Laporan Case 2 Gis Kel 3 2003 (1)

8/18/2019 Laporan Case 2 Gis Kel 3 2003 (1)

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LAPORAN TUTORIAL

SISTEM GASTROINTESTINAL KASUS 2

“DECOMPENSATED LIVER CIRRHOSIS E.C.CHRONIC ACTIVE VIRAL

HEPATITIS B”

Tutor: Mia Ku !iati" #r. M.$%

O&%':

KELOMPOK (

)a#'i&&a U!a!iRia*i Ku u!a#%+iVi%*#ri )ir'a*# Ni a, a 'a Ni a D+iRi- i Ra'!a* Mu&/a*aAu&ia Nur A!a&iaS%rra V%&&/ M%tri$a Ra*iMu'a!!a# Ir /a# H%*#aRi-a*a Ka*ia+ati 0A*11ita G'a a*/

Dau&i$a Ca*ti$a )a% i

3 33 23(23 33 23343 33 23253 33 23363 33 23 33 33 23243 33 23 43 33 23523 33 23573 33 6

3 33 3(5

)AKULTAS KEDOKTERAN

UNIVERSITAS ISLAM BANDUNG

23 5

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DA)TAR ISIDAFTAR ISI....................................................................................................................................1OVERVIEW CASE.........................................................................................................................1

BAB I...............................................................................................................................................3BASIC SCIENCE............................................................................................................................3

A. ANATOMI LIVER...............................................................................................................3B. HISTOLOGI LIVER..........................................................................................................12C. FISIOLOGI.........................................................................................................................16

1. LIVER.............................................................................................................................162. METABOLISME BILIRUBIN.......................................................................................18

BAB II...........................................................................................................................................21CLINICAL SCIENCE...................................................................................................................21

A. JAUNDICE.........................................................................................................................21B. HEPATITIS.........................................................................................................................25

1. Per e!""# $e%"&'&'( (e)"r" *+*+...................................................................................252. He%"&'&'( B.......................................................................................................................25

C. CIRRHOSIS.......................................................................................................................,,D. SHOC-...............................................................................................................................51E. PEMERI-SAAN................................................................................................................52

1. Per)*&"#e *( L'/er B' %(0.............................................................................................522. Te( F*# (' He%"r.............................................................................................................553. Ser ') M"r er(...........................................................................................................55,. Per'& #e" T"%..................................................................................................................565. I#&er%re&"(' * &r"( *#! e4"+'#"&' #................................................................................586. -"r" &er'(&' Tr"#(*!"&...................................................................................................5

F. FARMA-OLOGI...............................................................................................................51. S +"& (&"&'#....................................................................................................................52. S%'r # ")& #e................................................................................................................63. D'e& Re#!"$ S !'*+.......................................................................................................6,. Pr %"# .......................................................................................................................62

G. PATOME-ANISME...........................................................................................................63H. IIMC...................................................................................................................................66I. BHP.....................................................................................................................................66

DAFTAR PUSTA-A.....................................................................................................................67

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OVERVIE0 CASEPr'" 3 &"$*#CC• *r'# e "% !"# +"&" *#'#

HISTOR9• Ur'# e "% !"# +"&" *#'# (e:" 1 +'# *• , $"r' 0 " * ;"&' *e< +" "'(e< #"*(e"• , &"$*# 0 " * %er#"$ :"*#!')e !e# "# ;"&' *e !"# %e#*r*#"# #";(* +" "#• T'!" %er#"$ !' '+*#'("('

FAMIL9 HISTOR9• I * !"# 2 ("*!"r" " '2#0" +e#!er'&" )$r #') $e%"&'&'(

PE• S) er" ')&er*(• He%"& +e " 0 =3 )+ !' ">"$ "r)*( ) (&" !"# P?@• Se!' '& #0er' &e "# %"!" '/er

LABHEMAATOLOGI• L'+; ('&

BLOOD CHEMISTRIES• T &" ' 'r* '# • B' 'r* '# !'re)& • SGOT • SGPT • A " '#e %$ (%$"&"(e

SEROLOGIC MAR-ER • HB(A

URINAL9SIS• M" r *#'# e "%• M' r ' 'r* '# = @

D'" # ('(• )$r #') ")&'/e /'r" $e%"&'&'( B er!"("r &e( (er '(• !'&er"%' (*%% r&'/e< (0+%& +"&') !"# & &" e!re(&

) *r(e• (""& ; > *%< $"(' &e( &e&"% " # r+"• %er)*&"#e *( '/er ' %(0

o (&"&*( )$r #') $e%"&'&'(o HBV DNA = @o HBeA = @

D' er' "#&'/'r" &$er"%0< #"+*# (& & ; > *%15 &$# (e&e "$ (& & ; > *%

• Ter '$"& (" '&

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• B" '"# "$* +e# e)' < " ! +e# +e+ e("r.• A# e e!e+"

PE• S) er" ')&er*(< JVP• S%'!er "# ' +"&" !' !"!".• ($ * !er 'r! e +*() e• G0#"e) +"(&'"• L'/er &'!" &er%" %"('• S$';&'# !* #e(( = @• S% e# +e " 0 =()$*;;#er III@• L (( "4' " $"'r • P'&&'# e!e+" %"!" "# e = @• P" +"r er0&$e+" = @< '/er #"' = @

LABHe+"& '

• Le* %e#'"• Se +e#& • A#e+'"• PT +e+"#:"#• H'%er ' 'r* '#e+'"• SGOT< SGPT • A *+'# • T &" %r &e'#

U &r"( *#!• S$r*# e# '/er< (% e# +e " 0< "()'&e(

Per'& #e" &"%• SAAG


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BAB I

BASIC SCIENCE

A. ANATOMI LIVER L'/er +er*%" "# e e#:"r &er e("r !' !" "+ &* *$< er"" *r"# e '$ 15 r< !"#

(e '&"r 1 , "&"* 2"(".L "('

o D"r' ">" "#" 2 +e#*:* e !e%"#< (e " '"# e("r +e#e+%"&' $0% )$ #!r'*+

"#"# !"# e%' "(&r'*+. Me+"#:"# e !" "+ $0% ) #!r'*+ 'r'< '#;er' r

!'";r" +"< 0"# +e+'("$ "# !"r' % e*r"< %"r*< %er')"r!'*+< !"# :"#&*# .

= FIG.2., A@o Ber"!" !' "#"# !"# 'r' *%%er *"!r"#& =*+*+#0" %"!" ('(' "#"#@.o -ECUALI *#&* e+" < (e+*" #*&r'e#& !'" ( r%(' !"r' GIT ">" #0" !' ">"

%er&"+" " ' e '/er e$ (0(&e+ /e#" % r&" .

F*# (' (e)"r" *+*+ " &'/'&"( +e&" ')< %e#0'+%"#"# ' e# !"# (e re(' ' e.

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A#&er' r "0er ; &$e ) r #"r0 ' "+e#& +e#0"+ *# %"!" (e e "$ 'r'

!e# "# r' $& "0er ; &$e ;" )'; r+ ' "+e#& !"# % (&er' r "0er #0"

+e#0"+*# !e# "# r' $& "0er ; &$e e((er +e#&*+. Le;& "0er ; &$e

;" )'; r+ ' "+e#& !"# e((er +e#&*+ er&e+* !"# +e+ e#&* left

triangular ligament .o Visceral surface

D' "%'(' e$ %er'& #e*+< e)*" ' %"!" fossa for the gallbladder !"# the

porta hepatic. Ada 2 sagital fissure, 0"# !'$* *# "# (e)"r" )e#&r" e$ transvers porta

hepatic, +e+ e#&* $*r*; H %"!" %er+* ""# /'()er" . =2.5 A@. RIGH !AGI A" #I!!$R% & (e)"r" "#&er' r !' e#&* e$ ; ((" ; r &$e

" "!!er. D"# (e)"r" % (&er' r !' e#&* e$ r /e ; r /e#" )"/". "%# !AGI A" #I!!$R% & (e)"r" "#&er' r " *r !' e#&* e$ ;'((*re ; r &$e

' "+e#&*+ &ere( "&"* r *#! ' "+e#&. D"# (e)"r" % (&er' r e$ ;'((*re ; r

&$e ' "+e#&*+ /e# (*+.R *#! ' "+e#& ;' r *( re+#"#& ; &$e *+ ' ')" /e'# &"$"& )"rr'e! >e

40 e#"&e! "#! #*&r'e#& r')$ ! ;r + &$e % ")e#&" & &$e ;e&*!.L' "+#e&*+ /e# (*+ ;' r *( re+#"#& ; &$e ;e&" !*)&*( /e# *( &$"&

($*#&e! ! ;r + &$e *+ ' ')" /e'# & &$e IVC< ($ r& )'r)*'&'# &$e '/er.T$e /'()er" (*r;")e '( re "&e! & &$e

o S'(' "#"# " '"# "#&er' r "+ *# K the gastric and pyloric areaso S*%er' r =;'r(&@ %"r& ; &$e !* !e#*+ Kthe duodenal areao Le((er +e#&*+ =+e *"( e !" "+ ;'((*re ; r ' "+e#&*+ /e# (*+@o G" "!!er =; ((" " "!!er@o C ') ; e4*re "#"# !"# &r"#(/er(e ) # "#"# K the colic areao G'#:" !"# (*%r"re#" "#"# K the renal and suprarenal areas

A#"& +')" L e( ; &$e L'/er • Se)"r" e4re" < '/er !' " ' +e#:"!' 2 & % r";' e( !"# 2 "))e(( r0 e( e$

re; e)&' # ; %er'& #e*+ !"r' %er+* ""# '&*.• M'! '#e % "#e !e "+ "r "# e$ %er e "&"# ;" )'; r+ ' "+e#& !"# e;& (" '&&" ;'((*re

0"# +e+'("$ "# "r e r' $& e !"r' (+" er e;& e.• B" '"# e( "#"# )"*!"&e e =% (&er' r (*%er' r@ !"# *"!r"&e e

="#&er' r '#;er' r@F*#)&' #" (* !'/'(' # ; &$e L'/er

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L'/er +e+%*#0"' ;*#)&' #" 0 '#!e%e#!e#& r' $& "#! e;& %"r&( =% r&" e(@

0"# *r"# e '$ * *r"##0" ("+". T"%'< '/er "#"# (e!' '& e *$ e("r.Se&'"% " '"# +e#er'+" %r'+"r0 r"#)$ $e%"&') "r&er0 !"# % r&" /e'# !"# !'

!r"'#"(e e$ $e%"&') !*)&.

P r&" $e%"&') =$e%"&') % r&" % r&" ;'((*re@ +er*%" "# &r"#(/er(e ;'((*re %"!"/'()er" (*r;")e '/er "#"&" )"*!"&e !"# *"!r"&e e< !'+"#" % r&" /e'# !"#

$e%"&') "r&er0 +"(* e '/er !"# $e%"&') !*)&( +e#'# " "# '/er.T$e % r&" $e%"&'( '/e( %"((" e & &$e % r&" /e'#< $e%"&') "r&er0< $e%"&') #er/e

% e4*(< $e%"&') !*)&(< !"# 0+%$"&') /e((e (.

Per'& #e" Re "&' #( ; &$e '/er Le((er +e#&*+< +e '# *%' % r&" &r'"!< ' e !*)&< $e%"&') "r&er0< !"# % r&"

/e'#K er:" "# !"r' '/er +e#*:* e((er )*r/"&*re ; &$e (& +")$ !"# 2 )+ %er&"+" !"r'

" '"# (*%er' r =;'r(& %"r&@ !* !e#*+. S'(' e "( !"# &e " !"r' e((er +e#&*+<

+e+"#:"# "#&"r" % r&" $e%"&') '/er !"# !* !e#*+ =&$e $e"& !* !e#" ' "+e#&@<

+e '# *%' % r&" &r'"!< e er"%" 0+%$ # !e(< 0+%$"&') /e((e (< !"# $e%"&') % e4*( ;

#er/e(. B" "'# "'# !"r' e((er +e#&*+< &$e $e%"& "(&r') ' "+e#&< +e+"#:"# "#&"r"

r /e ; r &$e ' "+e#&*+ /e# (*+ ; &$e '/er !"# &$e e((er )*r/"&*re ; &$e (& +")$.

He%"&') Se +e#&"&' #D' " ' +e#:"!' 8 (e +e#&

o I POSTERIOR CAUDATE SEGMENTo II e;& % (&er' r = "&er" @ (e +e#&o III Le;& "#&er' r "&er" (e +e#&o IV Le;& +e!'" (e +e#&o V R' $& "#&er' r +e!'" (e +e#&o VI R' $& "#&er' r "&er" (e +e#&o VII R' $& % (&er' r "&er" (e +e#&o VIII R' $& % (&er' r +e!'" (e +e#&

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B ! Ve((e ( ; &$e L'/er L'/er (e%er&' %"r* %"r*< +e+%*#0"' 2 ! (*%% 0 =";;ere#& /e((e (@ ! +'#"#

/e# *( !"# 1 e((er "r&er'" .

1. Ar&er'A ! +'#" A r&"

S% e#') "r&er0 Ce '") &r*# Le;& "(&r') "r&er0

Me(e#&er') '#;er' r He%"&') "r&er0 Me(e#&er') (*%er' r

Le;& )$ ') "r&er0 R' $& )$ ') "r&er0

De()e#!'# ) # 'ommon hepatic artery Hepatic proper artery A()e#!'# ) #

Le;& He%"&') "r&er0 R' $& $e%"&') "r&er0C0(&') "r&er0 " "!!er

2. Ve'#

I#;er' r +e(e#&er') /e'# S*%er' r +e(e#&er') /e'# %"#)re"&')) !* !e#" /e'# S% e#') /e'#

P r&" Ve'# Le;& R' $& "(&r') /e'#Ve#* % r&"

D'(&r' *&'# /e'#I# e& /e#* e S'#*( '!Ce#&r" '( /e'#

Ber " *# !e# "# (* * "r'( /e'#He%"&') /e'#

I#;er' r Ve#" C"/"

Ve((e ( "#! Ner/e( ; &$e L'/er

• P r&" /e'#

D' e#&* e$ (*%er' r +e(e#&er') !"# ( e#') /e'# % (&er' r !"r' #e) %"#)re"(

!"# "()e#! e "#&er' r IVC " '"# !"r' % r&" &r'"! !' $e%"& !* !e#" ' "+e#& =;' .2.51@• =75 8 @ +e+ ">" !"r"$ e '/er. P r&" ! +e# "#!*# (e '&"r , e '$

(' e# !"r"$ +e# e+ " ' "# e :"#&*# !"r' (0(&e+') )'r)*'&< +e#!* *# %"re# '+

$e%"r =(e $e%"r $e%"& ('&@.• P r&" /e'# Me+ ">" $"+%'r (e *r*$ #*&'(' !'" ( r%(' e$ GI &r")& = e). '%'!"&' '/er !' '+%"&' (0(&e+@ e ('#*( '! '/er =2.53@

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• He%"&') "r&er0

• =2 25 @ !"r"$ !'&er'+" e$ '/er< !'!'(&r' *(' "# ">" %"!" (&r* &*r # #

%"re# '+" < $*(*(#0" '#&r"$e%"&') ' e !*)&(.• He%"&') "r&er0 D"%"& !' " ' +e#:"!'

o C ++ # $e%"&') "r&er0< !"r' )e '") &r*# e r' '# "(&r !* !e#" "r&er0o He%"&') "r&er0 %r %er< !"r' r' '# "(&r !* !e#" "r&er0 !"# ';*r)"&' # #0" e

)" "# )" "# "r&er' 'r' !"# "#"# '/er.

o Se&'"% " '"# !"r' %r'+"r0 r"#)$ +e+ e#&* /"()* "r (e +e#&. Le;& e

(e +e#& 1 ,< !"# r' $& e (e +e#& 7 8.

T$e L0+%$"&') Ve((e ( ; &$e L'/er

• S*%er;')'" 0+%$"&')( 0"# &er e&" !' (* %er'& #e" ;' r *( )"%(* e ; &$e '/er

=G '(( # ( )"%(* e@< 0"# +e+ e#&* %er+* ""# *"r.• Dee% 0+%$"&')( 0"# &er e&" !' :"r'# "# ' "& 0"# er:" "# er("+""# !e# "#

%er)" "# "# !"r' % r&" &r'"! !"# $e%"&') /e'#(.

• P"!" ('(' "#&er' r !'%$"r" +"&') !"# /'()er" (*r;")e

S*%er;')'" 0+%$"&')( Dee% 0+%$"&')(

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He%"&') 0+%$ # !e=&er%e#)"r !'(e '&"r $e%"&') /e((e ( "#! !*)& !' e((er +e#&*+@

Ce '") 0+%$ # !e

-e+ " ' er!r"'#"(e e C$0 e )'(&er#=!' "&e! (") %"!" *:*# '#;er' r !"r' &$ r")') !*)&@

P"!" ('(' % (&er' r !'%$"r" +"&') !"# /'()er" (*r;")e

S*%er;')'" 0+%$"&')(

P$re#') 0+%$ # !e =%"!" "re "re" ; &$e '/er@A&"*

J '# Dee% 0+$"&')( = er:" "# er("+""# !e# "# $e%"&') /e'# 0"# " "# er("&*

!' '#;er' r /e#" )"/"@

Me e>"&' !'";r" +" e P (&er' r +e!'"(&'#" 0+%$ # !e(

R' $& 0+%$"&')( "#! &$ r")') !*)&

• A!" e er"%" 0+%$"&') /e((e ( +e# ' *&' r*&e 0"# "'#

• Fr + &$e % (&er' r (*r;")e ; &$e e;& e & >"r! &$e e( %$" e" $'"&*( ; &$e !'"%$r" +

& e#! '# e;& "(&r') 0+%$ # !e(• Fr + &$e "#&er' r )e#&r" !'"%$r" +"&') (*r;")e " # &$e ;" )'; r+ ' "+e#& &

%"r"(&er#" 0+%$ # !e(• A # &$e r *#! ' "+e#& ; &$e '/er & &$e *+ ' ')*( "#! 0+%$"&')( ; &$e "#&er' r

" ! +'#" >" .

Per("r";"# L'/er • Ce '") % e4*( He%"&') #. % e4*( =)" "# !"r' $e%"&') "r&er0 % r&" /e'# %"!" '/er@

&er!'r' !"r' (0+%"&$e&') ;' er(.• P"r"(0+%"&$e&') ;' er( !"r' "#&er' r !"# % (&er' r /" " &r*# (.• Ner/e ;' er( er:" "# er("+" /e((e (< !"# ' '"r0 !*)& +"(* !"r' % r&" &r'"!.

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B. HISTOLOGI LIVER L'/er !' "%'(' e$ "%(* ;' r (" &'%'( 0"# +er*%" "# :"r'# "# ' "& !"# +e#e " !'

" '"# $' *+< !'+"#" % r&" /e'# !"# $e%"&') "r&er0 +"(* e !" "+ r "# !"# !'+"#" $e%"&')!*)& "#"# !"# 'r' :* " 0+%$"&') e *"r. Ser" *& re&')* "r $" *( 0"# (" '# er$* *# "#

+e# e ' '# ' !"# +e#0 # (e '/er !"# (e e#! &e ('#*( '! !"r' * * *( '/er.

H%8ati9 Lo u&%He%"& ('& +er*%" "# (e e%'&e 0"# er " *# !' '#&er) ##e)&e! % "&e(. He%"& ('&

&er(*(*# r"&*("# +e#:"!' $e%"&') * e( 0"# +er*%" "# *#'& ;*# (' #" !"r' '/er. Se&'"% * e

+e+' ' ' 3 ("+%"' 6 % r&" "re" !' %er';er#0" !"# /e#* e 0"# !'(e *& )e#&r" /e'# !' " '"#

&e# "$#0". P r&" #e( !' (*!*& !"r' * e( &er!'r' !"r' :"r'# "# ' "& 0"# +e# ' "& /e#* e

=)" "# !"r' % r&" /e'#@< "r&er' e =)" "# !"r' $e%"&') "r&er0@ !"# !* &*( =)" "# !"r' (0(&e+

' e !*)&@ K e&' " (&* &*r '#' !'(e *& % r&" &r'"!.Ve#* e +e+ ">" !"r"$ !"r' (*%er' r !"# '#;er' r +e(e#&er') !"# (% e#') /e'#. Ar&er' e

+e+ ">" !"r"$ !"r' )e '") &r*# ; " ! +'#" " r&". D* &*( +e+ ">" ' e 0"# !'('#&e('( e$

(e %"re# '+" =$e%"& ('&@ !"# +e#0" *r "##0" e $e%"&') !*)&. D'!" "+ % r&" "re" %*# &er!"%"&

(er" *& ("r"; !"# 0+%$"&').

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He%"& ('& er("&* ("&* ("+" "'# +e+ e#&* (e%er&' "&* "&" !' !'#!'# !"# % "&e(

&er(*(*# (e)"r" +e '# "r !'(e e ' '# )e#&r" /e'#. D"r' %er';er e )e#&r" < % "&e( !"r' $e%"& ('&

er)" "# !"# er"#"(& + ('( (e)"r" e "( +e+ e#&* (&r* &*r (e%er&' (% # e. S%")e !'"#&"r"

% "&e( !'(e *& '/er ('#*( '! +e# "#!*# +' r /"( * "&*r 0"# %e#&'# . S'#*( '! 0"#

er!' "&"(' 'rre * "r '#' &er(*(*# !"r' "%'("# 0"# !' #&'#* !"r' ;e#e(&r"&e! e#! &$e '" )e . Se

e#! &e &er%'("$ !"r' $e%"& ('& !' ">"$#0" e$ "(" "+'#" 0"# !'( #&'#*< &'%'(< !"# ("# "&

(e+%'& 0"# !'(e *& %er'('#*( '!" (%")e =&$e (%")e ; D'((e@L'/er ('#*( '! !' e ' '# ' !"# !'(*%% r& e$ "%'("# re&')* "r ;' er 0"# $" *(. D*" (e

%e#&'# 0"# er$* *# "# !e# "# ('#*( '!1. S&e "&e +")r %$" e =-*%;;er )e @ !'&e+* "# !' (e '&"r (e e#! &e ('#*( '! !"# !'

*+'#" (*r;")e !'!" "+ ('#*( '! '"("#0" !e "& % r&" "re". F*# (' *&"+"#0" *#&*

+e+e)"$ er'&r ('& 0"# (*!"$ &*" !"# ;ree $e+e *#&* !' *#" "# e+ " '< +ere+ /e

" &er "&"* !e r'( 0"# +*# '# +e+"(* ' % r&" ! !"r' *(*( !"# (e " "' "#&' e#

%re(e#&'# )e =APC@ %"!" '+*#'&"( "!"%&';.2. F"& (& r'# )e =I& )e @ +er*%" "# (+" '%'! !r % e& +e# "#!*# /'&"+'# A. (e '#'

+e+ e#&* (e '&"r 8 (e !' '/er &"%' (* '& *#&* !' '$"&< +e#0'+%"# /'&"+'# A<

+e+%r !* (' ECM< !"# +e+%*#0"' ;*# (' re * "(' !" "+ '+*#'&"( " .H%8ato9/t%

Mer*%" "# (e % 0$e!r" 0"# e("r !e# "# 6 "&"* e '$ %er+* ""# !"# !'"+e&er#0" 2

3 +' r +e&er. D'!" "+#0" &er!"%"& +'& #!r'" (e "#0" 2 (e < #*) e' 0"# %$er')" !"#

e("r :* " #*) e '. Per+* ""# !"r' $e%"& ('& er #&" !e# "# !'#!'# ('#*( '! +e " *' %er'('#*( '!" (%")e !"# !e# "# %er+* ""# $e%"& ('& "'#. Te+%"& !'+"#" 2 $e%"& ('&

er!e "&"# !'%'("$ "# e$ r*"# &* * "r 0"'&* ' e )"#" ')* *(.C"#" ')* ' +er*%" "# " '"# %er&"+" !"r' (0(&e+ ' e !*)& !"# !e# "# !'"+e&er 1 2

+' r +e&er. Me+ r"#e (e !e "& )"#" ')* ' +e+' ' ' &' $& :*#)&' #. G"% :*#)&' # +*# '#

&er!"%"& !'"#&"r" $e%"& ('&< +e+*# '# "# '#&er)e * "r ) ++*#')"&'# !"# r!'#"(' "#&"r (e .

A 'r"# ' e er ">"#"# "r"$ !e# "# " 'r"# !"r"$ 0"'&* !"r' )e#&r" e %er';er =" 'r"# !"r"$ !"r'

%er';er e )e#&r" @. De "& % r&" "re" !' %er';er< ' e )"#" ')* ' +e# " 'r "# ' e e ' e !*)&* e(

0"# &er(*(*# "&"( (e e%'&e )* '!" !'(e *& )$ "# ' )0&e(. D"r' ' e !*)&* e( " "# !'" 'r "# e

' e !*)& !' % r&" (%")e 0"# !' "%'(' e%'&e )* '!" "&"* ) *+#"r. L" * " "# +e e "r !"#

+e#0"&* +e+ e#&* r' $& "#! e;& $e%"&') !*)& " * +e#'# " "# '/er.

13


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14


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15


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C. )ISIOLOGI

1. LIVER

F*# (' !"("r $"&' !"%"& !' " ' +e#:"!'

1. F*# (' /"()* "r *#&* +e#0'+%"# !"# +e#0"r'# !"r"$.2. F*# (' Me&" '(+e< 0"# er$* *# "# !e# "# (e " '"# e("r ('(&e+ +e&" '(+e

&* *$3. F*# (' (e re(' !"# e ( re(' 0"# er%er"# +e+ e#&* e+%e!* 0"# +e# " 'r +e " *'

(" *r"# e+%e!* e (" *r"# %e#)er#""#.

F*# (' U&"+" !"r' L'/er !"# He%"& ('&

)UNGSI PROCESS INVOLVED1. Me&" '(+e Pr &e'# - S'#&e('( !"# (e re(' " *+'# % "(+" %r &e'#

- F r+"(' *re" !"r' "++ #'"

- De"+'#"(' "("+ "+'#- S'#&e('( ;" & r " * "(' V


18/70

e# '+ e# '+ !' e(&'/e &"%' e+%e!* er%er"# !" "+ %r (e( %e#)er#""#< "re#" e+%e!* er;*# ('

!" "+ #e&r" '("(' !"# +e#!' *(' "("+ "+ *# e e/e !'+"#" e# '+ e# '+ %"# re"( !"%"&

er;*# (' !" "+ (" *r"# %e#)er#""#.E+%e!* +e# "#!*# %r !* %r !* (e re& r' (e%er&' ' e %' +e#& = ' 'r* '# @< !'+"#"

' 'r* '# '#' !'$"(' "# !"r' %e+e)"$"# H . E+%e!* :* " +e# "#!*# e(&er < e+" < ;"&

( * e $ r+ #e< !"# e)'&$'#. H"+%'r (e+*" ' e (" &( !' re" ( r%(' e+ " ' !' ' e*+ !"#

!'"# *& e+ " ' e$ !"r"$ e $"&'. Se re(' ' e e !* !e#*+ er "#:*& ("+%"' !* !e#*+

( # . - #&r (e re(' e+%e!* !"# %e# e *"r"# e+%e!* !'%e# "r*$' e$

1. Se re&'# !'%r !* (' e$ !* !e#*+< 0"# !'"# *& +e " *' ('r * "(' e $"&'. Se re&'# '#'

+e#(&'+* "(' (e re(' e+%e!* e$ $"&'.2. C$ e)0(& '#'# D'%r !* (' e$ !* !e#*+< !'"# *& +e " *' ('r * "(' e " "!!er.

C$ e)0(& '#'# +e#(&'+* "(' " "!!er *#&* #&r" ('< !e# "# !e+' '"# +e#0e " "#

re e"(e e+%e!* e !* !e#*+.3. S&'+* "(' #er/e /" " +e#0e " "# " "!!er er #&r" (' !"# +e#0e " "# re e"(e

!"r' e+%e!* e !* !e#*+.

P"!" +"(" e+ r0 #')< '/er +er*%" "# &e+%"& *&"+" $e+"& % 'e('(. H" '#' &er:"!' +* "'

!"r' * "# e 2 $'# " e 7< e+*!'"# er *r"# $'# " (e(""& (e e *+ "$'r.

S& r" e /'&"+'#(

•

L'/er +er*%" "# &e+%"& *&"+" %e#0'+%"#"# /'&"+'# "r*& e+" =A.D.E.!"# -@.!e/'('e#(' /'&"+'# !"%"& &er:"!' e&' " "!"#0" +" " ( r%(' !"r' e+" < "' %e#0e " #0"

"re#" $e%"&') "&"* e (&r"$e%"&' .• V'& B12 !' " ( r%(' !' &er+'#" ' e*+< !"# !' !* *# e$ '#&r'#(') ;")& r 0"# !'$"(' "#

e$ %"r'e&" (e !' "+ *# < !"# e+*!'"# " "# !' ('+%"# !' !" "+ $"&' (e "+" 2 3

&"$*#. -e"!""# !e;'('e#(' !"%"& +e#0e " "# +e " "(&') "#e+'"=%er#')' *( "#e+'"@• L'/er :* " +e#0'+%"# ; "&e !"# +er* "$#0" +e#:"!' e#&* " &';#0 "0"'&*

&e&r"$0!r ; "&e. De;'('e#(' ; "&e :* " !"%"& +e#0e " "# "#e+'" +e " "(&' < #"+*#

e '$ )e%"& !' "#!'# "# !e# "# B12< "re#" '/er +e#0'+%"# ; " &e $"#0" e er"%" * "# (":".

2. METABOLISME BILIRUBIN A a! a!i*o r%9/9&% '#

H%!o1&o i*

17


19/70

RETICULOC;TE)% r%9/9&% ENDOTHELIAL

H%!% CELL< SPLEEN<CO %=8ir%# BONE

MARRO0< Heme oksigenase LIVER

O2< NADPH HFe3 < CO

NADP

Bi&i>%r#i* ????? 'i@au

Biliverdin reduktase NADPH H

NADP

Bi&iru i* u*9o*@u1at%# ????? $u*i*1

Cir9u&ati*1? i&iru i* a& u!i* 9o!8&%= PLASMA

DARAH

Bi&iru i*?&i1a*#i* 9o!8&%= 2 UDP?1&u9oro*i a9i# bilirubin glukoronosil transferase

2 UDP ? #a* F? i&iru i* 1&u9uro*i#% HEPATOC;TE

bakteri β glukoronidase BILE DUCT

Si$&u Uro i&i*o1%* ????? t#$ %r+ar*a SMALL INTESTINEE*t%ro'%8ati9

St%r9o i&i*o1%* COLON

Uro i&i* t%r9o i&i*

+e>"r"#"' uri*% Me>"r#"' )ECES

B' 'r* '# +er*%" "# %r !* " $'r %e# *r"'"# $e+e. Se " '"# e("r ' 'r* '# er"(" !"r'

%e+e)"$"# er'&r ('& *"< !"# ('("#0" &er*&"+" !"r' %er%*&"r"# $e+ %r &e'# $"&' !"# !"r' !e(&r* ('

er'&r ('& 0"# "r* &er e#&* !" "+ (*+(*+ &* "# .D" "+ e"!""# ;'(' '(< +"(" $'!*% er0&r ('& +"#*('" (e '&"r 12 $"r' !"# er'&r ('&

" "# +e# " "+' '('(. Se (e er'&r ('& &*" !' e *"r "# !"r' ('r * "(' !"# !'$"#)*r "# e$ '+%".

18

GIN AL


20/70

A% %r &e'# !"r' $e+ '# !'$'!r '('( +e#:"!' +% #e# "("+ "("+ "+'# #0". -"&" '(+e

$e+e !"r' (e+*" $e+e%r &e'# &er:"!' !" "+ ;r" (' +' r ( + (e re&' * e#! &e e$ ('(&e+

e# 0+ 0"# +% e ( 0"'&* heme o(sigenase . L"# "$ ">" %e+e)"$"# * *( $e+e '" "$

%e+*&*("# :e+ "&"# +e&e#" 0"# " "# +e+ e#&* ' '/er!'#< (*"&* &e&r"%'r '#'er. Be('

+e# " "+' e er"%" " ' re" (' re!* (' !"# ('!"('< re" (' re" (' '#' +e+er * "# (' e# !"#

NADPH. P"!" " $'r re" (' !' e "( "# Fe 3 0"# !"%"& !' *#" "# e+ " '< "r # + # ('!"

0"# er"(" !"r' "& + "r # :e+ "&"# +e&e#" !"# ' '/er!'#. B' '/er!'#< (*"&* %' +e#

er>"r#" $':"* " "# !'re!* (' e$ biliverdin redu(tase !"# " "# +e+ e#&* %' +e# er>"r#"

*#'# 0"'&* ' 'r* '# =*#) #:* "&e!@. Per* "$"# >"r#" %"!" +e+"r +er*%" "# %e&*#:*

re" (' !e r"!"(' '#'.B' 'r* '# =*#) #:* "&e!@ er(';"& e '$ (* "r "r*& !" "+ "'r !' "#!'# "# !e# "#

' '/er!'#. D" "+ (e&'"% 1 r $e+ '# 0"# '('( " "# +e+ e#&* 35 + ' 'r* '#. B' 'r* '#!"r' :"r'# "# re&' * e#! &e "!" "$ e#&* 0"# (e!' '& "r*& !" "+ % "(+" !"# "'r. B' 'r* '# '#'

" "# !'' "& # # /" e# !"# !'"# *& e$ albumin e $e%"r. D" "+ 1 + % "(+" $"#0" e '$

*r"# 25 + ' 'r* '# 0"# !"%"& !'' "& *"& %"!" " *+'#. B' 'r* '# 0"# +e e '$' :*+ "$ '#'

$"#0" &er' "& # "r $'# " +*!"$ e%"( !"# er!';;*(' e:"r'# "#.B' 'r* '# 0"# ("+%"' !'$"&' " "# !' e%"( !"r' " *+'# !"# !'"+ ' %"!" %er+* ""# ('#*( '!

$e%"& ('& e$ (*"&* %r &e'# %e+ ">" 0"'&*ligandin . S'(&e+ &r"#(% r& !';"(' '&"(' '#' +e+%*#0"'

"%"('&"( 0"# ("# "& e("r &e&"%' %e# "+ ' "# ' 'r* '# " "# &er "#&*# %"!" e "#)"r"#

%r (e( 0"# " "# !' e>"&' ' 'r* '# er' *".B' 'r* '# # #% "r " "# +e#e&"% !" "+ (e :' " &'!" !'* "$ +e#:"!' e#&* "r*&.

He%"& ('& " "# +e# * "$ ' 'r* '# +e#:"!' e#&* "r*& 0"# !"%"& !'e ( re(' "# !e# "#

+*!"$ e!" "+ "#!*# e+%e!*. Pr (e( %er* "$"# &er(e *& +e ' "& "# "("+ * r #"& 0"#

!' #:* "(' "# !e# "# !"# Q ' 'r* '#< !' "&" '('( e$ en)ym bilirubin

glu(oronosiltransferase . Re" (' #:* "(' '#' er "# (*# !*" &"$"%< +e+er * "# UDP "("+

* r #"& (e " "' ! # r * r #"&. T"$"% %er&"+" " "# +e+ e#&* ' 'r* '#

+ # * r #'!" = ' 'r* '#@ (e " "' (e#0">" "#&"r" 0"# e+*!'"# !' #/er(' +e#:"!'

' 'r* '# !' * r #'!" =Q ' 'r* '#@ 0"# "r*& %"!" &"$"% e!*".E ( re(' ' 'r* '# "r*& e!" "+ (" *r"# !"# "#!*# e+%e!* =+e+"(* ' ' e )"#" ')* '

!"# " "# er" $'r !' ' e !*)&@ er "# (*# !e# "# +e "#'(+e &r"#(% r& " &'; 0"# +e ">"#

r"!'e# #(e#&r"('. D" "+ e"!""# ;'(' '(< (e *r*$ ' 'r* '# 0"# !'e ( re(' "# e "#!*#

e+%e!* er"!" !" "+ e#&* &er #:* "('.

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B' 'r* '# &er #:* "(' 0"# +e#)"%"' ' e*+ &er+'#" !"# # !'$'!r '(" e$ en)ym

ba(teri * glu(oronidase !"# %' +e# 0"# e "( !"r' * r #'!" !'re!* (' e$ " &er' *(*(

+e#:"!' *r ' '# e#< (*"&* (e#0">" &e&r"%'r &" er>"r#". Ur ' '# e# *+*+#0" !' ">" e

) # *#&* !'* "$ +e#:"!' (&er) ' '# e#. Se '&"r 2 *r ' '# e# !'" ( r (' e+ " ' !"r'

' e*+ !"# !' e+ " ' "# e $"&' *#&* !' re #:* "(' !"# (e er" !'e ( re(' "# e+ " ' e !" "+

e+%e!*. Se:*+ "$ e)' 0"# ( !"r' ('r * "(' e#&er $e%"&' '#' " "# +e+"(* ' '#:" !"#

" "# !'e ( re(' "# +e " *' *r'#. D"# +"('$ !' ) #< (&er) ' '# e# " "# er* "$ +e#:"!'

*r ' '# !"# (&er) ' '#. D"# " "# +e>"r#"' ;e(e(.

BAB II

CLINICAL SCIENCE

A. AUNDICE +aundice "!" "$ +"#';e(&"(' '#' 0"# +*#)* e&' " e/e % "(+" ' 'r* '# !" "+

!"r"$ e '$ !"r' ,5 + L " ' "& %e#'+ *#"# %' +e# e+%e!* !" "+ &* *$ (e$'# "

+e# " ' "& "# >"r#" e *#'# "# %"!" * '&< ( er"< !"# +* (". +aundice !"%"& !' "(';' "(' "# +e#:"!' 1. rehepatic -aundice haemolytic /2. Hepatic -aundice congenital !"# hepatocellular /0. osthepatic -aundice obstructive "&"*cholestatic /

1. rehepatic -aundiceSe '&"r 85 ' 'r* '# &er e#&* !"r' %e+e)"$"# (e !"r"$ +er"$ &*" !" "+ ('(&e+

+ # ('& +" r ;" " * &er:"!' "&" '(+e $e+ '# =&er*&"+" !" "+ '+%"@ (e$'# "

$e+e !"%"& !'* "$ +e#:"!' ' '/er!'# " * +e+ e#&* '' 'r* '# &" &er #0* "(' (e&e "$

'&* ' 'r* '# " "# !' #:* "(' "# !e# "# "("+ * r #"& !' $"&'< !"# " "# +e+ *"&

' 'r* '# +e#:"!' e '$ +*!"$ "r*& "'r.

20


22/70

B' 'r* '# &" &er #0* "(' " "# er"!" !" "+ ('r * "(' e&' " $"&' &'!" +"+%*

+e# #:* "(' "# ' 'r* '#. B' 'r* '# &" &er #0* "(' &'!" +*!"$ "r*& (e$'# " &'!"

" "# !'e ( re(' "# e !" "+ *r'#.D" "+ e"!""# %e#'# "&"# e)e%"&"# !e(&r* (' (e !"r"$ +er"$ "&"* &er!"%""

%e#0" '& $e+ '('(< +" " ' 'r* '# " "# er e '$"# !"# +e e '$' "%"('&"( ' 'r* '# &"

&er #0* "('< +e( '%*# #0* "(' !"# &r"#(;er %' +e# e+%e!* er:" "# !e# "# # r+" .

A ' "" "!"r ' 'r* '# &" &er #0* "(' !" "+ !"r"$ +e#'# "&. -"re#" ' 'r* '# &"

&er #0* "(' &'!" "r*& !" "+ "'r +" " &'!" !"%"& !'e ( re(' "# e !" "+ *r'# !"#

' 'r* '#*+'" &'!" &er:"!'. Te&"%' %e+ e#&* "# *r ' '# e# +e#'# "& =" ' "& !"r'

%e#'# "&"# e "# ' 'r* '# &er$"!"% $"&' !"# %e#'# "&"# #0* "(' !"# e ( re('@< 0"#

(e "#:*" +e# " ' "& "# %e#'# "&"# e ( re(' !" "+ ;e(e( !"# e+'$ (e$'# " !"%"&

er>"r#" e "%.I &er*( 0"# &'+ * (er'# !'(e *& ' &er*( $e+ '&' .Be er"%" %e#0e " ' &er*( $e+ '&' 0"# (er'# "!" "$ $e+ '# " # r+"

=$e+ '# S %"!" "#e+'" (e (" '&@< (e !"r"$ +er"$ " # r+" =(;er ('& ('( $ere!'&er@<

"#&' !0 !" "+ (er*+ =R$ "&"* '# +%"&' ' '&"( &r"#(;*(' "&"* (e " '"# " ' "& %e#0" '&

$e+ '&' "*& '+*#@< %e+ er'"# "& "&"#< !"# e er"%" '+; +" =%e+ e("r"# '+%"

!"# %e#'# "&"# $e+ '('(@.

2. Hepatic +aundicePe#0e " #0" "!" "$ e "'#"# # e#'&" $'%er ' 'r* '#e+'" !"# e "'#"# !"r' $"&'.

-e!*"#0" +e# " ' "& "# er*(" "# !' $"&'. D'"#&"r"#0" 0"'&* ". G' er& syndrome-e "'#"# # e#'&" 0"# !'(e " "# "re#" %e#*r*#"# :*+ "$ e# '+ UDP *)*r # (0

&r"#(;er"(e 0"# " "# +e# #:* "(' "# ' 'r* '# !e# "# "(" + *) r #"&. D'&"#!"' e$

$'%er ' 'r* '#e+'" &" &er #0* "(' r'# "# = 5 + 1 + @ !"# ' &er*(.-e "'#"# '#' &er:"!'

%"!" 2 7 !"r' % %* "(' !"# '"("#0" +e#0er"# %r'"< %e#0" '& '#' * "# +er*%" "#

%e#0" '& (er'*(.J*+ "$ re&' * ('& # r+" < ' 'r* '# &" &er #0* "(' " "# (e!' '& +e#'# "&< !"#

(0#!r +e '#' "('+%& +"&' . -e"!""# '#' !"%"& !' "&' !e# "# ;e# "r '&" 0"# !"%"&

+er"# ("# e# '+ UDP *)*r # (0 &r"#(;er"(e.

.Cr' er N"::"r (0#!r +ePe#0" '& '#' +er*%" "# %e#0" '& 0"# :"r"# . Me+' ' ' 2 &'%e< 0"'&*

• T'%e 1

21


23/70

Mer*%" "# "# *"# $ere!'&er 0"# :"r"# < %e#0e " #0" "!" "$ e# re(e('; " ' "& e# '+

UDP *)*r # (0 &r"#(;er"(e &'!" "!" ("+" (e " ' (e:" "$'r. -"re#" #0* "(' ' 'r* '#

&'!" !"%"& &er:"!'< +" " e+%e!* &'!" er>"r#" !"# "!"r ''r* '# &" &er #0* "('

+e "+%"*' 2 + 1 + (e$'# " +e#0e " "# er# ' &er*(. F & &er"%' !"%"&

+e# *r"# ' $'%er ' 'r* '#e+'" &" &er #0* "(' *#&* (e+e#&"r" >" &*< &e&"%' '"("#0"

"0' " "# +e#'# " %"!" &"$*# %er&"+" e$'!*%"##0".• T'%e 2

Be#&* 0"# e '$ r'# "# !'+"#" &er:"!' !e;'('e#(' e# '+ UDP *)*r # (0 &r"#(;er"(e

0"# r'# "#.-"!"r ' 'r* '# &" &er #0* "(' !" "+ (er*+ e '$ re#!"$ =6 2 + 1 + @

!"# ' &er*( !"%"& &'!" &er '$"& ("+%"' +"(" re+":".-e"!""# '#' !"%"& !' "&' !e# "#

;e# "r '&" 0"# !"%"& +er"# ("# e# '+ UDP *)*r # (0 &r"#(;er"(e.P"!" e!*" &'%e

'#' ("+" ("+" !'&e+* "# e/e ' 'r* '# &" &er #0* "(' 0"# +e#'# "&.

).D* '# J $#( # (0#!r +eMer*%" "# e "'#"# "*& ( +" re)e(('/e !'+"#" '/er &'!" +"+%*

+e# e ( re(' "# ' 'r* '# 0"# &er #:* "('< !' "re#" "# "!"#0" +*&"(' !' )"#" ')* "r

+* &'(%e(';') r "#') "#' # &r"#(% r&er CMOAT .H" '#' +e# " ' "& "# :"*#!')e. L'/er

" "# &er '$"& $'&"+ "re#" "!"#0" !e% ('& !"r' +e "#'# ' e %' +e#&.

!. R & r (0#!r +ePe#0" '& '#' +'r'% !e# "# D* '# (0#!r +e< !"# !e# "# "!"#0" !e;e !" "+

'#&r")e * "r '#!'# %r &e'# ; r ' 'r* '#.D' %e#0" '& '#' &'!" "!" !e% ('& %' +e#.e. He%"& )e * "r :"*#!')e

A!"#0" er*(" "# !' $e%"& ('& !"# '#&r"$e%"&') ' '"r0 &ree +e# " ' "& "#

%e#'# "&"# :*+ "$ *#) #:* "&e! !"# ) #:* "&e! ' 'r* '#. Ter '$"& :* " "!"#0"

%e#'# "&"# ) &&'# &'+e< (er*+ " "#'#e "+'# &r"#;er"(e< !"# (er*+ "(%"r&"&e

"+'# &r"#(;er"(e.-er*(" "# !' $e%"& ('& '#' !"%"& !'(e " "# er+")"+ e"!""#< !'"#&"r"#0" "!" "$

• I#;e (' /'r*(

V'r*( $e%"&'&'( A< B< C< E. E%(&e'# B"rr /'r*(.

• I#;e (' " &er'Se%er&' Le%& (%'r ('( = We' ( !'(e"(e @< 0"'&* '#;e (' " &er' !'&* "r "# !"r' "'r e#)'#

*)'# .• A*& '+*# "&"*drug1induce damage• H"e+ )$r +"& ('(

22


24/70

-e "'#"# A*& ( +" re(e('; !"r' +e&" '(+e Fe< !"# !"%"& +e#0e " "# )'rr$ ('(<

-aundice < !"# liver failure.• W' ( # ( !'(e"(e

-e "'#"# "*& ( +" re)e(('/e !"r' +e&" '(+ ) %%er< 0"# !"%"& +e#0e " "# )'rr$ ('(

!"# -aundice .

3. osthepatic -aundiceP"!" % (&$e%"&') : "*#!')e< (" *r"# *#&* ' 'r* '# &" &er #0* "(' +e#*:*

' '"r0 &ree &er < !"# +e#0e " "# ) #:* "&e! 'r* '# " "# +"(* e !" "+ ('r * "('.

-"re#" ' 'r* '# &" &er #0* "(' '#' !"%"& "r*& +" " " "# +e#0e " "# *r'#e +e#:"!'

e "%. -"re#" ' 'r* '# &" &er #0* "(' &'!" !"%"& +"(* e !* !e#*+ +e#0e " "#

;e(e( &'!" " "# &er>"r#"' !"# ;e(e( " "# &er '$"& %*)"&.Pe#'# "&"# "r"+ "r"+ e+%e!* !" "+ !"r"$ +e#'+ * "# "&" "&" %"!"

' &er*(.I &er*( 0"# !'" ' "& "# e$ $'%er ' 'r* '#e+'" &er #0* "(' '"("#0" e '$

*#'# !' "#!'# "# !e# "# $'%er ' 'r* '#e+'" &" &er #0* "('. Per* "$"# >"r#"

er '("r !"r' *#'# :'# " +*!" "&"* &*" ("+ "' *#'# $':"* ' " &er:"!' (&r* (' & &"

" 'r"# e+%e!*.Per* "$"# '#' +er*%" "# * &' "!"#0" ' &er*( e(&"&' "&"* !'(e *& :* "

' &er*( (&r* &';. - e(&"&' !"%"& er(';"& '#&r"$e%"&' =+e# e#"' (e $"&'< "#" ' * ' "&"*

"# ' ". Pe#0e " &er(er'# "!" "$ %e#0" '& $e%"& (e * "r !'+"#" (e %"re# '+ $"&'

+e# " "+' er*(" "# " ' "& /'r*( $e%"&'&'( "&"* er " "' :e#'( ('r ('(@ "&"* e (&r"$e%"&' =+e# e#"' (" *r"# e+%e!* !' *"r $"&'. Pe#0e " &er(er'# #0" "!" "$ (*+ "&"# "&*

e+%e!*< '"("#0" %"!" *:*# ">"$ !* &*( e! *(< C" "+%* " V"&er'< C" "%*&

%"# re"(@.Pe#0e " !"r' (&r* (' :"*#!')e !'"#&"r"#0" "!" "$ " (& #e(< ' '"r0 (&r')&*re<

) # e#'&" ' '"r0 "&re('"< )"r)'# +" ; %"#)re"( r ' e !*)&(< !"# %"#)re"&'&'(.

23


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B. HEPATITIS

. P%r %#aa* '%8atiti %9ara u!u!

2. H%8atiti B• De;'#'('

I#;e (' %"!" '/er 0"# er% &e#('" +e# "#)"+ :'>" 0"# !'(e " "# e$ /'r*( $e%"&'&'( B

C$r #') He%"&'&'(B "!" "$ #e)r '#; "+"(' %"!" $e%"r " ' "& '#;e (' HBV 0"# %er('(&e#

e '$ !"r' 6 * "#• E%'!e+' '

D*#'" &er!"%"& (e '&"r 2, :*&" %e#!er'&" !'+"#" 78 r' * +e#'# " !*#'" %er&"$*##0".

I#! #e('"


26/70

• Tr"#(+'('

1. B ! !0 ; *'! ) #&")&

2. Se4*" ) #&")&3. Me!')" !e#&" &re"&

,. N"( +'" ))*%"&' #" e4% (*re5. I#:e)&' # !r* *(e6. Per'#"&" &r"#(+'(( #7. Pe# *#""# " "& RT er("+" (e%er&' (' "& ' ' !"# " "& )* *r

• F" & r Re('

1. H + $e&er (e4*" < PS- 2. Re('%'e# &r"#(;*(' !"r"$ !"# ! # r#0"3. Pe&* "( e(e$"&"#,. Pe# *#" #"r " (*#&'

5. R'>"0"& ' * r #'( $e%"&'&'(6. R'>"0"& e *"r " "&"* r"# !' r*+"$ $e%"&'&'(

• E&' ' He%"&'&'( B /'r*( =HBV@

• - "(';' "('

1. Ber!"("r "# +"#;e( !"# (er '(#0"". He%"&'&'( B -r #' 0"# M"('$ A &'; =He%"&'&'( B -r #' A &';@

- H (AG = @- DNA VHB 1 5 %' +- Pe#'# "&"# ALT 0"# +e#e&"% !"# %er('(&e#- T"#!" &"#!" %e#0" '& $"&' r #' - B' %(' $"&' &er!"%"& "+ "r"# %er"!"# "# " &'; - H eA !"%"& % ('&'; "&"*%*# #e "&';

. C"rr'er VHB I#" &'; =I#")&'/e HBV C"rr'er S&"&e@- H (A = @- DNA VHB 1 5 %' +- ALT # r+"- B' %(' &er!"%"& e "'#"# :"r'# "# 0"# +'#'+"

2. H'(& ')" A)&'/'&0 I#!e4 =HAI@

Ko!8o*%* S$or Ne r ('( %er'% r&" !e# "# "&"* &"#%" r'! '# #e r ('( 1Re e#er"(' '#&r" * "r !"# #e r ('( ; " ,I#; "+"(' % r&" ,

S$or D%ra@at

1 3 M'#'+"

25


27/70

, 8 R'# "#12 Se!"#

13 18 Ber"&

A &'/'&"( Per"!"# "# &'!" "!" %er"!"# "# % r&" +'#'+"

1 %er"!"# "# % r&" * "r &"#%" #e r ('(

2 '+'&'# % "&e #e)r ('( r'# "# !e# "# "&"* #e r ('( * "r ; "

3 '+'&'# % "&e #e)r ('( (e!"# !e# "# "&"* #e r ('( ; " er"&

, '+'&'# % "&e #e)r ('( er"& !e# "# "&"* r'! '# #e r ('(

F' r ('(

&"#%" ;' r ('(

1 ;' r ('( &er "&"( %"!" #" % r&" 0"# +e e "r

2 %e+ e#&* "# (e%&" %er'% r&" !e# "# "r('&e &*r +"('$ *&*$

3 ;' r ('# (e%&" r'! '# &"#%" ('r ('( 0"# :e "(

, e+*# '#"# %"(&' ('r ('(

26


28/70

P"& e#e('( %"& ;'(' '

27


29/70

28


30/70

• M"#';e(&"(' - '#'(A)*&e P$"(e

F"(e %r ! r+"• D'+* "' (e:" 6 18 $"r'• O#(e& '#('!' *(• R*&e %"re#&er" < (e4*"

F"(e Pr ! r+" =%re')&$er')@• Ter:"!' (e&e "$ 2 +'# * &er%"%"r • Ge:" " F"&' *e< M" "'(e< N"*(e"< V +'&< He"!")$e< H0%er" '"< C * $< Fe/er F"(e ')&$er')

• Ter:"!' (e&e "$ 1 2 +'# * (e&e "$ %r ! r+" !"# er" $'r (e&e "$ 2 6+'# *• Ter:"!' $e%"& )e * "r !e(&r*)&' # !"# '#&r"$e%"&') ' e (&"('( ("+%"' :"*#!')e• L'/e e# "r e!• S& ' $&er • Pr & + '# &'+e +e+"#:"#• I&)$'#F"(e re) /er0

• Ter:"!' (e&e "$ 6 8 + &er%"%"r • L'/er ;*#)&' # &e(& +e#*r*#• L'/er &e&"% +e+ e("r • C$r #') $e%"&'&'( '(" +* "' %"!" % '#& '#'

=T" "&"!" 9"+"!"@C$r #') %$"(e

o A('+%& +"&'(o S' # ; e#! '/er (&" e

"@ He%"&') (0#&$e&') ;*#)&' #L > " *+'#Pr # e! %r &$r + '#e &'+e

He%"&') e4)re& r0 ;*#)&' #

Pe#'# "&"# ' 'r* '# @ P r&" $0%er&e#(' #

S% e# +e " 0• T$r + )0& %e#'"#• Le*) %e#'"• A#e+'"A()'&e( !"# e!e+"G"(&r e( %$" e" /"r')e(

C. He%"&') e#)e%$" %"&$0

29


31/70

Per* "$"# (e#( r'*+Me+ r0I#( +#'"

E4&r"$e%"&') +"#;e(

Ar&$r'&'(P 0"&e#&'( # !*(" = e#er" ' e! /"()* '&'(@Me+ r"# %r ';er"&'/e +er* #e%$r'&'(Le* )0&e ) "(&') =)*&"#e*(@ /"()* '&'(D"+" e &"r e& r "# =: '#&< '!#e0< ( '#@

• D'" # ('(- M"#;e(- Pe+er' (""# F'('

o A)*&e• M' ! $e%"& +e " 0• S% e# +e " 0• S%'!er "# ' +"

o J"*#!')e !' +e+ r"#e +*)*(< ( er"< ( '#- L"

o Pe#'# "&"# ATL e '$ e("r !"r' AST !'(e " "# e$ "!"#0" #e)r ('( 1 2 4 !"r' # r+"

%*#)" %e#'# "&"# &er:"!' (""& :"*!'#)eo

Pe#'# "&"# A " '#e %$ (%$"&"(e 2 3 4-"re#" ' '"r0 e%'&$e '" )e !"+" eo Pe#'# "&"#" ) #:* "&e! !"# *#) #:* "&e! ' 'r* '#

De# "# r"# e 85 3, + L =5 2 + !L@

Ser 0

30


32/70

o A)*&e "#&' HBV I M !"# HB(A = @ "#&' HAV !"# "#&' HVCo F'r(& /'r" %r &e'#

HB(A !"# HBeAM*#)* %"!" e"r 0 1 2 + !"# "&e 11 12 > HB)A &er " * re#!"$ *#&* !'!e&e ('

o A#&' !0 &er e#&* =P"!" ;"(e ) #/" e(e#&@I M K A#&' HB)A#&' H eA#&' HB(

o W'#! > Per' !eTer:"!' %"!" (""& HB(A &e "$ +e#*r*# !"# $"#0" "#&' !0 A#&' H ) 0"#

&er!e&e ('

H'(& '

o L'/er B' (%0o S"# "& :"r"# !' *&*$ "# *#&* !'" # ('(o D"%"& +e+ e!" "# ")*&e !"# )$r #'(o G"+ "r"#

B" #e! $e%"& )0&e = &er+'#" $e%"&') /e#* e@- Gr"#* "r - P" e )0& % "(+" !e# "# e# "r e! #*) e'

- M* &'#*) e"&e!Per'/e#* "r $e% & )0&e +e#:"!' "('! ;' "re#" "% %& ('(- Ter e#&* A('; !' !0=) *#)' +"# !0@- )0& % "(+" !e#(e- Irre * "r ($"%e- P0)# &') #*) e'L"'##0" +e# " "+' re e#er"&'/e $0%er% "('"J"!'< (e)"r" e(e *r*$"# &er:"!' * "r !'("rr"0 !'(r*%& )e % "&e

31


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- F )" #e)r ('(- C #; *e#& #e)r ('(

I#; "++"& r0 )e

- L0+%$ )0&e !"# +")r %$" e- P "(+"< #e*&r ;' < e ('# ;' )e- -*%;er )e +e# " "+' $0%er% "('"- M # #*) e"r )e

D' " ' :"!' !*" e +%

1. He%"&'&'( B r #' " &'; o HB(A % ('&'; !"# HBV DNA e '$ e("r 1 5 ) %0 + < %e#'# "&"# ALT

+e#e&"% "&"* '#&er+'&&e#&o D' " ' +e#:"!' 2< +e#*r*& HBeA P ('&'; !"# Ne "&';

2. C"r'er HBV '#" &';o HB(A % ('&'; !e# "# HBV DNA re#!"$ 1 5 ) %0 +o ALT # r+" !"# &'!" "!" e *$"#

- "(';' "(' H'(& %"& '

A &'/'&"( %er"!"# "# % r&" !"# * "r

Gr"!e P"& 'T'!" "!" %er"!"# "# "&"* %er"!"# "# +'#'+"

1 Per"!"# "# %er'% r&" &"#%" #e r ('( "&"*%*# * "r 2 L'+'&'# % "&e #e)r ('( r'# "# "&"* #e r ('( * "r er(';"& ; "3 L'+'&'# % "&e #e)r ('( (e!"# !"# "&"* #e r ('( )" er"&, L'+'&'# % "&e #e)r ('( er"& !"# "&"* r'!'# #e)r ('(

Der":"& ;' r ('(

S&" e P"& 'T'!" "!"

1 F' r ('( &er "&"( %"!" #" % r&" 0"# +e e "r 2 Pe+ e#&* "# (e%&" %er'% r&" "&"* (e%&" % r&" % r&" !e# "# "('&e &*r *3 D'(& r(' "r('&e &*r =;' r ('( (e%&" r'! '# @ &"#%" ('r ('( 0"# :e "(, -e+*# '#"# ('r ('( "&"* %"(&' ('r ('(

• Tre"&+e#&

T*:*"# &er"%' $e%"&'&'( B r #'( "!" "$ *#&* +e# e '+'#"(' (e)"r" er+" #"

re% ' "(' VHB !"# +e#)e "$ %r re(' %e#0" '& $"&' +e#:"!' ('r ('( 0"# er% &e#('"

32


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+e#*:* " " $"&'< !"# +e#)e "$ "r('# +" $e%"& (e * "r. S"("r"# %e# "&"#

"!" "$ +e#*r*# "# "!"r HBV DNA (ere#!"$ +*# '#< (er #/er(' HBeA !"#

# r+" '("(' "!"r ALT. S"("r"# (e e#"r#0" "!" "$ +e# $' "# #0" HB(A < #"+*#

("+%"' (""& '#' e er$"(' "##0" $"#0" er '("r 1 5 < (e$'# " ("("r"# &er(e *& &'!"

!' *#" "#. Pe#' "'"# re(% # &er"%' $e%"&'&'( B r #'(

R% 8o* T%ra8i K%t%ra*1a*

1. -'+'">' Pe#*r*#"# "!"r ALT +e#:"!' # r+"

2. V'r '-"!"r HBV DNA +e#*r*# &'!" &er!e&e (' = 1 5 copies + @

HBeA +e#:"!' HBeA

3. H'(& 'P"!" %e+er' (""# ' %(' $"&'< '#!e ( " &';'&"( $'(& ' +e#*r*# %" '#

&'!" 2 "# " !' "#!'# "# (e e *+ &er"%'

,. Re(% # +% '& Ter%e#*$'#0" r'&er'" ' '+'">'< /'r ' !"# +e# $' "# #0" H (A

Se(*"' !e# "# re +e#!"(' the American Association for the !tudy of "iver

Disease &er"%' !' er' "# %"!" %e#!er'&" $e%"&'&'( B r #'(< !e# "#

(0"r"& . HBeA % ('&'; !"# HBV DNA 1 5 copies + !"# "!"r ALT 2 "&"(

"&"( "# " # r+" . 2 . HBeA % ('&'; !"# HBV DNA 1 5 copies + !"# "!"r

ALT 2 "&"( "&"( "# " # r+" &'!" %er * &er"%'< $"#0" %er * !'e/" *"(' (e&'"% 6 12

* "#< e)*" ' ' " %e+er' (""# $'(& ' +e#*#:* "# "!"#0" #e r '#; "+"(' &'# "&

(e!"# ("+%"' er"& ( . HBeA #e "&'; !"# HBV DNA 1 5 copies + !"# "!"r

ALT 2 "&"( "&"( "# " # r+" . 6 . Pe#!er'&" ('r ('( $"&' !e# "# HBV DNA

1 5 copies + Ta %& 5. S""& '#'< "!" 5 :e#'( "& 0"# !'re +e#!"(' "# *#&*

&er"%' $e%"&'&'( B r #'( !' A+er' " Ser' "&< 0"'&* '#&er;er # " ;" 2 < "+'/*!'#<

"!e; /'r !'%'/ 4' < e#&e)"/'r !"# %e '#&er;er # " ;" 2" Ta %& .H" 0"# $"r*(

!'%er&'+ "# "# (e e *+ +e+*&*( "# %' '$"# "& "!" "$ e"+"#"# :"# "

%"#:"# < e;' "(' !"# '"0". W" "*%*# (""& '#' %' '$"# &er"%' $e%"&'&'( B r #'( +e#:"!'

e '$ "#0" < #"+*# %er( " "# 0"# +"('$ e *+ &er%e)"$ "# "!" "$ %r e+

re('(&e#(' "& !"# &'# '#0" "# " re "%( (""& &er"%' !'$e#&' "#

R%$o!%*#a i t%ra8i '%8atiti B $ro*i

HB%A1HBV DNA

J

ALT

Strat%1iP%*1o ata*

33


35/70

35copies !&

2 4 BANNE;' "(' &er$"!"% &er"%' re#!"$

O (er/"('< &er"%' ' " ALT +e#'# "&

2 4

BANN

M* "' &er"%' !e# "# '#&er;er # " ;"< "+'/*!'#"&"* "!e; /'r

%nd point &er"%' Ser #/er(' HBeA !"#

&'+ * #0" "#&' HBe

D*r"(' &er"%'

• I#&er;er # (e "+" 16 +'# *

• L"+'/*!'# +'#'+" 1 &"$*#< "#:*& "# 3 6

* "# (e&e "$ &er:"!' (er #/er(' HBeA• A!e; /'r +'#'+" 1 &"$*#

B' " &'!" +e+ er' "# re(% # "!" #&r"'#!' "('<

'#&er;er # !' "#&' "+'/*!'# "!e; /'r

B' " re('(&e# &er$"!"% "+'/*!'#< er' "# "!e; /'r

2 4

BANN

M* "' &er"%' !e# "# '#&er;er # " ;"< "+'/*!'#

"&"* "!e; /'r. I#&er;er # "&"* "!e; /'r< !'%' '$

+e# '# "& e *&*$"# %er *#0" &er"%' :"# "

%"#:"# .

E#! % '#& &er"%' # r+" '("(' "!"r ALT !"# HBV

DNA =%e+er' (""# PCR@ &'!" &er!e&e ('.

D*r"(' &er"%'

• I#&er;er # (e "+" ("&* &"$*#

•

L"+'/*!'# (e "+" 1 &"$*#• A!e; /'r (e "+" 1 &"$*#

B' " &'!" +e+ er' "# re(% # "!" #&r"'#!' "('

'#&er;er # !' "#&' "+'/*!'# "!e; /'r.

34


36/70

B' " re('(&e# &er$"!"% "+'/*!'#< er' "# "!e; /'r.

2 4 BANN T'!" %er * &er"%'

S'r ('( $"&'

Ter +%e#("(' "+'/*!'# "&"* "!e; /'r

De +%e#("(' "+'/*!'# ="&"* "!e; /'r@<'#&er;er # #&r"'#!' "('< &r"#(% "#&"(' $"&'

S'r ('( $"&'Ter +%e#("(' (er/"('

De +%e#("(' r*:* e %*("& &r"#(% "#&"(' $"&'

I#&er;er #

I#&er;er # &'!" +e+' ' ' $"('"& "#&'/'r*( "# (*# &e&"%' +er"# ("# &er e#&* #0"

er " "' +")"+ %r &e'# e;e & r 0"# +e+%*#0"' $"('"& "#&'/'r*(. Ber!"("r "# (&*!' +e&"

"#" '('( 0"# +e ' "& "# 875 %"('e# $e%"&'&'( B r #'( !e# "# HBeA % ('&'; (er #/er('

HBeA &er:"!' %"!" 18 < %e#*r*#"# HBV DNA &er:"!' %"!" 37 !"# # r+" '("(' ALT

&er:"!' %"!" 23 =T" e 6@. S" "$ ("&* e *r"# "# '#&er;er # "!" "$ e;e ("+%'# !"#

%e+ er'"# (e)"r" '#:e ('. D ('( '#&er;er # 5 1 :*&" MU 3 " ' +'# * (e "+" 16 +'# *

P%r a*#i*1a* I*t%r-%ro*" &a!i>u#i* #a* a#%-o>ir" %*t%9a>ir #a* 8%1i*t%r-%ro* 8a#a

8%*#%rita '%8atiti B $ro*i #%*1a* HB%A1 8o iti- #a* HB%A1 *%1ati- 5

I*t%r-%ro*

a&-a 2 VS

Ta*8a

t%ra8i

2?26

!i*11u

La!i>u#i*

VS P&a % o

52 !i*11u

A#%-o>ir

VS

P&a % o

6 !i*11u

E*t%9a>ir

VS

La!i>u#i*

6 !i*11u

P%1i*t%r-%ro*

VS

La!i>u#i*

6 !i*11u

H%8atiti B

$ro*i #%*1a*

HB%A1

HBV DNA 37 =17@ ,, =16@ 21 = @ 67 =36@ 25 =, @

35


37/70

(er*+ &"

&er!e&e (' = @

Ser #/er('

HBeA18 16 18 =, 6@ 12 =6@ 21 =18@ 27 =2 @

HB(A (er*+

&" &er!e&e ('

= @

8 =2@ 1 = @ = @T" "!"

!"&"T" "!" !"&"

N r+" '("(' ALT

= @23 ,1 72 =7 2,@ ,8 =16@ 68 =6 @ 3 =62@

Per "' "#

$'(& '( = @T" "!" !"&"

, 56 =23

25@53 =25@ 72 =26@ 38 =3,@

Durability

response = @8

5 8 =T"

"!" !"&"@

T" "!"

!"&"

T" "!"

!"&"T" "!" !"&"

H%8atiti B

$ro*i #%*1a*

HB%A1 ?

HBV DNA

(er*+ &"

&er!e&e (' = @

6 7 =1

2 @

5 7 =T"

"!" !"&"@51 = @ =72@ 63 =73@

N r+" '("(' ALT

= @

6 7 =1

2 @

6 7 =T"

"!" !"&"@72 =2 @ 78 =71@ 38 =73@

Per "' "#

$'(& '( = @

T" "!"

!"&"

6 =T" "!"

!"&"@6, =33@ 7 =61@ ,8 =, @

Durability

response = @

2 25 =T"

"!" !"&"@

1 =T"

"!" !"&"@

1 =T"

"!" !"&"@

T" "!"

!"&"3 =1 @

L"+'/*!'#

L"+'/*!'# +er*%" "# "#&'/'r*( +e " *' e;e %e# $"+ "&"# &r"#( r'%(' (e "+"

(' *( re% ' "(' /'r*( $e%"&'&'( B. Pe+ er'"# "+'/*!'# 1 + $"r' (e "+" 1 &"$*# !"%"&

+e#e "# HBV DNA< # r+" '("(' ALT< (er #/er(' HBeA !"# +e# *r"# ' %r re('

;' r ('( (e)"r" er+" #" !' "#!'# "# % "(e =17@. N"+*# "+'/*!'# +e+')* re('(&e#('.

36


38/70

D' "% r "# "$>" re('(&e#(' &er$"!"% "+'/*!'# (e e("r e '$ !"r' 32 (e&e "$ &er"%'

(e "+" ("&* &"$*# !"# +e#:"!' 57 (e&e "$ &er"%' (e "+" 3 &"$*# =18@. R'(' re('(&e#('

&er$"!"% "+'/*!'# +e#'# "& !e# "# +" '# "+"#0" %e+ er'"#. D" "+ (*"&* (&*!' !'

A('"< re('(&e#(' e# &'% +e#'# "& !"r' 1, %"!" &"$*# %er&"+" %e+ er'"# "+'/*!'#<

+e#:"!' 38 < , < 66 !"# 6 +"('# +"('# %"!" &"$*# e 2" "!e; /'r +e+ er' "# $"(' e '$ "' (e)"r"

(' #';' "# =% < 1@ !" "+ $" re(% # $'(& '< # r+" '("(' ALT< (er #/er(' HBeA

!"# %e#*r*#"# "!"r HBV DNA. -e"+"#"# "!e; /'r 1 + ("+" !e# "# % "(e =2 @.

H"! '0"#+'( e& " +e+ er' "# "!e; /'r %"!" %e#!er'&" $e%"&'&'( B r #'( !e# "# HBeA

#e "&';. P"!" %"('e# 0"# +e#!"%"& "# 1 + "!e; /'r &er:"!' %e#*r*#"# HBV DNA

(e)"r" er+" #" !' "#!'# "# % "(e < #"+*# e;' "('#0" +e# $' "# %"!" e/" *"('

+'# * e ,8.

P"!" e +% 0"# +e!"%"& "# "!e; /'r (e "+" 1,, +'# * e;' "('#0" !"%"&

!'%er&"$"# "# !e# "# re('(&e#(' (e e("r 5< =21@. -e e '$"# "!e; /'r !' "#!'# "#

"+'/*!'#< !' ("+%'# r'(' re('(&e##0" e '$ e)' :* " "!e; /'r !"%"& +e#e "# 9MDD

+*&"#& 0"# re('(&e# &er$"!"% "+'/*!'#.

Pe '#&er;er #

L"* e& " =22@ +e " * "# %e#e '&'"# &er"%' %e '#&er;er # &*# " !' "#!'# "#

+ '#"(' %"!" 8,1 %e#!er'&" $e%"&'&'( B r #'(. -e +% %er&"+" +e#!"%"& "#

%e '#&er;er # " ;" 2" =Pe "(0(@ 18 * +'# * % "(e &'"% $"r'< e +% e !*"

+e#!"%"& "# %e '#&er;er # " ;" 2" =Pe "(0(@ 18 * +'# * "+'/*!'# 1 + $"r'

37


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!"# e +% e &' " +e+%er e$ "+'/*!'# 1 + $"r'< (e "+" ,8 +'# *. H"(' #0"

%"!" " $'r +'# * e ,8< 0"'&* =1@. Ser #/er(' HBeA &er&'# ' %"!" %e '#&er;er #

&"#%" + '#"('< 0"'&* 27 < !' "#!'# "# + '#"(' =2, @ !"# "+'/*!'# &*# "

=2 @. =2@. Re(% # /'r ' &er&'# ' %"!" %e '#&er;er # "+'/*!'# =86 @. =3@.

N r+" '("(' ALT &er&'# ' %"!" "+'/*!'# =62 @. =,@. Re(% # HB(A %"!" +'# * e 72

%e '#&er;er # &*# " 8 %"('e#< &er"%' + '#"(' 8 %"('e# !"# "+'/*!'# &'!" "!"

(er #/er('. =5@. Re('(&e#(' =+*&"(' 9MDD@ %"!" +'# * e ,8 !'!"%"& "# %"!" 6

=27 @ %"('e# !e# "# "+'/*!'#< %"('e# =, @ %"!" e +% + '#"('< !"# =6@. E;e

("+%'# re "&'; +'#'+" %"!" e&' " e +% . D'('+%* "# "$>" er!"("r "# $"('

+ '#"(' =(er #/er(' HBeA < # r+" '("(' ALT< %e#*r*#"# HBV DNA !"# (*%re('

HB(A @< %e '#&er;er # +e+ er' "# $"(' e '$ "' !' "#!'# "# "+'/*!'#.

A#" N*) e &'!e L"'##0"

D' ("+%'# e#&e)"/'r< (""& '#' e er"%" "& "#&'/'r*( (e!"# !" "+ &"$"%

%e#e '&'"#< (e%er&' &e '/*!'#e< e+&r')'&" '#e< ) e/*!'#e !"# LB 8 38 =ANA 38 @.

Ber!"("r "# (&*!' ")" *&"< &e '/*!'#e , 8 + (e "+" 52 +'# * !"%"&

+e#*r*# "# HBV DNA ("+%"' 6 (< !"# r'(' &'+ * #0" +*&"(' 9MDD &*r*# (e e("r

,< . E+&r')'&" '#e 0"# +er*%" "# !er'/"& "+'/*!'#< +e+%*#0"' % &e#(' !"# %e *"#

0"# $"+%'r ("+" !e# "# "+'/*!'# !" "+ +e+')* &er:"!'#0" +*&"(' 9MDD. C e/*!'#e

0"# +er*%" "# "#" %'r'+'!'#< (e!"# !" "+ (&*!' ;"(e II. Pe+ er'"# ) e/*!'#e 1

2 + $"r' (e "+" 28 $"r' !"%"& +e#*r*# "# 3 ( HBV DNA =23@.

Pe+er' (""# /'r ' *#&* +e# * *r :*+ "$ HBV DNA (er*+ ("# "& %e#&'#

"re#" !"%"& +e# "+ "r "# &'# "& re% ' "(' /'r*(. A!" e er"%" %er( " "# er "'&"#

!e# "# %e+er' (""# "!"r HBV DNA. P%rta!a < +e& !e 0"# !' *#" "# *#&*

+e# * *r "!"r HBV DNA. S""& '#' "!" e er"%" :e#'( %e+er' (""# HBV DNA< 0"'&*

r"#)$e! DNA< $0 r'! )"%&*re< ' *'! $0 r'!' "&' # !"# PCR. D" "+ %e#e '&'"#<

*+*+#0" &'&er HBV DNA !'* *r +e# *#" "# "+% ';' "('< (e%er&' +'(" #0" PCR<

"re#" !"%"& +e# * *r ("+%"' 1 1 ) %'e( + . K% #ua < e er"%" %"('e# !e# "#

$e%"&'&'( B r #'( +e+' ' ' "!"r HBV DNA ; * &*"&';. K% ti1a < %e#e#&*"# "+ "# "&"(

"!"r HBV DNA 0"# +e#)er+'# "# &'# "& %r re(';'&"( %e#0" '& $"&'. S" "$ ("&*

38


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e%e#&'# "# "'# %e#e#&*"# "!"r HBV DNA "!" "$ *#&* +e+ e!" "# "#&"r" )"rr'er

$e%"&'&'( '#" &'; !e# "# $e%"&'&'( B r #'( !e# "# HBeA #e "&'; "!"r 1 5 ) %'e( +

e '$ +e#*#:* "# )"rr'er $e%"&'&'( '#" &';. S""& '#' &e "$ !'(e%" "&' "$>" "!"r HBV

DNA 1 5 ) %'e( + +er*%" "# "&"( %e#e#&*"# *#&* $e%"&'&'( B r #'(=,


41/70

#e r '#; "+"(' e '$ er"& !' "#!'# "# %"!" ALT 0"# # r+" . P"('e# !e# "# "!"r ALT

# r+" +e+' ' ' re(% # (er ' 0"# *r"# "' %"!" &er"%' "#&'/'r" . O e$ (e " '&*

%"('e# !e# "# "!"r ALT # r+" !'%er&'+ "# "# *#&* &'!" !'&er"%'< e)*" ' ' " $"('

%e+er' (""# $'(& ' +e#*#:* "# %r (e( #e r '#; "+"(' " &';

I#!' "(' T$e*r"%e&') e#! () %0< P") e! Ce !"# V'&"+'# - "!" "$ *#&* +e# $'#!"r'

"!"#0" (0 $'% / e+' "re#" %e#!"r"$"# " ' "& %e#"# "#"#. Ber' *& %e#:e "("##0"

Per!"r"$"# (" *r"# +" "# " '"# "&"( =SMBA@ +er*%" "# %e#0e " %e#&'# + r&" '&"(

!"# *#:*# "# %"('e# e r*+"$ (" '&< !e# "# '#('!e#(' (e '&"r 2"& !' B" '"# I +* Pe#0" '& D" "+< "&"* 38 !"r' (e *r*$ %e#!er'&" 0"#

!'r">"& !' S* " '"# G"(&r e#&er He%"& '. Te #' e#! ( %' +"('$ +er*%" "#

&"#&"# "# !" "+ +e#"# "#' %"('e# !e# "# %er!"r"$"# (" *r"# +" "# " '"# "&"( " *&

=SMBA@ +"('; # #/"r'(e" . T*:*"# %e#e '&'"# "!" "$ *#&* +e#' "' e;e &'/'&"( e#! ( %' &er"%e*&' %"!" %e#!er'&" SMBA< $*(*(#0" %e#!er'&" !" "+ e"!""# (0 $e+ r" ' .

S* :e %e#e '&'"# "!" "$ %"('e# 0"# %"!" %e+er' (""# e#! ( %' e+er e#(' !'&e+* "#

* *( %e%&' *+ !e# "# %er!"r"$"# "r&er'" 0"# +e# " 'r "&"* +ere+ e(< "&"* e *"#

!"r"$. E#! ( %' &er"%e*&' +e#)" *% '#:e (' e%'#e;r'#< &er+ " * "('< $e+ '% "&"*

&er"%' + '#"(' ' " !'%er * "#. Pr'+"r0 e#! % '#& %e#e '&'"# '#' "!" "$ %er!"r"$"#

er* "# !" "+ 3 $"r' (e&e "$ e#! ( %'. Se) #!"r0 e#! % '#& er*%" %er!"r"$"# * "#

!" "+ 3 $"r' (e&e "$ &'#!" "# e#! ( %' !"# ":* + r&" '&"(. Pe#e '&'"# !' " * "# !' U#'&

G">"& D"r*r"& RSHS %er' !e De(e+ er 2 5 De(e+ er 2 6. D" "+ *r*# >" &*

%e#e '&'"#< &e "$ !' " * "# 1.2 1 %r (e!*r e#! ( %' !"# 21 e#! ( %' &er"%e*&' .

Ter!"%"& 81 %e#!er'&" !e# "# $e+"&e+e('( 0"# +"(';< +e e#" "&"* $e+"& e '". -"!"r

$e+ '# er '("r "#&"r" 1< "#'&" =61


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&'!" "!" %er!"r"$"# * "# !" "+ ; > *% (e "+" 3 $"r'. A# " + r&" '&"( (e e("r

,< . E#! ( %' &er"%e*&' &'!" !"%"& !' " * "# %"!" 5 %e#!er'&" !e# "# e *"# !"r"$

e("r !"# %e#!er'&" '#' "# (*# !' " * "# &'#!" "# %e+ e!"$"#.

•

- +%' "('C'rr$ ('(Ter:"!' (e '&"r 25 , !"r' %e#!er'&" He%"&'&'( BHe%"& )e * "r )"r)'# +"Ter:"!' (e '&"r 1 !"r' 1 r"# %e#!er'&" $e%"&'&'( B !e# "# )'rr$ ('(F* +'#"#& $e%"&'&'( BTer:"!' 1 !'"#&"r" 1 r"# %e#!er'&" $e%"&'&'( B. - +% ' "(' 0"# &er+"(*

!" "+ +e!')" e+er e#)0.A% "(&') "#e+'"P*re re! )e "% "('"

• Pr # ('(U#&* $e%"&'&'( B (e#!'r' +"('$ #"+. J' " (*!"$ &er!"%"& +% ' "(' !"%"& +e#:"!'

"! +" "+< &er*&"+" +% ' "(' ;* +'#"# $e%"&'&'( B 0"# +e+' ' ' e4&re+ 0 $' $

+ r&" '&0 r"&e.

• P"& ' A#"& +' He%"&'&'(

-r #'( !"# " *& %"!" %e#0" '& $e%"&'&'( !' ee!" "# er!"("r "# >" &* !"# %r (e(. Ber!"("r "# >" &* "%" ' " " *& '&* 6 * "#< !"# "%" ' " r #'( &er:"!' 6 * "#. Se "'# '&*< %er e!""# (e)"r" %r (e( '#&'#0" %"!" A *& '&* &er:"!' $"#0" %"!" 1 :"r'# "# "&"* (e !"# e *+ &er:"!' %e#0e "r"#< #"+*# "%" ' " r #'( (*!"$ +e#:"!'

%e#0e "r"# e " '"# (e $e%"&') "'##0" "$ "# e r "# "#&*# e+%e!* !' (e '&"r $e%"r.A. A *& He%"&'&'(

M r; ' Pe+ e("r"# $e%"r< e+er"$"#< e$':"*"# ' " &er:"!' ) e(&"('(T"+%" "# He%"& )0&e '#:*r0 S>e '# =B" #'# !e e#er"&' #@

C$ e(&"('( &er:"!' (*+ "&"# e+%e!* !' )"#" ')* ' "&"* (" *r"# P"!" /'r*( $r%"&'&'( C &er:"!' %er e+" "# $e%"& ('& 0"# r'# "# He%"& ('& Ne r ('( "+ "r"# (e er&*+%* < r*%&*r< !"#

"% %& ('( "%" ' " (e+" '# %"r"$ +" " " "# &er:"!' r'! '##e)r ('(

Per* "$"# re e#er"&'; &er:"!' %r ';er"(' %"!" (e $e%"& ('& #0"

Per* "$"# re" (' %"!" (e ('#*( '! &er:"!' " *+* "(' !e r'("%" ' " &e "$ &er:"!' %r (e( ;" ('& ('( !' (e ('#*( '! e$ (e

*;;er =+" r ;" @ S" *r"# % r&" +e# " "+' re(% # '#; "+"(' !"# "!"#0" #e)r ('(

!' " '"# $e%"r

41


43/70

B. -r #' He%"&'&'(M r; ' T"+%" "# 0"# e '$ er"& !' "#!'# "# " *&T"+%" "#

Ter:"!' %er* " "# (e $e%"& ('( I#:*r0< #e)r ('(< !"# &er:"!' re e#er"('P"!" (" *r"# % r&" &er:"!' '#; "+"(' !"# "!"#0" %e#0e "r"# e :"r'# "# (e '&"r (e$'# " +e#'+ * "# #e)r ('( %"!" (e $e%"r =I#&er;")e $e%"&'&'(@ !"# "!"#0"

r'! '# '#; "+"(' #e)r ('(Ter:"!' %e+ e#&* "# ;' r ('(

P"!" /'r*( $e%"&'&'( B &er:"!' r *#! "(( $e%"& )0&eP"!" /'r*( $e%"&'&'( ) &er:"!' %r ';er"(' (e e%'&e !"# " re "& 0+%$ '!

42


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C. CIRRHOSIS• De;'#'('

-e"!""# %"& '( 0"# +e#"#!" "# (&"!'*+ " $'r ;' r ('( $e%"&') 0"# er "# (*#

(e)"r" %r re('; !'&"#!"' !e# "# !'(&%r(' "r('&e &*r $e%"r !"# %e+ e#&* "# # !* *(

re e#er"&'/e

• E%'!e+' 'Me#'# "& %"!" Ne "r" !e# "# #(*+(' " ) $ &'# 'A+er' " 36 1 . r"#D' I#! #e('" RS ("r!:'& ,1 !"r' (e *r*$ %"('e#P" '# "#0" !'(e " "# "re#" /'r*( $e%"&'&'( B !"# CD +'#"# %"!" " ' " ' !e)"!e 5

• F" & r re('

N*&r'(' re#!"$He%"&'&'( /'r*(X"& $e%"& & (' W' ( # ( !'(e"(eHe+ r +"& ('(-e "'#"# :"#&*#

• E&' '

43


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A ) $C$r #') /'r" $e%"&'&'(A*& '++*#e $e%"&'&'(N # " $ ' (&e"& $e%"&'&'(B' '"r0 ('r ('(

C"r!'") ('r ('(-r'%& e#' ('r ('(

• - "(';' "('Se)"r" '#'(

- +%e#("&"De +%e#("&"

Se)"r" #/e#(' #"M" r # !* "rM' r # !* "r C"+%*r"#

Se)"r" e&' ' !"# + r; 'A ) $/'r" $e%"&'&'(-e&*r*#"#Me&" ')B' '"r0C"r!'")-r'%& e#'

44


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• P"&$ e#e('( !"# %"& ;'(' '

45


47/70

• D'" # ('(G"+ "r"# r"!' '(

46


48/70

B'"("#0" !' e&"$*' (""& (e(e r"# +e " * "# %e+er' (""# e(e$"&"# r*&'# "&"*

(e>" &* ( r'#'# . Te( ;*# (' $"&' +e '%*&' "+'# &r"#(;er"(e< " " ' ; (;"&"(e<

"++" *&"+' &r"#(%e%&'!"(e< ' 'r* '#< " *+'# !"# >" &* %r &r + '#.o A(%"r&"&e "+'# &r"#(;er"(e =AST@ "&"* (er*+ *&"+' (" "(e&"& =SGOT@

!"# " "#'#e "+'# &r"#(;er"(e =ALT@ "&"* (er*+ *&"+' %'r*/"& &r"#("+'#"(e

=SGPT@ +e#'# "& &"%' &'!" e '&* &'# '. AST e '$ +e#'# "& !"r' ALT.o A " ' ; (;"&"(e +e#'# "& *r"# !"r' 2 ("+%"' 3 " ' "&"( # r+" "&"(.o G"++" *&"+' &r"#(%e%&'!"(e #(e#&r"('#0" ("+" (e%er&' " " ' ; (;"&"(eo B' 'r* '#< #(e#&r"('#0" '(" # r+" %"!" ('r ('( $"&' +%e#("&" &"%' '("

+e#'# "& %"!" ('r ('( 0"# "#:*&.o A *+'#< #(e#&r"('#0" +e+ *r* (e(*"' !e# "# %er *r* "# ('r ('(o G * '#< #(e#&r"('#0" +e#'# "& %"!" ('r ('(o Pr &r + '# &'+e +e#)er+'# "# &'# "&"# !er":"& !'(;*# (' $"&' +" " %"!"

('r ('( $"&' +e+"#:"#o N"&r'*+ (er*+ +e#*r*# &er*&"+" %"!" ('r ('( $"&' !e# "# "('&e(

Pe+er' (""# r"!' '( "r'*+ +e" !"%"& +e '$"& /"r'(e( *#&* #;'r+"('

"!"#0" $'%er&e#(' % r&". USG !"%"& +e '$"& (*!*& $"&'< %er+* ""# $"&'< * *r"# $"&'<

$ + e#'&"( !"# "!"#0" +"((". P"!" ('r ('( "#:*&< $"&' +e# e)' !"# # !* "r<

%er+* ""# 'rre * "r !"# "!"#0" %e#'# "&"# e e#'&"( %"re# '+. Se "'# '&* USG

:* " '(" *#&* +e '$"& "('&e(< (% e# +e " 0< &$r + ('( !"# %e e "r"# /e#" % r&".

P"!" (&"!'*+ +%e#("(' (e+%*r#" "!"# "!"# ("# "& (* '& +e#e " "#!'" # ('( ('r ('( $"&'. P"!" %r (e( "#:*&"# +*# '# '(" !'&e " "# !'" # ('(

!e# "# %e+er' (""# ;'(' < " r"& r'*+ !"# USG. P"!" (&"!'*+ !e +%e#("&"

!'" # ('( "!"# " " &'!" (* '& "re#" e:" " !"# &"#!" &"#!" '#'( (*!"$ &"+%"

!e# "# "!"#0" +% ' "('.

• M"#" e+e#&

T*:*"#

Me# *r"# ' %r re(' %e#0" '&Me# $'#!"r' "$"# K "$"# 0"# '(" +e#"+ "$ er*(" "# $e%"r Pe#)e "$"# !"# %e#"# "#"# +% ' "('J' " &'!" &er:"!' &r"*+" $e%"&') er' "# !'e& %r &e'# 1 r - BB !"# " r' 2 K

3 " $"r'A . S'r ('( +%e#("&"

47


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U#&* +e# *r"# ' %r re(' er*(" "# $"&'< &er"%' %"('e# *#&* +e# $' "# "#

e&' '". He%"&'&'( "*& '+*# S&er '! "&"* '++*# (*%re((';

. He+ r +"& ('( F e & +' (e&'"% +'# * ("+"%' #(e#&r"(' e(' # r+" !"#

!'* "# (e(*"' e *&*$"#). L'/er !'(e"(e # # " ) $ ') Pe#*r*#"# er"& "!"# *#&* +e#)e "$ )'rr$ ('(!. He%"&'&'( B

• L"+'/*!'#eo Ter"%' '#' 1o 1 + r" $"r' (e "+" 1 &"$*#< #"+*# %e+ er'"# (e&e "$ K 12

* "# !"%"& +e#0e " "# +*&"(' %"!" TNDD (e$'# " !"%"& &er:"!'

re('(&e#(' "&• '#&er;er # " ;"

(e)"r" (*#&' (* *&"# 3 MIU 3 " ' +'# * (e "+" , K 6 * "#

e. He%"&'&'( C• I#&er;er # (e)"r"(*#&' (* *&"# 5 MIU 3 " ' +'# *• R' "/'r'# 8 K 1 + $"r'(e "+" 6 * "#

;. F' r ('( $"&'• A#&';' r &' Le '$ +e# "r"$ e%"!" %er"!"# "# !"# &'!" &er$"!"%

;' r ('(< +e# *r"# ' " &'/'&"( (e (&e "&"• - '('# Me#*r*# "#e;e %er"!"# "# !"# +e#)e "$ %e+ e#&* "#

" e#• Me& &re ("& !"# V'&"+'# A

B . S'r ('( De +%e#("&"". A('&e(• T'r"$ "r'#• M* " K +* " !' er' !'e& re#!"$ "r"+ 5


50/70

W" &* %e#!"r"$"# " *&o Pre%"r"& ( +"& (&"&'# "&"* &re &'!o S er &er"%' "&"* ' "(e e#! ( %'

Per'& #'&'( ")&er'" (% #&"#o Se; &" ('# IVo A+ (' '#o A+'# ' ('!"

S'#!r +$e%"& re#"A&*r e(e'+ "# "# "r"+!"# "'rTr"#(% "#&"(' $e%"r Ter%"' !e;'#'&'/e %"!" %"('e# ('r ('( !e +%e#("&"

• - +% ' "('

1. Per'& #'&'( ")&er'" (% #&"#I#;e (' )"'r"# "('&e( e$ ("&* :e#'( " &er' &"#%" "!" * &' '#;e (' (e *#!er '#&r"

" ! +'#" < '"("#0" &"#%" e:" " :' " "!" er*%" !e+"+ !"# #0er' " ! +e#2. S'#!r +" $e%"& re#"

G"# *"# ;*# (' '#:" " *& er*%' ' *r'"< %e#'# "&"# *re*+< %e#'# "&"#

re"&'#'#< &"#%" "!"#0" e "'#"# r "#') '#:" . -er*(" "# $e%"r +e#0e " "#

%e#*r*#"# %er;*(' e '#:" (e$'# " &er:"!' "# *"# ;' &r"(' +er* *(3. H'%er&e#('% r&"

M"#';e(&"(' er*%" /"r'(e( e( %$" *( !'+"#" 2 K , %"('e# %e)"$ (e$'# "

&er:"!' %er!"r"$"#. 2 3 %"('e# +e#'# " !" "+ >" &* 1 &"$*#,. E#(e;" %"&' $e%"&')

-e "'#"# #e*r %(' '"&r' " ' "& !'(;*# (' $e%"r< 0"# !'&"#!"' !e# "# "# *"# &'!*r

='#( +#'" "&"*$'%er'#( +#'"@< "# *"# e("!"r"# $'# " +"5. S'#!r + $e%"& %* + #" H'!r & r" ( < H'%er&e#('% r& %* + #"

• Pr # ('(Ber/"r'"('< !'%e# "r*$' e er"%" ;")& r e&' '< er"" er*(" "# $e%"r< +% ' "('

!"# %e#0" '& "'# 0"# +e#0er&"'

1. - "(';' "(' )$' ! %* $U#&* +e#' "' %r # ('( %"!" "%('e# ('r ('( 0"# " #" +e#:" "#' %er"('

49


51/70

2. MELD () reU#&* +e#' "' %r # ('( %"('e# ('r ('( 0"# +e#:" "#' %r (e!*r &r"#(:* * "r

'#&r"$e%"&') % r& ('(&e+' ($*#& =TIPS@P"r"+e&er INR< B' 'r* '# & &" < Cre"&'#'#e Se " "' %re!')& r %re %er"&'/e re('

+ r&" '&"( %"!" %"('e# ('r ('( 0"# +e#:" "#' %er"('. S r 15 + r&" '&"( &'# '

D. SHOCK

-e"!""# +e# "#)"+ :'>" !'+"#" !e '/er0 #*&r'(' &'!" +e#)* *%' !"# " "#+e+%e# "r*$' )"r!'") *&%*#. T'!" (e'+ "# "#&"r" (*%% 0 !"# !e+"#!

1. H0% / e+') ($ ) • T")$0)"r!'"• T")$0%#e"• M*)*( +e+ r"#e er'#• We" %er'%$er" %* (e• Or& (&"&' •

H'% &e#('• H'% %er;*('2. S$ ) )"r!' e#')

• Me#*r*##0" )"r!'") *&%*& "r#" %e#*r*#"# #&r" &' '&'• V *+e /er "!• Ter!"%"& 2 #!'(' # # )"r!'") 0"'&* )"r!'") # # &"+% #"!e (er&" ' "&er"

%#e*+ &$ r"43. Ne*r e#') ($ )

• -"re#" %er* "$"# /"()* "r & #e (e$'# " &er:"!' $'% %er;*(' !' " '"# " $'r

r "#• E&' ' (%'# e%'!*r" "#"(&e('< %e#*r*#"# ('+%"&'(

,. Se%('(• Ser'# &er:"!' %"!" "#" • -"re#" ('(&e+' '#; "++"& r0 re(% # &er$"!"% '#;e ('• I#;e (' +e#0e " "# %e#'# "&"# %er+e" ' '&"( +e!'"& r '#; "+"(' !"#

)"'r"# e *"r e e (&r"/"()* "r (e$'# " &er:"!' $'% %er;*('

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E. PEMERIKSAAN

. P%r9uta*%ou Li>%r Bio8 /De;'#'('

Pr (e!*r 0"# +e# *#" "# # #ee! e 0"# !'+"(* "#+e e>"&' * '&<

:"r'# "#(* *&"#< '#&er) (&" +*() e< !"# %er'& #e*+ +e#*:* '/er *#&* !'"+ '

(%e)'+e# !"r':"r'# "# '/er I#!' "('

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G. PATOMEKANISME

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H. IIMC

− A(0 S0*r" 3

[D"# +*(' "$ "%"%*# 0"# +e#'+%" "+* "!" "$ "re#" %er *"&"# &"# "#+* (e#!'r'< !"# A "$ SWT+e+""; "# "#0" =!"r' e(" "$"# e(" "$"# +*@.\

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DA)TAR PUSTAKA• A#"& +0 C '#')" 0 Or'e#&e! M re 5&$ e! 2 5• J*# *e'r" (.B"(').H'(& 0.12&$.2• Te4& ; Me!')" P$0(' G*0& # 11E!• 2 1 R '#( C &r"# P"&$ ') B"('( ; D'(e"(e 8&$ E!• M)C"#)e P"&$ %$0(' 0 T$e B' ') B"('( ; r D'(e"(e '# A!* &( "#! C$' !re# 6&$• Te4& ; G"(&r e#&er 0 T" "&"!" 9"+"!"• Pr'#)'% e( ; I#&er#" Me!')'#e H"rr'( # (• J">e& < Me #') A!e er ( Me!')" M')r ' 0 =2,e< M)Gr"> H' < 2 7@• -"& *# B"(') C '#')" P$"r+") 0 &$ e! 2 3• B* * ":"r I +* Pe#0" '& D" "+ UI e!'(' VI

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Laporan Case 2 Gis Kel 3 2003 (1)

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