kuliahtumor hati.ppt
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ABSES HATIABSES HATI
ALI IMRON YUSUF,SpPD,KGEH,FINASIM ALI IMRON YUSUF,SpPD,KGEH,FINASIM
DIVISI GASTRO-HEPATOLOGIDIVISI GASTRO-HEPATOLOGI
BAG-I.PENYAKIT DALAM F.K. UNILA/RSUDBAG-I.PENYAKIT DALAM F.K. UNILA/RSUDDr.ABD MOELOEK BANDAR LAMPUNGDr.ABD MOELOEK BANDAR LAMPUNG
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ABSES HATI ABSES HATI
Bent! "n#e!$" p%&% '%t"Bent! "n#e!$" p%&% '%t"
Se(%r% )) * A+$e$ '%t" %)+"!Se(%r% )) * A+$e$ '%t" %)+"!
A+$e$ '%t" pen"! A+$e$ '%t" pen"!
%$%* +%!ter",p%r%$"t,0%)r,)%pn ne!r$"$%$%* +%!ter",p%r%$"t,0%)r,)%pn ne!r$"$
$ter" +er$)+er &%r" $"$te) %$tr-"nte$t"n%$ter" +er$)+er &%r" $"$te) %$tr-"nte$t"n%
&" t%n&%" &n %&%n% pr$e$ $pr%$" &n &" t%n&%" &n %&%n% pr$e$ $pr%$" &npe)+ent!%n p$ t.&.* 0%r"n%n '%t"pe)+ent!%n p$ t.&.* 0%r"n%n '%t"
ne!rt"!,$e "n#%)%$" .ne!rt"!,$e "n#%)%$" .
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A+$e$ H%t" A)+% A+$e$ H%t" A)+%
Diperkirakan diderita10 %Diperkirakan diderita10 % PENDUDUK DUNIA,PENDUDUK DUNIA,
TERUTAMA NEGARA BERKEMBANG TERINFEKSI E.Histolytika TERUTAMA NEGARA BERKEMBANG TERINFEKSI E.Histolytika
10 % MENIMBULKAN GEALA10 % MENIMBULKAN GEALA
I!si"#!s $ Taila!" 0,1& %I!si"#!s $ Taila!" 0,1& % Indonesia 5-15 % /tahunIndonesia 5-15 % /tahun
LAKI LAKI ' (ANITALAKI LAKI ' (ANITA
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PAT)GENESISPAT)GENESIS
Be) &"!et%'" $e(%r% p%$t"Be) &"!et%'" $e(%r% p%$t"
D"&% %.. #%!tr 2"ren$" p%r%$"t,ntr"$",D"&% %.. #%!tr 2"ren$" p%r%$"t,ntr"$",")n&epre$" pe0%),penrn%n ")n"t%$")n&epre$" pe0%),penrn%n ")n"t%$
$eer &%n re$"$ten$" p%r%$"t$eer &%n re$"$ten$" p%r%$"t
Me!%n"$)e* $tr%"n e. '"$tt"!% %&% %nMe!%n"$)e* $tr%"n e. '"$tt"!% %&% %n
p%ten &%n nn p%tenp%ten &%n nn p%ten
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E.'"$tt"!% ne)pe p%&% )!$% $$E.'"$tt"!% ne)pe p%&% )!$% $$
per$%!%n $%3%r "nte$t"n% $e $"$.per$%!%n $%3%r "nte$t"n% $e $"$.
Pene+%r%n %)+% &%r" $$ !e'%t"Pene+%r%n %)+% &%r" $$ !e'%t"$e+%"%n +e$%r 2"% 2en% prt%$e+%"%n +e$%r 2"% 2en% prt%
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GE4ALA KLINISGE4ALA KLINIS
DEMAMDEMAM
NYERI PERUT KANAN ATASNYERI PERUT KANAN ATAS
HEPATOMEGALIHEPATOMEGALI
KADANG GE4ALANYA TIDAK KHASKADANG GE4ALANYA TIDAK KHAS
ANOREKSIA ANOREKSIA
KADANG DEMAMKADANG DEMAM
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PEMERIKSAAN LABORATORIUMPEMERIKSAAN LABORATORIUM
U))n% e!$"t$"$U))n% e!$"t$"$
Ke%"n%n #%% '%t" r"n%n $%)p%" $e&%nKe%"n%n #%% '%t" r"n%n $%)p%" $e&%n
Ser" %)+% , $pe$"#"! nt! &%er%' nnSer" %)+% , $pe$"#"! nt! &%er%' nn
en&e)"!en&e)"!
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PEMRIKSAAN PENUN4ANGPEMRIKSAAN PENUN4ANG
ULTRASONOGRAFIULTRASONOGRAFI
T SANT SAN
THORAK FOTOTHORAK FOTO
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DIAGNOSISDIAGNOSIS
DEMAMDEMAM
NYERI PERUT KANAN ATASNYERI PERUT KANAN ATAS
HEPATOMEGALI 5NYERI TEKANHEPATOMEGALI 5NYERI TEKAN
LEUKOSITOSISLEUKOSITOSIS
DIAFRAGMA LETAK TINGGIDIAFRAGMA LETAK TINGGI
SEROLOGI AMUBA MENDUKUNGSEROLOGI AMUBA MENDUKUNG
USGUSG
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KRITERIA SHERLOKKRITERIA SHERLOK
HEPATOMEGALI YANG NYERI TEKANHEPATOMEGALI YANG NYERI TEKAN
LEUKOSITOSISLEUKOSITOSIS
PENINGGIAN DIFRAGMA KANAN DANPENINGGIAN DIFRAGMA KANAN DANPERGERAKAN YANG KURANGPERGERAKAN YANG KURANG
ASPIRASI ADA PUS ASPIRASI ADA PUS
USG ADA GAMBARAN RONGGAUSG ADA GAMBARAN RONGGA RESPON TERHADAP OBAT AMUBISIDRESPON TERHADAP OBAT AMUBISID
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KOMPLIKASIKOMPLIKASI
TERSERING RUPTUR.TERSERING RUPTUR.
DAPAT TER4ADI KE *DAPAT TER4ADI KE *
PLEURAPLEURA PARUPARU
PERIKARDIUMPERIKARDIUM
USUSUSUS
INTRAPERITONEALINTRAPERITONEAL
KULITKULIT
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PENGOBATANPENGOBATAN
DERIVAT NITROIMIDA6OLEDERIVAT NITROIMIDA6OLE
DAPAT DIBERIKAN ORAL DAN INTRADAPAT DIBERIKAN ORAL DAN INTRA
VENAVENA DAPAT MEMBUNUH BTK TROPO6OITDAPAT MEMBUNUH BTK TROPO6OIT
INTESTINAL,EKSTRA INTESTINAL,KISTAINTESTINAL,EKSTRA INTESTINAL,KISTA
DOSIS AN4URAN 7 8 9::-;9: ) 9DOSIS AN4URAN 7 8 9::-;9: ) 9$%)p%" 1: '%r"$%)p%" 1: '%r"
HLORO<UINHLORO<UIN
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TINDAKANTINDAKAN
BISA DILAKUKAN ASPIRASI AIRANBISA DILAKUKAN ASPIRASI AIRAN
ABSES DENGAN GUIDED USG APABILA ABSES DENGAN GUIDED USG APABILA
ADA ANAMAN RUPTUR DAN DIAMETER ADA ANAMAN RUPTUR DAN DIAMETER
= ; M= ; M
DI RSM TINDAKAN INI MERUPAKANDI RSM TINDAKAN INI MERUPAKAN
PROSEDUR BIASAPROSEDUR BIASA
TINDAKAN BISA BERULANG-ULANGTINDAKAN BISA BERULANG-ULANG
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1717
Kolesistitis-GallstoneKolesistitis-Gallstone
ALI IMRON YUSUF ALI IMRON YUSUF
DIVISI GASTRO-HEPATOLOGI BAG-DIVISI GASTRO-HEPATOLOGI BAG-
I.PENYAKIT DALAM F.K. UNILA/RSUDI.PENYAKIT DALAM F.K. UNILA/RSUDDr.ABD MOELOEK BANDAR LAMPUNGDr.ABD MOELOEK BANDAR LAMPUNG
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KOLESISTITISKOLESISTITIS
Y I *Re%!$" "n#%)%$" %!t &&Y I *Re%!$" "n#%)%$" %!t &&
!%n&n e)pe& &"$ert%"!%n&n e)pe& &"$ert%"
!e'%n ner" pert !%n%n %t%$,!e'%n ner" pert !%n%n %t%$,ner" te!%n &%n p%n%$ +%&%n.ner" te!%n &%n p%n%$ +%&%n.
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ETIOLOGI DAN PATOGENESISETIOLOGI DAN PATOGENESIS
FAKTOR*STASIS AIRAN EMPEDU ,INFEKSIFAKTOR*STASIS AIRAN EMPEDU ,INFEKSI
KUMAN DAN ISKEMIA DD KANDUNG EMPEDU.KUMAN DAN ISKEMIA DD KANDUNG EMPEDU.
PENYEBAB UTAMA * BATU KANDUNGPENYEBAB UTAMA * BATU KANDUNG
EMPEDU SEKITAR >:?.EMPEDU SEKITAR >:?.
FAKTORLAIN*KEPEKATAN AIRAN EMPEDU,FAKTORLAIN*KEPEKATAN AIRAN EMPEDU,
KOLESTEROL,LISOLESITIN,DAN P G YANGKOLESTEROL,LISOLESITIN,DAN P G YANG
MERUSAK DINDING KANDUNG EMPEDU.MERUSAK DINDING KANDUNG EMPEDU.
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GE4ALA KLINISGE4ALA KLINIS
NYERI PERUT KANAN ATASNYERI PERUT KANAN ATAS
NYERI TEKANNYERI TEKAN
PANASPANAS RASA SAKIT MEN4ALAR KEPUNDAKRASA SAKIT MEN4ALAR KEPUNDAK
ATAU SKAPULA KANAN ATAU SKAPULA KANAN
UMUMNYA @ANITA GEMUK= 7: THNUMUMNYA @ANITA GEMUK= 7: THN MURPHY SIGNMURPHY SIGN
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DIAGNOSISDIAGNOSIS
GE4ALA KLINISGE4ALA KLINIS
ULTRASONOGRAFIULTRASONOGRAFI
SKINTIGRAFI SAL-EMPEDU DGN RADIOSKINTIGRAFI SAL-EMPEDU DGN RADIO AKTIF,TAPI TEHNIK SUKAR. AKTIF,TAPI TEHNIK SUKAR.
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PENGOBATANPENGOBATAN
ISTIRAHATISTIRAHAT
OBAT PENGHILANG RASA SAKITOBAT PENGHILANG RASA SAKIT
ANTIBIOTIK ANTIBIOTIK 4IKA PERLU KOLESISTEKTOMI4IKA PERLU KOLESISTEKTOMI
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PROGNOSISPROGNOSIS
9 ? SEMBUH SPONTAN,TAPI9 ? SEMBUH SPONTAN,TAPI
KANDUNG EMPEDU TEBAL,FIBROTIKKANDUNG EMPEDU TEBAL,FIBROTIK
PENUH DGN BATU TDK BERFUNGSI.PENUH DGN BATU TDK BERFUNGSI.
KADANG MEN4ADI GANGREN,KADANG MEN4ADI GANGREN,
EMPYEMA DAN PERFORASI,FISTEL,EMPYEMA DAN PERFORASI,FISTEL,
ABSES HATI ATAU PERITONITIS. ABSES HATI ATAU PERITONITIS.
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GALL STONEGALL STONE
SERING DITEMUKANDI NEGARA DIBARATSERING DITEMUKANDI NEGARA DIBARAT
SUKU INDIAN TINGGI * 7:-;: ?SUKU INDIAN TINGGI * 7:-;: ?
DI BARAT 4ARANG MENGALAMI KOLIKDI BARAT 4ARANG MENGALAMI KOLIK
DI INDIAN 9:? KOLIK DAN KOMPLIKASI*DI INDIAN 9:? KOLIK DAN KOMPLIKASI*
KOLESISTITIS,KOLANGITIS DAN PANKREATITISKOLESISTITIS,KOLANGITIS DAN PANKREATITIS
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PATOGENESIS BATU EMPEDUPATOGENESIS BATU EMPEDU
DIPERLUKAN FAKTOR UTAMA *DIPERLUKAN FAKTOR UTAMA *
1.SUPERSATURASI KOLESTEROL1.SUPERSATURASI KOLESTEROL
C.HIPOMOTILITAS KANDUNGC.HIPOMOTILITAS KANDUNG
EMPEDUEMPEDU
.NUKLEASI EPAT.NUKLEASI EPAT
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4ENIS BATU EMPEDU4ENIS BATU EMPEDU
BATU KOLESTEROLBATU KOLESTEROL
BATU % BILIRUBINAT PIG-OKLATBATU % BILIRUBINAT PIG-OKLAT
BATU PIGMEN HITAMBATU PIGMEN HITAM
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GE4ALA KLINIKGE4ALA KLINIK
1 A SIMPTOMATIK1 A SIMPTOMATIK
C SIMPTOMATIKC SIMPTOMATIK
DGN KOMPLIKASI Y I * DGN KOMPLIKASI Y I *KOLESISTITIS AKUT,IKTERUS,KOLESISTITIS AKUT,IKTERUS,
KOLANGITIS DAN PANKREATITIS.KOLANGITIS DAN PANKREATITIS.
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MANIFESTASI KLINIKMANIFESTASI KLINIK
1 KOLIK BILIER, INI O.K.SPASME TONIK AKIBAT1 KOLIK BILIER, INI O.K.SPASME TONIK AKIBATOBSTRUKSI TRANSIEN DUKTUS SISTIKUS OLEHOBSTRUKSI TRANSIEN DUKTUS SISTIKUS OLEHBATU, BIASANYA TIMBUL MALAM HARI,NYERIBATU, BIASANYA TIMBUL MALAM HARI,NYERITERUTAMA DIDAERAH EPIGASTRIUM.TERUTAMA DIDAERAH EPIGASTRIUM.
C KOLESISTITIS AKUT>:->9?C KOLESISTITIS AKUT>:->9?
KOLESISTITIS KRONIKKOLESISTITIS KRONIK
7 KOLEDOKOLITIASIS DAN KOLANGITIS,INI O.K.7 KOLEDOKOLITIASIS DAN KOLANGITIS,INI O.K.MIGRASI BATU KE DUK- KOLEDOKUS, GE4ALAMIGRASI BATU KE DUK- KOLEDOKUS, GE4ALA
UTAMA* NYERI >;?,IKTERIK->?,TRIAS HAROTUTAMA* NYERI >;?,IKTERIK->?,TRIAS HAROT>?.>?.
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DIAGNONISDIAGNONIS
YANG PALING TEPAT DENGANYANG PALING TEPAT DENGAN
E U SE U SKEBERHASILAN* >; ? DIBANDINGKEBERHASILAN* >; ? DIBANDING
USG BIASA.USG BIASA.
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PE MERIKSAAN -RADIOLOGIPE MERIKSAAN -RADIOLOGI
FOTO POLOS ABDOMENFOTO POLOS ABDOMEN
KOLESISTOGRAFIKOLESISTOGRAFI
PENATAHAN HATI DGN HIDAPENATAHAN HATI DGN HIDA T SANT SAN
PT PERKUTANIUS TRANSHEPATIPT PERKUTANIUS TRANSHEPATI
KOLANGIOGRAFI KOLANGIOGRAFI ERPERP
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Table Risk Factors Associated withTable Risk Factors Associated with
Cholesterol Gallstone FormationCholesterol Gallstone Formation
Older AgeOlder Age
Female GenderFemale Gender
ObesityObesity
Weight LossWeight Loss
Total ParenteralTotal Parenteral
!trition!trition
PregnancyPregnancy
"ncreased cholesterol secretion and"ncreased cholesterol secretion anddecresed bile acid synthesisdecresed bile acid synthesis
"ncreased cholesterol secretion and"ncreased cholesterol secretion andincreased intestinal transit timeincreased intestinal transit time
Cholesterol hy#ersecretion into bile andCholesterol hy#ersecretion into bile andincreased cholesterol synthesis $iaincreased cholesterol synthesis $iaincreased %&G-CoA red!ctase acti$ityincreased %&G-CoA red!ctase acti$ity
Cholesterol hy#ersecretion into bile'Cholesterol hy#ersecretion into bile'red!ced bile acid synthesis andred!ced bile acid synthesis andgallbladder hy#omotilitygallbladder hy#omotility
Gallbladder hy#omotilityGallbladder hy#omotility
"ncreased cholesterol secretion and"ncreased cholesterol secretion andgallbladder hy#omotilitygallbladder hy#omotility
R"(K FACTOR PROPO()* &)TA+OL"C A+OR&AL"T,
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Table Risk Factors Associated withTable Risk Factors Associated withCholesterol Gallstone FormationCholesterol Gallstone Formation
*r!gs*r!gs
ClobrateClobrate
Oral contra-Oral contra-ce#ti$esce#ti$es
)strogen)strogentreat-ment intreat-ment inwomenwomen
)strogen)strogen
treat-ment intreat-ment inmenmen
ProgestogensProgestogens
Ce.tria/oneCe.tria/one
*ecreased bile acid concentration as a*ecreased bile acid concentration as ares!lt o. s!##ression o. 0res!lt o. s!##ression o. 0-hydro/ylase acti$ity and decreased-hydro/ylase acti$ity and decreasedACAT acti$ityACAT acti$ity
"ncreased cholesterol secretion"ncreased cholesterol secretion
Cholesterol hy#ersecretion into bile andCholesterol hy#ersecretion into bile andred!ced bile acid synthesisred!ced bile acid synthesis
Cholesterol hy#ersecretion into bileCholesterol hy#ersecretion into bile
*iminished ACAT acti$ity and increased*iminished ACAT acti$ity and increasedcholesterol secretioncholesterol secretion
Preci#itation o. an insol!ble calci!m-Preci#itation o. an insol!ble calci!m-
ce.tria/one saltce.tria/one salt
*ecreased gallbladder motility*ecreased gallbladder motility
R"(K FACTOR PROPO()* &)TA+OL"C A+OR&AL"T,
α
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Table Risk Factors Associated withTable Risk Factors Associated with
Cholesterol Gallstone FormationCholesterol Gallstone Formation
Genetic Predis-Genetic Predis-#osition#osition
ati$e Americansati$e Americans
(candina$ians(candina$ians
*iseases o. the Ter-*iseases o. the Ter-minal "le!mminal "le!m
Li#id ProleLi#id Prole *ecreased %*L*ecreased %*L
"ncreased trigly-"ncreased trigly- ceridescerides A#oli#o#rotein )-1A#oli#o#rotein )-1
"ncreased cholesterol synthesis and"ncreased cholesterol synthesis andred!ced con$ersion o. cholesterolred!ced con$ersion o. cholesterol
into bile saltsinto bile salts"ncreased cholesterol secretion into"ncreased cholesterol secretion into
bilebile
%y#osecretion o. bile salts .rom%y#osecretion o. bile salts .romdiminished bile acid #ooldiminished bile acid #ool
"ncreased acti$ity o. %&G-CoA"ncreased acti$ity o. %&G-CoAred!ctasered!ctase
"ncreased acti$ity o. %&G-CoA"ncreased acti$ity o. %&G-CoAred!ctasered!ctase
Pro#osed #ron!cleatorPro#osed #ron!cleator
R"(K FACTOR PROPO()* &)TA+OL"C A+OR&AL"
Table Common Clinical &ani.estations o. GallstoneTable Common Clinical &ani.estations o. Gallstone
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Table Common Clinical &ani.estations o. GallstoneTable Common Clinical &ani.estations o. Gallstone*isease*isease
(ym#toms+"L"AR, COL"C
(e$ere' #oorly locali2ed e#igastric or right !##er 3!adrant$isceral #ain growing in intensity o$er 45 min and remainingconstant .or 4-6 hr' o.ten with na!sea
Fre3!ency o. attacks $aries .rom days to monthsGas' bloating' 7at!lence' and dys#e#sia are not related to stones
AC8T) C%OL)C,(T"T"(
059 are #receded by attacks o. biliary colic
:isceral e#igastric #ain gi$es way to moderately se$ere' locali2ed#ain in the right !##er 3!adrant' back' sho!lder' or' rarely'chest
a!sea with some emesis is .re3!entPain lasting ; 6 hr .a$ors cholecystitis o$er colic
C%OL)*OC%OL"T%"A("(
O.ten asym#tomatic(ym#toms <when #resent= are indisting!ishable .rom biliary colicPredis#oses to cholangitis and ac!te #ancreatitis
C%OLAG"T"(
Charcot>s triad o. #ain' ?a!ndice' and .e$er is #resent in 0@9Pain may be mild and transient and is o.ten accom#anied by
chills
&ental con.!sion' lethargy' and deliri!m are s!ggesti$e o.bacteremia
Table Common Clinical &ani.estations o. GallstoneTable Common Clinical &ani.estations o. Gallstone
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Table Common Clinical &ani.estations o. GallstoneTable Common Clinical &ani.estations o. Gallstone*isease*isease
at!ral history
+"L"AR, COL"C
A.ter initial attack' @9 ha$e no .!rther sym#tomsThe remainder de$elo# sym#toms at a rate o. 69 #er year
and se$ere com#lications at rate o. 49 #er year
AC8T) C%OL)C,(T"T"(
5@9 resol$e s#ontaneo!sly in 0-4@ days witho!t s!rgery
Le.t !ntreated' 4@9 are com#licated by a locali2ed#er.oration and 49 by a .ree #er.oration and #eritonitis
C%OL)*OC%OL"T%"A("(
at!ral history is not well dened' b!t com#lications are
more .re3!ent and se$ere than .or asym#tomatic stonesin the gallbladder
C%OLAG"T"(
%igh mortality i. !nrecogni2ed' with death .rom se#ticemia)mergent decom#ression o. the C+* <!s!ally by )RCP=
dramatically im#ro$es s!r$i$alB
Table Common Clinical &ani.estations o. GallstoneTable Common Clinical &ani.estations o. Gallstone
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Table Common Clinical &ani.estations o. Gallstone*isease*isease
Physical ndings+"L"AR, COL"C
&ild-to-moderate gallbladder tendermess d!ring an attack with
mild resid!al tenderness lasting daysO.ten a com#letely normal e/amination
AC8T) C%OL)C,(T"T"(
Febrile b!t !s!ally 4@DOF !nless com#licated by gangrene or#er.oration
Right s!bcostal tenderness with ins#iratory arrest <&!r#hy sign=
Pal#able gallbadder in 9' es#ecially in #atients ha$ing their rstattack &ild ?a!ndice in D@9' higher .re3!ency in elderlyC%OL)*OC%OL"T%"A("(
O.ten a com#letely normal e/amination i. the obstr!ction isintermittent
Ea!ndice with #ain s!ggests stones' whereas #ainless ?a!ndice anda #al#able gallbladder .a$or malignancy
C%OLAG"T"(Fe$er in 59Right !##er 3!adrant tenderness in @9
Ea!ndice in only @9Peritoneal signs in only 459%y#otension and mental con.!sion coe/ist in 459 and s!ggest
gram-negati$e se#sis
Table Common Clinical &ani.estations o. GallstoneTable Common Clinical &ani.estations o. Gallstone
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Laboratory ndings+"L"AR, COL"C
8s!ally normal
"n #atients with ndings o. only !ncom#licated biliary colic' anele$ated bilir!bin' alkaline #hos#hatase' or amylase s!ggestscoe/isting C+* stones
AC8T) C%OL)C,(T"T"(
Le!kocytosis o. 4D'@@@ to 45'@@@ with bandemia iscommon+ilir!bin may be D-1 mgHdL and transaminase and alkaline
#hos#hatase may be ele$ated e$en in the absence o. C+* stoneorhe#atic in.ection
&ild amylase ele$ation is seen e$en in absence o. #ancreatitis". bilir!bin ;1 or amylase ; 4@@@' s!s#ect C+* stone
C%OL)*OC%OL"T%"A("(
)le$ated bilir!bin and alkaline #hos#hatase seen with C+*obstr!ction
+ilir!bin ;4@ mgHdL s!ggests malignant obstr!ction or coe/isting
hemolysisTransient Is#ikeJ in transaminases or amylase s!ggests #assage o.
a stone
C%OLAG"T"(
Le!kocytosis in @9' b!t remainder may ha$e normal W+C co!ntwith bandemia as the only hematologis nding
+ilir!bin ;D mgHdL in @9' b!t when D mgHdL the diagnosis maybe missed
Alkaline #hos#hatase is !s!ally ele$ated+lood c!lt!res are !s!ally #ositi$e' es#ecially d!ring chills or .e$er
s#ike' and grows two organisms in hal. o. #atients
*isease*isease
7/23/2019 kuliahTumor Hati.ppt
http://slidepdf.com/reader/full/kuliahtumor-hatippt 35/35
DAFTAR PUSTAKADAFTAR PUSTAKA
BUKU A4AR IPD 4ILID 1 ED- IVBUKU A4AR IPD 4ILID 1 ED- IV FUNDAMENTAL OF GASTROENTROLOGI, ALIHFUNDAMENTAL OF GASTROENTROLOGI, ALIH
BAHASA DALDIONO DKKBAHASA DALDIONO DKK
KULIAH IPD Dr. YUKE, FK.UNPADKULIAH IPD Dr. YUKE, FK.UNPAD GREENBERGER,4N,PAUMGARTNER,GGREENBERGER,4N,PAUMGARTNER,G
DESEASE OF THE GALLBLADDER AND BILEDESEASE OF THE GALLBLADDER AND BILEDUT "n PRINIPLES OF INTERNALDUT "n PRINIPLES OF INTERNAL
MEDIINE,HORRISONS 19 t' ED,VOL-C,e&-MEDIINE,HORRISONS 19 t' ED,VOL-C,e&-BRAUN@ALD ETALL,C::1.BRAUN@ALD ETALL,C::1.
THANKS FOR YOUR ATTENTION.THANKS FOR YOUR ATTENTION.
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