6
III.1./. eala Klinik
T%n)% mem%n*%ng e'iologin$%/ ge,%l% *%n '%n*% &linis u'%m% &oles'%sis neon%'%l %*%l%h i&'0(us/ 'in,% %&oli&/ *%n u(in $%ng be(%(n% gel%)+ N%mun/ 'i*%& %*% s%'u )un ge,%l% %'%u '%n*% &linis $%ng )%'ognomoni& un'u& %'(esi% bilie(+ Ke%*%%n umum b%$i )%*% %&'u l%hi( bi%s%n$% b%i&+ I&'e(us bis% 'e(lih%' se,%& l%hi( %'%u '%m)%& ,el%s )%*% minggu &e 4+ Koles'%sis e&s'(%he)%'i& h%m)i( sel%lu men$eb%b&%n 'in,% $%ng %&oli&+ Sehubung%n *eng%n i'u seb%g%i u)%$% )en,%(ing &%s%( '%h%) )e('%m%/ *i%n,u(&%n mel%&u&%n )engum)ul%n 'in,% 4 )o(si+ Bil% sel%m% bebe(%)% h%(i &e'ig% )o(si 'in,% '0'%) %&oli&/ m%&% &emung&in%n bes%( *i%gnosisn
%$%*%l%h &oles'%sis
e&s'(%he)%'i&+ Se*%ng&%n
)%*% &oles'%sis
in'(%he)%'i&/ %(n% 'in,% *em)ul be(-lu&'u%si )%*% )0m0(i&s%%n 'in,% 4 )o(si Ikterus
I&'e(us 'imbul *i&%(en%&%n he)%( $%ng imm%'u( )%*% b%$i b%(u l%hi(+ No(m%ln$% i&'e(us %&%n menghil%ng )%*% 96"! h%(i se'el%h l%hi(+ Te'%)i b%$i *eng%n %'(esi% bile(/ i&'e(usn$% %&%n sem%&in n$%'% *%l%m 64 minggu Urin yan -er2arna ela"
H%l ini *iseb%b&%n &%(en% bili(ubin $%ng mening&%' *%l%m *%(%h/ &emu*i%n bili(ubin 'e(-il'(%si mel%lui gin,%l/ *%n *ibu%ng mel%lui u(in+ 3eses A/h#li/
eses %0holi0 'imbul *i&%(en%&%n 'i*%& %*%n$% bili(ubin $%ng m%su& &e *%l%m usus un'u& me%(n%i -eses+ Penurunan -erat -adan
1( '( 4
III.1.d. Pemeriksaan 3isik
P%*% )eme(i&s%%n -isi&/ 'i*%& %*% 'emu%n $%ng )%'hognomoni0 un'u& %'(esi% bilie( •
B%$i *eng%n %'(esi% bilie( bi%s%n$% meng%l%mi )e('umbuh%n no(m%l *%n )ening&%'%n be(%' b%*%n sel%m% minggu )e('%m% &ehi*u)%n+
•
He)%'omeg%li
,
7
•
S)lenomeg%li menun,u&&%n si(osis $%ng )(og(esi- *eng%n hi)e('ensi )o('%l+
•
Mu(mu( ,%n'ung menun,u&&%n %*%n$% &el%in%n )%*% ,%n'ung
*
III.1.e. Pemeriksaan Penunan
Belum %*% s%'u )un )eme(i&s%%n )enun,%ng $%ng *%)%' se)enuhn$% *i%n*%l&%n un'u& membe*%&%n %n'%(% &oles'%sis in'(%he)%'i& *%n e&s'(%he)%'i&+ Se0%(% g%(is bes%(/ )eme(i&s%%n *%)%' *ib%gi men,%*i 4 &elom)o&/ $%i'u )eme(i&s%%n : "8 L%bo(%'o(ium (u'in *%n &husus un'u& menen'u&%n e'iologi *%n menge'%hui -ungsi h%'i 7*%(%h/ u(in/ 'in,%8 8 Pen0i'(%%n/ un'u& menen'u&%n )%'ensi s%lu(%n em)e*u *%n menil%i )%(en&im h%'i 48 Bio)si h%'i/ 'e(u'%m% bil% )eme(i&s%%n l%in belum *%)%' menun,%ng *i%gnosis %'(esi% bilie(+
15 Pemeriksaan la-#rat#rium
a) Pemeriksaan rutin P%*% se'i%) &%sus &oles'%sis h%(us *il%&u&%n )eme(i&s%%n &%*%( &om)onen bili(ubin un'u& membe*%&%nn$% *%(i hi)e(bili(ubinemi% -isiologis+ Sel%in i'u *il%&u&%n )eme(i&s%%n *%(%h 'e)i leng&%)/ u,i -ungsi h%'i/ *%n g%mm%6GT+ K%*%( bili(ubin *i(e& < mg=*l 'i*%& sesu%i *eng%n obs'(u&si 'o'%l+ Pening&%'%n &%*%( SGOT=SGPT 3 "! &%li *eng%n )0ning&%'%n g%mm%6GT 5 &%li/ lebih meng%(%h &e su%'u &el%in%n he)%'oselule(+ Seb%li&n$%/ )ening&%'%n SGOT 5 &%li *eng%n )ening&%'%n g%mm%6GT 3 5 &%li/ lebih meng%(%h &e &oles'%sis e&s'(%he)%'i&+ Menu(u' i'ge(%l*/ &%*%( g%mm%6GT $%ng (en*%h 'i*%& men$ing&i(&%n &emung&in%n %'(esi% bilie(+ Kombin%si )ening&%'%n g%mm%6GT/ bili(ubin se(um 'o'%l %'%u bili(ubin *i(e&/ *%n %l&%li -os-%'%se mem)un$%i s)esi-isi'%s ;/;2 *%l%m menen'u&%n %'(esi% bilie(+
b) Pemeriksaan khusus
*
8
Peme(i&s%%n %s)i(%si *uo*enum 7DAT8 me(u)%&%n u)%$% *i%gnos'i& $%ng 0u&u) sensi'i-/ 'e'%)i )enulis l%in men$%'%&%n b%h% )eme(i&s%%n ini 'i*%& lebih b%i& *%(i )eme(i&s%%n @isu%lis%si 'in,%+ P%l%s&% men$%'%&%n b%h% &%(en% &%*%( bili(ubin *%l%m em)e*u h%n$% "!2/ se*%ng&%n &%*%( %s%m em)e*u *i *%l%m em)e*u %*%l%h #!2/ m%&% 'i*%& %*%n$% %s%m em)e*u *i *%l%m 0%i(%n *uo*enum *%)%' menen'u&%n %*%n$% %'(esi% bilie(+
!5 Pen/itraan
a) Pemeriksaan ultrasonografi Theoni mengemu&%&%n b%h% %&u(%si *i%gnos'i0 USG 992 *%n *%)%' *i'ing&%'&%n bil% )eme(i&s%%n *il%&u&%n *%l%m 4 -%se/ $%i'u )%*% &e%*%%n )u%s%/ s%%' minum *%n sesu*%h minum+ Bil% )%*% s%%' %'%u sesu*%h minum &%n*ung em)e*u be(&on'(%&si/ m%&% %'(esi% bilie( &emung&in%n bes%( 7;!28 *%)%' *ising&i(&%n+ Dil%'%si %bno(m%l *u&'us bilie(/ 'i*%& *i'emu&%nn$% &%n*ung em)e*u/ *%n mening&%'n$% e&ogeni'%s h%'i/ s%ng%' men*u&ung *i%gnosis %'(esi% bilie(+ N%mun *emi&i%n/ %*%n$% &%n*ung em)e*u 'i*%& men$ing&i(&%n &emung&in%n %'(esi% bilie(/ $%i'u %'(esi% bilie( 'i)e I = *is'%l+
b) Sintigrafi hati Peme(i&s%%n sin'ig(%-i sis'em he)%'obilie( *eng%n iso'o) Te0hne'ium ;;m mem)un$%i %&u(%si *i%gnos'i& sebes%( ;1/<2+ Sebelum )eme(i&s%%n *il%&u&%n/ &e)%*% )%sien *ibe(i&%n -enob%(bi'%l 5 mg=&gBB=h%(i )e( o(%l/ *ib%gi *%l%m *osis sel%m% 5 h%(i+ P%*% &oles'%sis in'(%he)%'i& )eng%mbil%n iso'o) oleh he)%'osi' be(l%ngsung l%mb%' 'e'%)i e&s&(esin$% &e usus no(m%l/ se*%ng&%n )%*% %'(esi% bilie( )(oses )eng%mbil%n iso'o) no(m%l 'e'%)i e&s&(esin$% &e usus l%mb%' %'%u 'i*%& 'e(,%*i s%m% se&%li+ Di l%in )ih%&/ )%*% &oles'%sis in'(%he)%'i& $%ng be(%' ,ug% 'i*%& %&%n *i'emu&%n e&s&(esi iso'o) &e *uo*enum+ Un'u& mening&%'&%n sensi'i@i'%s *%n s)esi-isi'%s )eme(i&s%%n sin'ig(%-i/ *il%&u&%n )enghi'ung%n in*e&s he)%'i& 7)en$eb%(%n iso'o) *i h%'i *%n ,%n'ung8/ )%*% meni' &e6"!+ In*e&s he)%'i& 3 5 *%)%' men$ing&i(&%n &emung&in%n %'(esi% bilie(/ se*%ng&%n in*e&s he)%'i&
+
9
*i%gnosis sebes%( ;1/<2+ To((isi mengemu&%&%n b%h% *%l%m men*e'0&si %'(esi% bilie(/ $%ng 'e(b%i& %*%l%h mengg%bung&%n b%sil )eme(i&s%%n USG *%n sin'ig(%-i+
c) Liver Scan S0%n )%*% li@e( *eng%n menggun%&%n me'o*e HIDA 7He)%'obili%($ Imino*e%0e'i0 A0i*8+ Hi*% mel%&u&%n )emo'(e'%n )%*% ,%lu( *%(i em)e*u *%l%m 'ubuh/ sehingg% *%)%' menun,u&%n bil%m%n% %*% blo&%*e )%*% %li(%n em)e*u+
d) Pemeriksaan kolangiografi Peme(i&s%%n
ERCP
(Endoscopic
Retrograde
holangio
Pancreaticograph!) m0(u)%&%n u)%$% *i%gnos'i& *ini $%ng be(gun% un'u& membe*%&%n %n'%(% %'(esi% bilie( *eng%n &oles'%sis in'(%he)%'i&+ Bil% *i%gnosis %'(esi% bilie( m%sih me(%gu&%n/ *%)%' *il%&u&%n )eme(i&s%%n &ol%ngiog(%-i durante operasionam. S%m)%i s%%' ini )eme(i&s%%n &ol%ngiog(%-i *i%ngg%) seb%g%i b%&u em%s un'u& membe*%&%n &oles'%sis in'(%he)%'i& *eng%n %'(esi% bilie(+
$5 Bi#"si hati
G%mb%(%n his'o)%'ologi& h%'i %*%l%h %l%' *i%gnos'i& $%ng )%ling *%)%' *i%n*%l&%n+ Di '%ng%n seo(%ng %hli )%'ologi $%ng be()eng%l%m%n/ %&u(%si *i%gnos'i&n$% men0%)%i ;52/ sehingg% *%)%' memb%n'u )eng%mbil%n &e)u'us%n un'u& mel%&u&%n l%)%(%'omi e&s)lo(%si/ *%n b%h&%n be()e(%n un'u& )enen'u%n o)e(%si K%s%i+ Kebe(h%sil%n %li(%n em)e*u )%s0% o)e(%si K%s%i *i#'u&%n oleh *i%me'e( *u&'us bilie( $%ng )%'en *i *%e(%h hilus h%'i+ Bil% *i%me'e( *u&'us "!! !! u %'%u "5!
*il%&u&%n fro"en section )%*% s%%' l%)%(%'omi e&s)lo(%si/
un'u& menen'u&%n %)%&%h )o('oen'e(os'omi
*%)%' *i&e(,%&%n+ G%mb%(%n
his'o)%'ologi& h%'i $%ng meng%(%h &e %'(esi% bilie( mengh%(us&%n in'e(@ensi be*%h se0%(% *ini+ F%ng men,%*i )e('%n$%%n %*%l%h %&'u $%ng )%ling o)'im%l un'u& mel%&u&%n bio)si h%'i+ H%(us *is%*%(i/ 'e(,%*in$% )(oli-e(%si *u&'ule( 7g%mb%(%n his'o)%'ologi& $%ng men$o&ong *i%gnosis %'(esi% bilie( 'e'%)i 'i*%&
4
10
)%'ognomoni&8 meme(lu&%n %&'u+ Oleh &%(en% i'u 'i*%& *i%n,u(&%n un'u& mel%&u&%n bio)si )%*% usi% # minggu
III.1.. Dian#sa
Di%gnosis %'(esi% bilie( *i'eg%&&%n be(*%s%(&%n %n%mnesis/ )eme(i&s%%n -isi& *%n )eme(i&s%%n )enun,%ng+ M%ni-es'%si &linis u'%m% %'(esi% bilie( %*%l%h 'in,% %&oli&/ %i( &emih se)e('i %i( 'eh/ *%n i&'e(us+ A*% em)%' &e%*%%n &linis $%ng *%)%' *i)%&%i seb%g%i )%'o&%n un'u& membe*%&%n %n'%(% &oles'%sis in'(%he)%'i& *%n e&s'(%he)%'i&/ $%i'u: be(%' b%*%n l%hi(/ %(n% 'in,%/ umu( )en*e(i'% s%%' 'in,% mul%i %&oli&/ *%n &e%*%%n he)%(+ K(i'e(i% ini 7T%bel "8 mem)un$%i %&u(%si *i%gnos'i& s%m)%i 12+ Mo$e( *&&+ men%mb%h&%n s%'u &(i'e(i% l%gi/ $%i'u g%mb%(%n his'o)%'ologi& h%'i
T%bel "+ Em)%' &(i'e(i% &linis 'e()en'ing un'u& membe*%&%n Koles'%sis In'(%he)%'i& *%n E&s'(%he)%'i&
III.1.. Dian#sa Dierential • • • •
Hi)o)l%si% bilie(/ s'enosis *u&'us bilie( Pe(-o(%si s)on'%n *u&'us bilie( M%ss% 7neo)l%sm%/ b%'u8 #nspissated bile s!ndrome
10
11
• • • •
He)%'i'is neon%'%l i*io)%'i& Dis)l%si% %('e(iohe)%'i& 7sin*(om Al%gille8 Pen$%&i' C%(oli 7)eleb%(%n &is'i& )%*% *u&'us in'(%he)%'i&8+ He)%'i'is
III.1.h. Penatalaksanaan %era"i medikament#sa
"8 Mem)e(b%i&i %li(%n b%h%n6b%h%n $%ng *ih%sil&%n oleh h%'i 'e(u'%m% %s%m em)e*u 7%s%m li'o&ol%'8/ *eng%n membe(i&%n :
enob%(bi'%l 5 mg=&gBB=h%(i *ib%gi *osis/ )e( o(%l+ enob%(bi'%l %&%n me(%ngs%ng enim glu&u(onil '(%ns-e(%se 7un'u& mengub%h bili(ubin in*i(e& men,%*i bili(ubin *i(e&8 enim si'o&(om P6<5! 7un'u& o&sigenis%si 'o&sin8/ enim N% K ATP%se 7mengin*u&si %li(%n em)e*u8+
Koles'i(%min " g(%m=&gBB=h%(i *ib%gi # *osis %'%u sesu%i ,%*%l )embe(i%n susu+ Koles'i(%min memo'ong si&lus en'e(ohe)%'i& %s%m em)e*u se&un*e(+
8 Melin*ungi h%'i *%(i %' 'o&si&/ *eng%n membe(i&%n :
As%m u(so*eo&si&ol%'/ 4"! mg=&gBB=h%(i/ *ib%gi 4 *osis/ )e( o(%l+ As%m u(so*eo&si&ol%' mem)un$%i *%$% i&%' &om)e'i'i- 'e(h%*%) %s%m li'o&ol%' $%ng he)%'o'o&si&+
%era"i nutrisi/ $%ng be('u,u%n un'u& memung&in&%n %n%&
'umbuh *%n be(&emb%ng seo)'im%l mung&in/ $%i'u : "8 Pembe(i%n m%&%n%n $%ng meng%n*ung medium chain trigl!cerides 7MCT8 un'u& meng%'%si m%l%bso()si lem%&+ 8 Pen%'%l%&s%n%%n *e-isiensi @i'%min $%ng l%(u'*%l%m lem%&+
%era"i -edah
11
12
Kasai Pr#sedur
P(ose*u(
$%ng
'e(b%i&
%*%l%h
mengg%n'i
s%lu(%n
em)e*u
$%ng
meng%li(&%n em)e*u &e usus+ Te'%)i )(ose*u( ini h%n$% mung&in *il%&u&%n )%*% 56"!2 )en*e(i'%+ Un'u& melom)%'i %'(esi% bilie( *%n l%ngsung menghubung&%n h%'i *eng%n usus h%lus/ *il%&u&%n )embe*%h%n $%ng *isebu' )(ose*u( K%s%i+ Pembe*%h%n %&%n be(h%sil ,i&% *il%&u&%n sebelum b%$i be(usi% 1 minggu+ Bi%s%n$% )embe*%h%n ini h%n$% me(u)%&%n )engob%'%n semen'%(% *%n )%*% %&hi(n$% )e(lu *il%&u&%n )en0%ng&o&%n h%'i+
G%mb%( 5+ K%s%i P(ose*u(e
P(ose*u( &%s%i bis% membu%' seb%gi%n )%sien be(umu( )%n,%ng+ N%mun/ -ungsi h%'i )%*% seb%gi%n )%sien l%inn$% sem%&in membu(u&+ Umumn$%/ )%sien *%'%ng &e (um%h s%&i' *%l%m &on*isi $%ng su*%h bu(u&/ $%&ni s%%' b%$i be(usi% lebih *%(i *u% bul%n+ Pen*e(i'% )en$%&i' gin,%l memili&i %l'e(n%'i- )engob%'%n *i%lis%/ 'e'%)i 'i*%& *emi&i%n h%ln$% *eng%n )en*e(i'% )en$%&i' h%'i $%ng be(%'+ .i&% h%'i su*%h 'i*%& be(-ungsi l%gi/ m%&% s%'u6s%'un$% )ilih%n )engob%'%n %*%l%h )en0%ng&o&&%n h%'i+
1!
13
Pen/ank#kan atau %rans"lantasi Hati
T(%ns)l%n'%si h%'i memili&i 'ing&%' &ebe(h%sil%n $%ng 'inggi un'u& %'(esi% bilie( *%n &em%m)u%n hi*u) se'el%h o)e(%si mening&%' se0%(% *(%m%'is *%l%m bebe(%)% '%hun 'e(%&hi(+ An%&6%n%& *eng%n %'(esi% bilie( se&%(%ng *%)%' hi*u) hingg% *e%s%/ bebe(%)% b%h&%n 'el%h mem)un$%i %n%&+ Kem%,u%n
*%l%m
o)e(%si
'(%ns)l%n'%si
'el%h
,ug%
mening&%'&%n
&emung&i%n%n un'u& *il%&u&%nn$% '(%ns)l%n'%si )%*% %n%&6%n%& *eng%n %'(esi% bilie(+ Di m%s% l%lu/ h%n$% h%'i *%(i %n%& &e0il $%ng *%)%' *igun%&%n un'u& '(%ns)l%'%si &%(en% u&u(%n h%'i h%(us 0o0o&+ B%(u6b%(u ini/ 'el%h *i&emb%ng&%n un'u& menggun%&%n b%gi%n *%(i h%'i o(%ng *e%s%/ $%ng *isebu' (e*u0e* sie %'%u s)li' li@e( '(%ns)l%n'%si/ un'u& '(%ns)l%n'%si )%*% %n%& *eng%n %'(esi% bilie(+
III.1.i. K#m"likasi Kolangitis: &omuni&%si l%ngsung *%(i s%lu(%n em)e*u in'(%he)%'i0 &e usus/
*eng%n %li(%n em)e*u $%ng 'i*%& b%i&/ *%)%' men$eb%b&%n %s0en*ing 0hol%ngi'is+ H%l ini 'e(,%*i 'e(u'%m% *%l%m minggu6minggu )e('%m% %'%u bul%n se'el%h )(ose*u( K%s%i seb%n$%& 4!6#!2 &%sus+ In-e&si ini bis% be(%' *%n &%*%ng6&%*%ng -ulmin%n+
A*% '%n*%6'%n*% se)sis 7*em%m/ hi)o'e(mi%/ s'%'us hemo*in%mi&
'e(g%nggu8/ i&'e(us $%ng be(ul%ng/ -eses %0holi0 *%n mung&in 'imbul s%&i' )e(u'+ Di%gnosis *%)%' *i)%s'i&%n *eng%n &ul'u( *%(%h *%n = %'%u bio)si h%'i+ Hipetensi portal: Po('%l hi)e('ensi 'e(,%*i se'i*%&n$% )%*% *u% )e('ig% *%(i %n%&6
%n%& se'el%h )o('oen'e(os'om$+ H%l )%ling umum $%ng 'e(,%*i %*%l%h @%(ises eso-%gus+ Hepatopulmonary syndrome dan hipertensi pulmonal: Se)e('i )%*% )%sien
*eng%n )en$eb%b l%in se0%(% s)on'%n 7si(osis %'%u )(ehe)%'i0 hi)e('ensi )o('%l8 %'%u *i)e(oleh 7be*%h8 )o('os$s'emi0 shun's/ shun's )%*% %('e(i@enosus )ulmo mung&in 'e(,%*i+ Bi%s%n$%/ h%l ini men$eb%b&%n hi)o&si%/ si%nosis/ *%n *$s)neu+ Di%gnosis *%)%' *i'eg%&%n *eng%n s0in'ig(%)h$ )%(u+ Sel%in i'u/ hi)e( #si )ulmon%l *%)%' 'e(,%*i )%*% %n%&6%n%& *eng%n si(osis $%ng men,%*i )en$eb%b &elesu%n *%n b%h&%n &em%'i%n men*%*%&+ Di%gnosis *%l%m &%sus ini *%)%' *i'eg%&%n oleh
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e0ho0%(*iog(%)h$+ T(%ns)l%n'%si li@e( *%)%' memb%li&%n shun's/ *%n *%)%' memb%li&&%n hi)e('ensi )ulmon%l &e '%h%) semul%+ Keganasan: He)%'o0%(0inom%s/ he)%'obl%s'om%s/ *%n 0hol%ngio0%(0inom%s *%)%'
'imbul )%*% )%sien *eng%n %'(esi% bilie( $%ng 'el%h meng%l%mi si(osis+ S&(ining un'u& &eg%n%s%n h%(us *il%&u&%n se0%(% 'e(%'u( *%l%m 'in*%& l%n,u' )%sien *eng%n o)e(%si K%s%i $%ng be(h%sil+
Hasil setelah aal #"erasi Kasai
Si(osis bilie( be(si-%' )(og(esi- ,i&% o)e(%si K%s%i g%g%l un'u& memulih&%n %li(%n em)e*u/ *%n )%*% &e%*%%n ini h%(us *il%&u&%n '(%ns)l%n'%si h%'i+ H%l ini bi%s%n$% *il%&u&%n *i '%hun &e*u% &ehi*u)%n/ n%mun *%)%' *il%&u&%n lebih %%l 7*%(i # bul%n hi*u)8 un'u& mengu(%ngi &e(us%&%n *%(i
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'i*%& %*%n$% *u&'us bilie( e&s'(%he)%'i& $%ng )%'en/ *%n bil% 'e(,%*i )en$uli' hi)e('ensi )o('%l+
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Pielone-(i'is %&u'
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In-e&si s%lu(%n %i( &emih be(ul%ng
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" bln6 'hn : P%n%s=hi)o'e(mi% '%n)% *i&e'%hui seb%bn$%/ g%nggu%n )e('umbuh%n/ %no(e&si%/ mun'%h/ *i%(e/ &e,%ng/ &om%/ &oli& 7%n%& men,e(i' &e(%s8/ %i( &emih be(b%u=be(ub%h %(n%/ &%*%ng6&%*%ng *ise('%i n$e(i )e(u'=)ingg%ng+ 6# 'hn
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&emih be(b%u *%n be(ub%h %(n%+
DIAN7SIS Biakan air kemih :
Di&%'%&%n in-e&si )osi'i- %)%bil% : 6
Ai( &emih '%m)ung )o(si 'eng%h : bi%&%n &um%n )osi'i- *eng%n ,uml%h &um%n J"!5=ml/ &%li be('u(u'6'u(u'+
6
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6 Peme(i&s%%n ul'(%sonog(%-i gin,%l un'u& menge'%hui &el%in%n s'(u&'u( gin,%l *%n &%n*ung &emih+ 6
Peme(i&s%%n Mi&sio Sis'o U(e'(og(%-i=MSU un'u& menge'%hui %*%n$% (e-lu&s+
1*
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6 Peme(i&s%%n )ielog(%-i in'(% @en% 7PI8 un'u& men0%(i l%'%( bel%&%ng in-e&si s%lu(%n &emih *%n menge'%hui s'(u&'u( gin,%l se('% s%lu(%n &emih+
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F%ng )en'ing %*%l%h membe*%&%n %n'%(% )ielone-(i'is *%n sis'i'is+ Ing%' %&%n )ielone-(i'is %)%bil% *i*%)%'&%n in-e&si *eng%n hi)e('ensi/ *ise('%i ge,%l%6ge,%l% umum/ %*%n$% -%&'o( )(e*is)osisi/ -ungsi &onsen'(%si gin,%l menu(un/ (es)ons 'e(h%*%) %n'ibio'i& &u(%ng b%i&+
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