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DMS 2005
Batu Saluran KemihBatu Saluran Kemih(Urolithiasis)(Urolithiasis)
Prof. DR.Dr. Doddy M. Soebadi, SpB, SpU –K Prof. DR.Dr. Doddy M. Soebadi, SpB, SpU –K
Rujukan:Rujukan:
Smith’s General Urology, Tanagho EA & Mc.AninchSmith’s General Urology, Tanagho EA & Mc.Aninch JWJW(eds.), ange Medical !oo"s # McGra$%(eds.), ange Medical !oo"s # McGra$% ill, 'th ed., ***ill, 'th ed., ***
(Campbell’s Urology, Walsh PC et al. (eds.), WB(Campbell’s Urology, Walsh PC et al. (eds.), WB Saunders Co., 8th ed., 2002) Saunders Co., 8th ed., 2002)
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DMS 2005
URINARY TRACT STONEURINARY TRACT STONE
C!SS"#"C!$"%&C!SS"#"C!$"%&
R"SK #!C$%RSR"SK #!C$%RS
D"!'&%S"SD"!'&%S"S
$R(!$M(&$$R(!$M(&$
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DMS 2005
URINARY TRACT STONEURINARY TRACT STONE
+ASS-+AT/+ASS-+AT/
gro01s2 gro01s2
'.'. MA-2 de3initi4e ca0ses2MA-2 de3initi4e ca0ses2
MM 2 meta5olic2 meta5olic
2 in3ection2 in3ection
AA 2 anatomic2 anatomic
-- 2 30nctional2 30nctional
.. dio1athicdio1athic
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DMS 2005
URINARY TRACT STONEURINARY TRACT STONE
MA- UrolithiasisMA- Urolithiasis
6e3ects in 10rine meta5olism (0ric acid related disorders)6e3ects in 10rine meta5olism (0ric acid related disorders)
y1ero7al0ric statesy1ero7al0ric states8rimary hy1ero7al0ria8rimary hy1ero7al0ria
Enteric hy1ero7al0riaEnteric hy1ero7al0ria
y1ercalcemic statesy1ercalcemic states
8rimary hy1er1arathyroidism8rimary hy1er1arathyroidism
y1erthyroidismy1erthyroidism
9itamin 6 a50se9itamin 6 a50se
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DMS 2005
URINARY TRACT STONEURINARY TRACT STONE
MA- UrolithiasisMA- Urolithiasis
y1ercalcemic states (cont.)y1ercalcemic states (cont.)
mmo5ili:ationmmo5ili:ation
6isseminated malignancies6isseminated malignanciesSarcoidosisSarcoidosis
;enal t050lar acidosis;enal t050lar acidosis
+hronic diarrhoeal states+hronic diarrhoeal states
+ystin0ria+ystin0riaUrinary in3ection $ith 0rease 1rod0cing microorganismsUrinary in3ection $ith 0rease 1rod0cing microorganisms
Anatomical and 30nctional a5normalitiesAnatomical and 30nctional a5normalities
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DMS 2005
URINARY TRACT STONEURINARY TRACT STONE
R"SK #!C$%RSR"SK #!C$%RS
'ene)i*+'ene)i*+ ::
– +ystin0ria2 a0tosomal recessi4e+ystin0ria2 a0tosomal recessi4e – ;TA (renal t050lar acidosis) < ty1e ;TA (renal t050lar acidosis) < ty1e
– Med0llary s1onge "idneyMed0llary s1onge "idney
'eorap-y : )epera)ure / -uidi)y'eorap-y : )epera)ure / -uidi)y
Die) : *a*iu 1 oaa)e in)ake 33Die) : *a*iu 1 oaa)e in)ake 33 Profe++ion: +eden)aryProfe++ion: +eden)ary
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DMS 2005
URINARY TRACT STONEURINARY TRACT STONE
Age Profession Nutrition Climate InheritaneSe! "entalit# Constitution Rae
A$normal renal %istur$e& Urinar# "eta$oli 'enetimorholog# urine o* trat infetion a$normalities fators
Inrease %erease&
e!retion of e!retion of E!retion of Urinar# +olumestone forming r#stalli,ation r#stalli,ationonstituents romoters inhi$itors
Ph#sio-hemial hange in the
state of suersaturation
A$normal r#stalluriaCr#stal aggregation
Cr#stal gro*th
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DMS 2005
URINARY TRACT STONEURINARY TRACT STONE
D"!'&%S"SD"!'&%S"S
4i+)ory4i+)ory
P-y+i*a ea.P-y+i*a ea. !ddi)iona :!ddi)iona :
– Urine, micro5iologyUrine, micro5iology
– Ser0m2 "idney 30nction, 0ric acidSer0m2 "idney 30nction, 0ric acid
– 8lain 7%ray # USG #988lain 7%ray # USG #98
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DMS 2005
Comosition of most imortant stoneComosition of most imortant stone
onstituentsonstituents
Chemial nameChemial name "ineral name"ineral name
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------O!alateO!alateCa O! "onoh#&rateCa O! "onoh#&rate .he*ellite.he*ellite
Ca O! &ih#&rateCa O! &ih#&rate .e&&*lite.e&&*lite
Phoshate Car$onate aatite %ahllite
Ca / Ph &ih#&rate Brushite
β-tri Ca hoshate .hitlo0ite
/#&ro!#aatite
"g Am hoshate he!1 Stru+ite
Uri ai&Uri ai& Uri ai&Uri ai& UriiteUriite
Urate Uri ai& &ih#&rate -
"ono amm1urate -
"ono so1 urate monoh#&1 -Stone assoiate& *2Stone assoiate& *2 3-#stine3-#stine --
In$orn error of meta$1In$orn error of meta$1 4anthine4anthine --
5678%ih#&ro!#a&enine5678%ih#&ro!#a&enine --
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DMS 2005
E9AUAS SEE=T-
TAM!AA/
U;TASS
MA-
TE;A8 SESUA
=EA/A/ 6ASA;
TA= 8E;U E9AUAS
SEA/JUT/>A
M/UM ? !A/>A=
U;/ @ JAM
S.=;EAT//
=ASUM
ST;AT
M/UM E! !A/>A=
8E;%=ASU;A %%%%% T TAB6E
8%ST;ATU;A %%%%% T =%% ST;AT
!AS+ META!SM E9AUAT/
ST;>
%;A>
ST/E A/A>SS
!62
SE;UM +;EAT//E
+A+UM
U;+ A+6
U;/E2
+UTU;E
1
/E-;TASS =ASUM
68AT= SE6E;A/A
/E-;TASS =ASUM
68AT= =M8=AS
E9AUAS META!= UAS
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
(6!U!S" M($!B%"K D!S!R (6!U!S" M($!B%"K D!S!R
!nane+a: peny. '", )uan, d+b, RPK,!nane+a: peny. '", )uan, d+b, RPK,
dii), oba)2andii), oba)2an
#o)o poo+ abd., "6P, US'#o)o poo+ abd., "6P, US'
Pe. Urin: U, biakan, p4Pe. Urin: U, biakan, p4
!nai+a ba)u!nai+a ba)u Pe. Dara-: krea)inin, ura), ka+iuPe. Dara-: krea)inin, ura), ka+iu
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DMS 2005
URINARY TRACT STONEURINARY TRACT STONE
(6!U!S" M($!B%"K U!S(6!U!S" M($!B%"K U!S
Urin 27 ja:Urin 27 ja: 8oue8oue
krea)ininkrea)inin
ka+iuka+iu +i)ra)+i)ra)
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
TE;A8TE;A8
– ME/GA/G=A/ />E;ME/GA/G=A/ />E;
– 8E/GAM!A/ !ATU8E/GAM!A/ !ATU
– TE;A8 8E/+EGAA/ !ATUTE;A8 8E/+EGAA/ !ATU =ASUM=ASUM
– TE;A8 -A;MA=GS !ATUTE;A8 -A;MA=GS !ATU =ASUM=ASUM
– TE;A8 -A;MA=GS !ATUTE;A8 -A;MA=GS !ATU ASAM U;ATASAM U;AT
– TE;A8 -A;MA=GS !ATUTE;A8 -A;MA=GS !ATU SST/SST/
– TE;A8 -A;MA=GS !ATUTE;A8 -A;MA=GS !ATU /-E=S/-E=S
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
TERAPITERAPI
: PEN'A"BI3AN BATUPEN'A"BI3AN BATU
;1;1 ES.3ES.35151 URSURS
<1<1 PN3PN3
=1=1 BE%A/ TERBUKABE%A/ TERBUKA
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
(S9 ;<(S9 ;<
– Sejak ;=>7Sejak ;=>7
– Me+in (S9 : ber)aba- ke*i, kekua)an ebi-Me+in (S9 : ber)aba- ke*i, kekua)an ebi-
renda-renda- – Modifika+i kri)eria indika+iModifika+i kri)eria indika+i
– Kon)ra indika+i ab+ou):Kon)ra indika+i ab+ou):? Mafora+i +kee)a bera)Mafora+i +kee)a bera)
? %be+i)a+ bera)%be+i)a+ bera)
? Prenan*yPrenan*y
? !neuri+a aor)a 1 a.renai+!neuri+a aor)a 1 a.renai+
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
(S9 2<(S9 2<
– Pain efek)if un)uk ba)u @ 20 Pain efek)if un)uk ba)u @ 20
– $idak idea un)uk ba)u kaik+ inferior 3;5 $idak idea un)uk ba)u kaik+ inferior 3;5
– 4a+i un)uk ba)u inja:4a+i un)uk ba)u inja:
Ukuran ba)uUkuran ba)u !nka beba+ ba)u A buan<!nka beba+ ba)u A buan<
@ ;0 @ ;0 2=2 2=2 >7>7<<
;020 ;020 5=>; 5=>; EEEE<<
3 20 3 20 ;=E0 70<;=E0 70<
re) ;0 – A0<re) ;0 – A0<
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
(S9 A<(S9 A<
– $erapi uanan )dk ebi- dari A – 5 F$erapi uanan )dk ebi- dari A – 5 F
– !n)ibio)ika -anya bia "SK G!n)ibio)ika -anya bia "SK G
– Pd -idronefro+i+ a)au inja )erinfek+i k1p nefro+)oyPd -idronefro+i+ a)au inja )erinfek+i k1p nefro+)oy
a)au P&a)au P&
– Maiu +-o*k Ha8e+:Maiu +-o*k Ha8e+:
? (e*)ro-ydraui*(e*)ro-ydraui* : A500 +-o*k+: A500 +-o*k+
? PieIoee*)ri*PieIoee*)ri* : 5000 +-o*k+: 5000 +-o*k+
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
(S9 7<(S9 7<
– (S9 un)uk ba)u ure)er:(S9 un)uk ba)u ure)er:
– Kuran uda- dipe*a- ) uanan 3<Kuran uda- dipe*a- ) uanan 3<
– Beruna un)uk ba)u ke*i @ > <Beruna un)uk ba)u ke*i @ > < – "n+i)u a)au pu+-JnJban"n+i)u a)au pu+-JnJban
– Kadan2 peru D+)en)Kadan2 peru D+)en)
– !nka beba+ ba)u A buan<:!nka beba+ ba)u A buan<:
? B.ure)er pro.B.ure)er pro. : 2 – ;00 re) A><: 2 – ;00 re) A><
? B.ure)er )ena-B.ure)er )ena- : 7 – ;00 re) A>=0<: 7 – ;00 re) A>=0<
? B.ure)er di+)aB.ure)er di+)a : E2 – ;00 re) A><: E2 – ;00 re) A><
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
URSURS
Sejak 2 dekadeSejak 2 dekade
– Ure)ero+kop baru:Ure)ero+kop baru:
? Minia)ur diae)er ebi- ke*i<Minia)ur diae)er ebi- ke*i<? en+a ebi- baik +eiriid<en+a ebi- baik +eiriid<
– Modai)a+ pen-an*ur baru:Modai)a+ pen-an*ur baru:
? U)ra+onik U)ra+onik
? (ek)ro-idrauik (ek)ro-idrauik
? a+er a+er
? Bai+)ik: Pneua)ik LSHi++ i)-o*a+)J< / eek)rokine)ik Bai+)ik: Pneua)ik LSHi++ i)-o*a+)J< / eek)rokine)ik
– 4a+i ebi- baik 4a+i ebi- baik
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
URSURS
– Pro+edur:Pro+edur:? !ne+)e+i uu a)au reiona!ne+)e+i uu a)au reiona
? DibaHa- fuoro+kopiDibaHa- fuoro+kopi
? ()rak+i or dipe*a- d:()rak+i or dipe*a- d: U)ra+onik U)ra+onik
(ek)ro-idrauik (ek)ro-idrauik
a+er a+er
Bai+)ik 1 pneua)ik Bai+)ik 1 pneua)ik
– G1 D+)en)G1 D+)en)
– !nka beba+ ba)u : =5 – ;00 re) ;0<!nka beba+ ba)u : =5 – ;00 re) ;0<
– RaHa) jaan a)au raHa) inap ; – 2 -ariRaHa) jaan a)au raHa) inap ; – 2 -ari
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
P& PC&, PC&<P& PC&, PC&< – Pro+edur:Pro+edur:
? !ne+)e+i uu a)au reiona!ne+)e+i uu a)au reiona
? #uoro+kopi: )ra*k nefro+)oi#uoro+kopi: )ra*k nefro+)oi
? ()rak+i or dipe*a- d:()rak+i or dipe*a- d: U)ra+onik U)ra+onik
(ek)ro-idrauik (ek)ro-idrauik
a+er a+er
Bai+)ik 1 pneua)ik Bai+)ik 1 pneua)ik
? Pipa nefro+)oi 2 – A -ari )o)a MRSPipa nefro+)oi 2 – A -ari )o)a MRS GG 5 -ari<5 -ari<
– !nka beba+ ba)u : >5 – ;00 re) ;5<!nka beba+ ba)u : >5 – ;00 re) ;5<
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
B(D!4 $(RBUK!B(D!4 $(RBUK!
;.;. Pieoi)o)oi 1 e)ended pieoi)o)oiPieoi)o)oi 1 e)ended pieoi)o)oi
2.2. &efroi)o)oi 1 ana)rop-i* nefroi)o)oi &efroi)o)oi 1 ana)rop-i* nefroi)o)oi
A.A. Mu)ipe radia nefroi)o)oiMu)ipe radia nefroi)o)oi7.7. $eknik -ipo)eria$eknik -ipo)eria
5.5. Ba)u G indika+i rekon+)ruk+iBa)u G indika+i rekon+)ruk+i
.. Ba)u u8 jun*)ion, y peru neo ipan)a+iBa)u u8 jun*)ion, y peru neo ipan)a+i
E.E. $idak ada fa+ii)a+ (S91URS1P&$idak ada fa+ii)a+ (S91URS1P&
>.>. Par+ia / )o)a &efrek)oiPar+ia / )o)a &efrek)oi
=.=. Ure)eroi)-o)oiUre)eroi)-o)oi
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
$(R!P" C4(M%S"S$(R!P" C4(M%S"S
Beruna un)uk $ )aba-an pd (S9, P&,Beruna un)uk $ )aba-an pd (S9, P&,
URS a)au beda- )erbuka.URS a)au beda- )erbuka.
;.;. Ba)u infek+iBa)u infek+i
2.2. Bru+-i)eBru+-i)e
A.A. Cy+)ineCy+)ine
7.7. Uri* a*idUri* a*id
5.5. Ca*iu oaa)e / aoniu ura)eCa*iu oaa)e / aoniu ura)e
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
$(R!P" P(&C('!4!&$(R!P" P(&C('!4!& B!$U K!S"UMB!$U K!S"UM
;.;. Menaikkan a+ukan *airanMenaikkan a+ukan *airan
2.2. Saran a+ukan ka+iuSaran a+ukan ka+iu
A.A. Sera)Sera)
7.7. Re+)rik+i ok+aa)Re+)rik+i ok+aa)
5.5. Menurani a+ukan pro)einMenurani a+ukan pro)ein
.. $-iaIide$-iaIide
E.E. !opurino!opurino
>.>. !kaine *i)ra)e !kaine *i)ra)e GG<<
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
$(R!P" C4(M%S"S$(R!P" C4(M%S"S
;.;. Ba)u infek+iBa)u infek+i Ba)u ane+iu aoniu po+p-a)e/ *arbona)eBa)u ane+iu aoniu po+p-a)e/ *arbona)e
apa)i)e diaru)kan denan :apa)i)e diaru)kan denan : – ar0tan '*C emiacridin (1 D.%@)ar0tan '*C emiacridin (1 D.%@)
– ar0tan S05yar0tan S05y
– Selama t7 anti5ioti"a, lar0tan dialir"an le$at "ateterSelama t7 anti5ioti"a, lar0tan dialir"an le$at "ateter
ne3rostomi2 mas0" & "el0ar selama 5e5era1a hari ata0ne3rostomi2 mas0" & "el0ar selama 5e5era1a hari ata0
mingg0mingg0 – Unt0" mem1erl0as 1erm0"aan, dila"0"an ESWUnt0" mem1erl0as 1erm0"aan, dila"0"an ESW
Beruna un)uk pa+ien ri+iko )ini un)uk opera+i a)auBeruna un)uk pa+ien ri+iko )ini un)uk opera+i a)au)indakan ain)indakan ain
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
$(R!P" C4(M%S"S$(R!P" C4(M%S"S
2.2. Ba)u bru+-i)eBa)u bru+-i)e
Dipakai aru)an a+aDipakai aru)an a+a
Dp dipakai un)uk +i+a ba)uDp dipakai un)uk +i+a ba)u
$eru)aa bia +erin kabu-$eru)aa bia +erin kabu-
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
$(R!P" C4(M%S"S$(R!P" C4(M%S"S
A.A. Ba)u *y+)ineBa)u *y+)ine
Dipakai aru)an ba+a p4 >.5 – =:Dipakai aru)an ba+a p4 >.5 – =:
– ar. $4!M 0.A10. o1 )ri-ydroye)-yar. $4!M 0.A10. o1 )ri-ydroye)-y
ainoe)-an<ainoe)-an<
– ar. !*e)y*y+)eine a)au kobina+i d $4!M<ar. !*e)y*y+)eine a)au kobina+i d $4!M<
Cara d per*u)aneou+ *-eoy+i+Cara d per*u)aneou+ *-eoy+i+
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
$(R!P" C4(M%S"S$(R!P" C4(M%S"S
7.7. Ba)u a+a ura)Ba)u a+a ura)
Dipakai aru)an ba+a p4 >.5 – =:Dipakai aru)an ba+a p4 >.5 – =:
– ar. $4!M 0.A10. o1 )ri-ydroye)-yar. $4!M 0.A10. o1 )ri-ydroye)-y
ainoe)-an<ainoe)-an<
Cara d per*u)aneou+ *-eoy+i+Cara d per*u)aneou+ *-eoy+i+
Dapa) d *ara ora *-eoy+i+:Dapa) d *ara ora *-eoy+i+: – !+.ura) dara-: ) aopurino / inu banyak !+.ura) dara-: ) aopurino / inu banyak
– p4 dinaikkan denan akai p4 dinaikkan denan akai
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
Peru )indakan uren 1 +eera:Peru )indakan uren 1 +eera:;.;. !da bak)erieia a)au +ep+i+!da bak)erieia a)au +ep+i+
2.2. Profe+i )er)en)u, )idak ei-a) ukuran ba)uProfe+i )er)en)u, )idak ei-a) ukuran ba)u
pre8en)if<:pre8en)if<:
;.;. Pio)Pio)
2.2. "n+inyur 1 pekerja kon+)ruk+i"n+inyur 1 pekerja kon+)ruk+i
A.A. Dok)er +pe+iai+ beda-Dok)er +pe+iai+ beda-
+eranan koik eba-ayakan oran ain+eranan koik eba-ayakan oran aina)au diri +endiri<a)au diri +endiri<
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
Pedoan )erapi ek+pek)a)if:Pedoan )erapi ek+pek)a)if:
;.;. Ukuran 7 a)au ebi- ke*iUkuran 7 a)au ebi- ke*i
2.2. Keu-an )idak enanuKeu-an )idak enanu
A.A. $idak ada "SK biakan, febri+, enii<$idak ada "SK biakan, febri+, enii<
7.7. $idak ada ob+)ruk+i -idronefro+i+<$idak ada ob+)ruk+i -idronefro+i+<
5.5. Mak+iu 7 inuMak+iu 7 inu
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
Peru diper-a)ikan un)uk )erapi ek+pek)a)if:Peru diper-a)ikan un)uk )erapi ek+pek)a)if:
;.;. !nane+a yan *era) keu-an<!nane+a yan *era) keu-an<
2.2. #o)o poo+ abd. B%#< a)au US'#o)o poo+ abd. B%#< a)au US'
A.A. "6P"6P
7.7. Biakan urinBiakan urin
5.5. Penderi)a koopera)if Penderi)a koopera)if
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
$erapi ek+pek)a)if:$erapi ek+pek)a)if:
;.;. Diure)ikaDiure)ika
2.2. K1p anae)ik b koik<K1p anae)ik b koik<
A.A. (er*i+e : ari, oa- raa y on*a)2(er*i+e : ari, oa- raa y on*a)2
7.7. Minu A7 i)er air Minu A7 i)er air
5.5. anan diberi an)ibio)ikaanan diberi an)ibio)ika
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DMS 2005
"ANA'E"ENT O9 URINARY TRACT STONE"ANA'E"ENT O9 URINARY TRACT STONE
$erapi ek+pek)a)if:$erapi ek+pek)a)if:
;.;. Diure)ika :Diure)ika :? 4C$ 25 ; F ; )ab4C$ 25 ; F ; )ab
2.2. K1p anae)ik b koik< :K1p anae)ik b koik< :? Mefenai* a* 1 Ke)oprofen )ab 1 +upMefenai* a* 1 Ke)oprofen )ab 1 +up
A.A. (er*i+e : ari, oa- raa y on*a)2(er*i+e : ari, oa- raa y on*a)2? oin, badin)on, )enni+ : A F 20 en 1 inuoin, badin)on, )enni+ : A F 20 en 1 inu
7.7. Minu A7 i)er air Minu A7 i)er air ? Bia faa inja noraBia faa inja nora
5.5. anan diberi an)ibio)ikaanan diberi an)ibio)ika? "SK G indika+i )indakan"SK G indika+i )indakan