Ileus paralitik/obstruksi

Apendisitis perforasi/akut
Peritonitis primer/skunder
Hernia
Invaginasi/intusepsi
Volvulus/malrotasi
Perforasi intestinal

Hernia
A hernia is defined as an
abnormal protrusion of an
organ or tissue through a
defect in its surrounding
walls
Although a hernia can
occur at various sites of
the body, these defects
most commonly involve
the abdominal wall,
particularly the inguinal
region.

Hernia Inguinal
Classified as direct or indirect
The sac of an indirect inguinal hernia passes from the internal inguinal
ring obliquely toward the external inguinal ring and ultimately into the
scrotum.
As indirect hernias enlarge, it sometimes can be difficult to distinguish
between indirect and direct inguinal hernias.
In contrast, the sac of a direct inguinal hernia protrudes outward and
forward and is medial to the internal inguinal ring and inferior epigastric
vessels.
Men are 25 times more likely to have a groin hernia than women
Indirect inguinal and femoral hernias occur more commonly on the right
side.
The predominance of right-sided femoral hernias is thought to be caused
by the tamponading effect of the sigmoid colon on the left femoral canal.

 Strangulation, the most common serious complication

of a hernia, occurs in only 1% to 3% of groin hernias and
is more common at the extremes of life.
Most strangulated hernias are indirect inguinal hernias.

Diagnosis
There may be associated pain or vague discomfort in the region, but groin
hernias are usually not extremely painful unless incarceration or strangulation
has occurred.
patients may experience paresthesias related to compression or irritation of the
inguinal nerves by the hernia.
The inguinal region is examined with the patient in the supine and standing
positions.
Inspects and palpates the inguinal region, looking for asymmetry, bulges, or a
mass.
Valsalva maneuver can facilitate identification of a hernia.
A bulge moving lateral to medial in the inguinal canal suggests an indirect
hernia.
If a bulge progresses from deep to superficial through the inguinal floor, a direct
hernia is suspected.
Ultrasonography also can aid in the diagnosis.
(CT) of the abdomen and pelvis may be useful for the diagnosis of obscure and
unusual hernias as well as atypical groin masses.
laparoscopy can be diagnostic and therapeutic for particularly challenging
cases.

Acute Appendisitis
Appendicitis occurs more frequently in Westernized
societies.
Acute appendicitis remains the most common
emergency general surgical disease affecting the
abdomen.
Appendicitis occurs most commonly in 10- to 19-yearolds.
One of the more common complications and most
important causes of excess morbidity and mortality is
perforation.

Pathogenesis
Fecaliths, incompletely digested food residue, lymphoid
hyperplasia, intraluminal scarring, tumors, bacteria, viruses, and
inflammatory bowel disease have all been associated with
inflammation of the appendix and appendicitis.
Obstruction lumen appendicitis
luminal distention, bacterial
overgrowth
inhibit dlow of lymph and blood
thrombosis,
ischemic necrosis
perforation distal appendix
Some cases of simple acute appendicitis may resolve
spontaneously or with antibiotic therapy, and recurrent disease is
remotely possible.
When perforation occurs, the resultant leak may be contained by
the omentum or other surrounding tissues to form an abscess.
Free perforation normally causes severe peritonitis
infective
suppurative thrombosis portal vein
intrahepatic abscesses
The prognosis of the develop this dreaded complication is very
poor.

Clinical Manifestation

Laboratory Testing
Does not identify patients with appendicitis but can help the clinician
work through the differential diagnosis.
White blood cell count is only mildly to moderately elevated in
approximately 70% of patients with simple appendicitis (with a
leukocytosis of 10,00018,000 cells/L)
A left shift toward immature polymorphonuclear leukocytes is
present in >95% of cases.
Urinalysis is indicated to help exclude genitourinary conditions that
may mimic acute appendicitis
Inflamed appendix that abuts the ureter or bladder may cause sterile
pyuria or hematuria.
Cervical cultures are indicated if pelvic inflammatory disease is
suspected.
Anemia and guaiac-positive stools should raise concern about the
presence of other diseases or complications such as cancer.

Imaging
Plain films of the abdomen not routinely obtained unless
the clinician is worried about other conditions such as
intestinal obstruction, perforated viscus, or ureterolithiasis.
Presence of a fecalith is not diagnostic of appendicitis
The effectiveness of ultrasonography as a tool to diagnosis
appen-dicitis is highly operator dependent.
Ultrasonography may facilitate early diagnosis.
Ultrasonographic findings suggesting the presence of
appendicitis include wall thickening, an increased
appendiceal diameter, and the presence of free fluid.
CT imaging may be very helpful, although it is important
not to be overly cautious and delay operative intervention
for those patients who are believed to have appendicitis.

Treatment
In the absence of contraindications, a patient who has a strongly
suggestive medical history and physical examination with supportive
laboratory findings should undergo appendectomy urgently.
In patients in whom the evaluation is suggestive but not convincing,
imaging and further study are appropriate.
Pelvic ultrasonography is indicated in women of childbearing age.
CT may accurately indicate the presence of appendicitis or other
intraabdominal processes.
Narcotics can be given to patients with severe discomfort, especially if
the first abdominal examination is completed before drugs are
administered.
All patients should be fully prepared for surgery and have any fluid and
electrolyte abnormalities corrected.
Either laparoscopic or open appendectomy is a satisfactory choice for
patients with uncomplicated appendicitis.

 Such patients are best served by treatment with broadspectrum antibiotics, drainage if there is an abscess >3 cm
in diameter, and parenteral fluids and bowel rest if they
appear to respond to conservative management.
The appendix can then be more safely removed 612
weeks later when inflammation has diminished.
Laparoscopic appendectomy is associated with less
postoperative pain and, possibly, a shorter length of stay
and faster return to normal activity.
have fewer wound infections, although the risk of
intraabdominal abscess formation may be higher.
Absent complications, most patients can be discharged
within 2440h of operation.
most common postoperative complications are fever and
leukocytosis.

Acute Peritonitis
Acute peritonitis, or inflammation of the visceral and parietal
peritoneum, is most often but not always infectious in origin,
resulting from perforation of a hollow viscus.
This is called secondary peritonitis, as opposed to primary or
spontaneous peritonitis, when a specific intraabdominal source
cannot be identified.
In either instance, the inflammation can be localized or diffuse.
Infective organisms may contaminate the peritoneal cavity after
spillage from a hollow viscus, because of a penetrating wound of
the abdominal wall, or because of the introduction of a foreign
object like a peritoneal dialysis catheter or port that becomes
infected.

 Secondary peritonitis most

commonly results from
perforation of the appendix,
colonic diverticuli, or the
stomach and duodenum. It may
also occur as a complication of
bowel infarction or incarceration,
cancer, inflammatory bowel
disease, and intestinal
obstruction or volvulus.
Over 90% of the cases of
primary or spontaneous
bacterial peritonitis occur in
patients with ascites or
hypoproteinemia (<1 g/L).

 Aseptic peritonitis is most commonly caused by the

abnormal pres-ence of physiologic fluids like gastric
juice, bile, pancreatic enzymes, blood, or urine.
The chemical irritation caused by stomach acid and
activated pancreatic enzymes is extreme and secondary
bacterial infection may occur.

Clinical Features
The cardinal signs and symptoms of peritonitis are acute, typically severe,
abdominal pain with tenderness and fever.
Elderly and immunosuppressed patients may not respond as aggressively to
the irritation.
Diffuse, generalized peritonitis is most often recognized as diffuse
abdominal tenderness with local guarding, rigidity, and other evidence of
parietal peritoneal irritation.
Bowel sounds are usually absent to hypoactive.
Most patients present with tachycardia and signs of volume depletion with
hypotension.
Laboratory testing typically reveals a significant leukocytosis, and patients
may be severely acidotic.
Radiographic studies may show dilatation of the bowel and associated
bowel wall edema.
Free air, or other evidence of leakage, requires attention and could
represent a surgical emergency.

Treatment
Mortality rates can be less than 10% for reasonably
healthy patients with relatively uncomplicated, localized
peritonitis.
Mortality rates >40% have been reported for the elderly
or immunocompromised.
Successful treatment depends on correcting any
electrolyte abnormalities, restoration of fluid volume
and stabilization of the cardiovascular system,
appropriate antibiotic therapy, and surgical correction of
any underlying abnormalities.

Intussuception
acquired invagination of the bowel into itself, usually involving
both small and large bowel.
The more proximal bowel that invaginates into more distal bowel
is termed the intussusceptum, whereas the recipient bowel that
contains the intussusceptum is termed the intussuscipiens.
Invagination of the bowel leads to edema, and ischemic changes
eventually supervene; thus intussusception is an urgent condition,
but prolonged delay in diagnosis is not uncommon, resulting in
increased risk for patients to present with obstruction, necrosis,
and bowel perforation.
Classic pediatric intussusception involves invagination of the distal
ileum into the colon, as ileocolic or ileoileocolic intussusception;
however, intestinal intussusception may occur along the entire
length of the bowel from the duodenum to the colon.

Etiology
Most cases of ileocolic intussusception occurring in
children are idiopathic.
Some reports suggest a viral etiology, most commonly
adenovirus, but enterovirus, echovirus, and human
herpes virus 6 also have been implicated.

Clinical Presentation
Idiopathic intussusception occurs most commonly in infants
between 2 months and 3 years of age, with a peak at age 5 to 9
months.
The classic clinical presentation of the child with intussusception
is colicky abdominal pain, vomiting, bloody stools, and a palpable
abdominal mass.
Children with intussusception should be diagnosed as early as
possible to avoid bowel ischemia, necrosis, and surgery.
The clinical signs and symptoms of intussusception are often
nonspecific and may overlap with those of gastroenteritis,
malrotation with volvulus, and in older children, Henoch-Schnlein
purpura.
Venous hypertension leads to hematochezia, with a typical
mixture of stool, blood, and blood clots described as currant jelly
stools, a finding highly suggestive of intussusception.
Intussuscepted bowel may prolapse through the rectum.

Diagnosis & Imaging

Treatment
Enema reduction should be
undertaken in children with
intussusception after surgical
consultation.
the only absolute
contraindications to enema
reduction are signs of
peritonitis on clinical
examination or free air on
abdominal radiographs .

Intestinal Obstruction & Malrotation

Clinical Presentation
Patients with obstruction may exhibit severe pain, abdominal
distension (unless involvement is in the proximal GI tract),
diaphoresis, stigmata of dehydration, and vomiting with inability to
tolerate oral input.
may be tachycardic (both from pain and hypovolemia).
Fever raises concerns for intestinal ischemia, perforation, and
peritonitis.
Small bowel obstruction leads to abdominal distension, cramping
discomfort in the middle or upper abdomen, and repeated
episodes of bilious vomiting.
If there is total obstruction, patients eventually become obstipated
On rectal examination, if the obstruction is high in the colon, the
rectum will be devoid of stool, but hard stool in the rectum may be
present if the patient has fecal impaction.

Evaluation & Management

initial evaluation in the emergency department is to determine the acuity
and severity of the childs illness.
The first pass on physical examination should quickly acquire information
regarding the patients critical features, beginning with the ABCs.
Vital signs should be evaluated for fever (in the setting of obstruction,
concerning for ischemia), tachycardia, hypotension (worrisome for
decompensated shock), and lownormal blood pressure with widened pulse
pressure (concerning for compensated shock).
Patients with vomiting should receive nothing by mouth (NPO) and should
have an intravenous (IV) line started for maintenance fluids
If there are signs of dehydration, isotonic fluid boluses are appropriate
until the patient is hemodynamically stable.
If the patient is ill appearing or has fever in the context of suspected
obstruction, the physician should strongly consider initiating IV antibiotic
therapy with adequate coverage for common gut flora (gram-negative and
anaerobic organisms) after obtaining a blood culture.

Laboratory Finding
If the patient is ill appearing or has fever in the context
of suspected obstruction, the physician should strongly
consider initiating IV antibiotic therapy with adequate
coverage for common gut flora (gram-negative and
anaerobic organisms) after obtaining a blood culture.
If the patient is ill appearing and has a fever, a blood
culture should be done before administration of
antibiotics.

Radiologic Test
Fluoroscopic
Barium water-soluble contrast agent : perforation
In patients who are medically unstable, who have a
history of trauma, or who have a suspected perforation,
the study of choice is the CT scan
GI endoscopy is a useful tool for diagnosing mucosal
disorders that may not be
obvious on radiologic imaging.
After enough clinical information is available to
determine whether the child should go to the operating
room, laparotomy or, at some centers, laparoscopy.

Reference
Longo DL, Kasper DL, Jameson JL, Fauci AS, Hauser SL, Loscalzo
J, editors. Harrisons Principle of Internal Medicine. 19th ed. USA:
McGraw-Hill; 2015.
Tanto C, Liwang F, Hanifati S, Pradipta EA, editors. Kapita
Selekta Kedokteran. Edisi 4. Jakarta: Media Aesculapius; 2014.
Intussusception Chapter. Kimberly E. Applegate. Caffey's
Pediatric Diagnostic Imaging, Chapter 108, 1135-1143.e1
HerniasChapter. Mark A. Malangoni andMichael J.
Rosen.Sabiston Textbook of Surgery, Chapter 46, 1114-1140
Intestinal Obstruction and MalrotationChapter. Andrew Chu.
Netter's Pediatrics, 109, 690-697