’s disease (E83.0)

Diseases of liver (K70-K77) (Hal. 585 – 590) K71 Toxic liver disease Includes: drug-induced: Ada : Use additional external cause code (Chapter XX), if … Excludes: … Perhatikan Excludes dan Includes yang mengikuti nomor code kategori ataupun subkategori  untuk memastikan kode yang akan dipilih adalah yang benar.

Disorders of Gallbladder; Biliary Tract and Pancreas (K80-K87) [Hal K80 Cholelithiasis Perhatikan nomor code yang berbeda bila gangguan ini disertai cholecystitis akut/kronik K81 Cholecydtitis Juga dibedakan antara yang akut dan kronik tanpa/dengan calculi. K83 Other diseases of biliary tract dan K86 Other diseases of pancreas Masing-masing ada Excludes:… K85 Acute pancreatitis termasuk abses pankreas. K84 kosong K87* Gangguan kantung/saluran empedu dan pancreas pada penyakit utamanya terklasifikasi di Bab lain.

Other Diseases of the Digestive System (K90-K93) [Hal. 594-596] K90 Intestinal malabsorption Excludes: yang terjadi postoperasi gastroentestinal (K91.2) K90.2 Blind loop syndrome NEC. Ada Excludes: … K90.4 Malabsorption due to intolerance, NEC. Ada Excludes: … K90.8 Other intestinal malabsorption Khusus untuk Whiplle’s disease K90.8 ! (M14.8*) K91 Postprocedural disorders of digestive system. NEC. Excludes: … Keadaan postprocedural adalah dinyatakan oleh dokternya, bukan interpretasi atau keputusan coder!

Other Disease od Digestive System K92 Other disease of digestive system Excludes: neonatal … K93* Gangguan organ-2 digestif lain pada penyakit yang terklasifikasi di Bab lain-lain  penyakit utamanya pakai tanda ! (dagger) K93.0* TB disorders of intestines, peritoneum and mesenteric glands (A18.3 !)  lihat [117] Excludes: TB peritonitis (K67.3*) K93.1* Megacolon in Chagas’ disease (B57.3*) K93.8* Disorders of other specified digestive organs in diseases classified elsewhere  lihat Ascariasis dengan komplikasi usus.

SOAL-SOAL LATIHAN Cari nomor kode istilah yang dicetak tebal dan diberi garis bawah dalam materi bacaan (reading 2) Latihan menentukan nomor kode istilah di bawah ini Oral leukoplakia (335) Leukoplakia - oral epithelium, including tongue (mucosa) K13.2 [562] K13.2 Leukoplakia and other distrurbances of oral epithelium including tongue Erythroplakia, Leukoedema of oral epith. … including tongue Leukokeratosis nicotina palati Smoker’s palate Excludes: hairy leukoplakia (K13.3)

Soal-soal Latihan (Lanjutan-1) Dental caries Dental (150) - see also condition (Condition – see Disease) - examination Z01.2 Sebaiknya gunakan Caries sebagai Lead-term Caries (90-91) - dental K 02.9 [552]  perlu rincian (bagian yang caries, dsb) agar tidak menggunakan code ber .9 Herpetic gingivostomatitis (245) B00.2 Herpes (265) - gingivostomatitis B00.2 [148] B00.2 Herpes viral gingivostomatitis and pharyngotonsillitis Herpesviral pharyngitis. Diagnose ini masuk ke laporan jumlah penyakit Herpes (kode berdagger) bukan gingivostomatitis.

Soal-soal Latihan (Lanjutan-2) Tukak duodenum dengan perdarahan dan perforasi  Ulcer duodenum, duodenal (eroded) (peptic) K26.9 - - with - - - hemorrhage K26.4 - - - - and perforation K26.2 Gastroenteritis hipersensitifitas susu, pasien usia 20th (244) - food hypersensitivity K52.2 [575] Bedakan dengan: Gastroenteritis keracunan makanan tercemar pepticida K52.1 (Use additional external cause code (cari di Bab XX))

LATIHAN SOAL-SOAL 1. Gangguan pencernaan No: GE akibat gangguan pencernaan No: Tukak lambung akibat minum aspirin dalam rangka terapi jantung, disertai perdarahan No: 4. Hernia incarcerata inguinalis kiri No: 5. Esophageitis No: 6. Stomatitis candidiasis, pasien HIV-AIDS No: 7. Dysentry amebiasis No: 8. Dysentri baksiler No: 9. Chronic Colitis No: 10. Pamcreatitis acute No:

LATIHAN SOAL-SOAL (Lanjutan) 11. Insulinoma No: 12. Hepatitis keracunan obat TB No: 13. Hepatitis keracunan makanan No: 14. Hepatoma No: 15. Hepatomegaly No: 16. Appendicitis abscess No: 17. Peritonitis komplikasi infeksi typhoid No: 18. TB mensentric No: 19. Regional enteritis No: 20. Gigi berlubang No: 21. Gigi susu tanggal No: 22. Gigi patah akibat jatuh No: