RUPTUR ESOFAGUS

RUPTUR HEPAR
RUPTUR USUS

ALDERS ALLEN KUSA NITBANI

BAGIAN BEAH RSUD WZ YOHANES KUPANG
ESOPHAGUS
https://sites.google.com/a/mtlstudents.net/the-digestive-
system/home/the-pharynx-and-the-esophagus/2-esophagus

http://www.nature.com/gimo/contents/pt1/full/gimo6.html
Gray’s Anatomy for students
?
 Perforation Esophagus

 Can result from  Clinical manifest.

 Iatrogenik  Site of perforation
(Endoscopy,  Pleural ?
Baloon dilation)  Infection ?
 Severe vomiting  Time repaired(24
 External trauma hrs)
 Rare causes  Minor (AB)

Gerard M. Doherty; current surgical diagnosis and treatment 12th ed. P;472-6
 Spontaneus (postemetic) Perforation
(Boerhaave’s Synd)

 Usually preexisting
esophageal
disease
 Heavy eat-drinking
 10% p-e-d
 All layers
 Left posterolat 3-5
cm GEJ
 Pleural torn
Gerard M. Doherty; current surgical diagnosis and treatment 12th ed. P;472-6
 Clinical finding
 Pain ……back
 Crepitus, dysphagia,
infec.(N)
 Tachycardia, tachypnea,
dyspnea (T)
 Hypotension
 Pneumothorax
 Hydrothorax
 Empyema
 L 70%, R 20%, B 10%
 Mediastinal crunch
(Hamman,s Sighn)

Gerard M. Doherty; current surgical diagnosis and treatment 12th ed. P;472-6
 Imaging
 X-Ray …air in the
tissues, along the
spine
 Mediastinum widening
 Plueral
Effusion…pneumothor
ax
 Esophagogram
 Ct scan

Gerard M. Doherty; current surgical diagnosis and treatment 12th ed. P;472-6
DIVERTIKULA ZENKER’S dan
DIVERTIKULA EPHIPRENICA
AKALASIA dan SPASME DIFUS ESOFAGUS

VARISES ESOFAGUS dan ESOFAGITIS

ADENOKARSINOMA ESOFAGUS
Laboratory

 Amylase content
 Amylase level
 Sign of infection
Potensially lethal lesions,
.i.e. lesions that can kill the patient in matter of hours

 a.pulmonary contusion
 b. aortic rupture
 c. tracheobronchial rupture
 d. oesophageal rupture
 e. diaphragmatic rupture
 f. myocardial contusion

Dr.Muhammad Nuralim Mallapasi.MD

SUB BAGIAN BEDAH TORAKS KARDIOVASKULAR
FAK KEDOKTERAN UNIVERSITAS HASANUDDIN
MAKASSAR
DIAGNOSIS
TERLAMBAT FATAL
TERAPI
 Treatment and Prognosis

 Antibiotics
 Early surgeries < 24 hrs
 Closure and external drainage

 Survival rate 90% <24 hrs

 50% late
 LIVER AND INTESTINE
RUPTURE
CAUSED:
1. TRAUMA

2. NON TRAUMA
EXPLOTION

Current explotion (Blast injury

Abdominal Trauma Mecanism:

 Blunt Trauma
 Penetrating Trauma – Gun shoot
Indication for DPL
1. Clinical doubt
2. Decrease of consiusnes after HT/ Intoxication

Contra Indication DPL

 Absolute” : laparotomy
 “Relative”: technical dificult do to obese,
hystori of abdominal surgery, late pregnant
 DPL

Indeks + +

- Aspirat
Blood > 10 ml > 5 ml
Fluids Intestine contens -

- Lavase
Ery. > 100.000/mm3 > 50.000/mm3
Leu > 500/mm3 > 200/mm3
Enzyme Amilase 20 IU/L -
Alk. Fosfatase IU/L -
Bile Konf. Biochemis
 Indication
Computerized tomography (CT)

 Good condition
 “Delayed presentation” > 24 hrs
 DPL doubt
 Susp. Retroperitoneal trauma, i.e haematuria
without urethral or vesical trauma
 Contra Indication for CT scan
 “Absolute”; laparotomy and pregnancy
 “Relative”; contras allergy
Ultrasonografi (USG)
 “More operator dependent”
 Quick, non ivasive, ceap
 Good for intraperitoneal free fluids and solid
organ trauma, retroperitoneal check.
 Not good for hollow viscus perforation.
Laparoscopy
 “Modern minimally invasive surgery”
 For diagnostic dan terapeutic
 Stable Haemodinamic
 Laparoscopic Weakness on
abdominal trauma
 Needs general anaesthetic
 Risk for pneumothraks if diaphragma
ruptured
 Risk for gas emboli at great veins trauma
Algorithm Blunt Abdominal Trauma

observe
Algorithm abdominal penetrating trauma
Jacobs MJ, gross R & Luk s : Atom, ‘Cine’-med. 2004
 Non operative treatment

 Stable haemodinamic
 60 – 70% on solid organ trauma, > 90% are
good
 “Screening” with CT scan
 Liver rupture
 Common solid organ ruptured caused by
abdominal blunt trauma.
 Fluids resucitation is mandatory.
 > 85 % liver ruptured  simple
haemostatic
 Pringle’s manouver (oklusion temporer)
porta hepatis  stop bleeding.
 Unstoped bleeding  damage control 
relaparatomi 24 – 48 hrs.
 Operation with time consumption :
- hypotermi
- acidosis metabolik
- koagulopathy
 LIVER INJURIES

 GRADING
Using the Organ Injury Scale of the
American Associated for the Surgery of
Trauma (AAST-OIS)
 LIVER INJURIES
 Grade I
 Nonexpanding subscapular hematoma, < 10%
surface area
 Capsular tear, non bleeding, < 1 cm in depth
 Incidence common
 Mortality: essentially none
 LIVER INJURIES
o Grade II
o Nonexpanding hematoma, subcapsular or intra-
parenchymal: 10 to 50% of surface area or <
10% in diameter
o Bleeding capsular tear
o Laceration 1 to 3 cm in depth, < 10 cm in length
o Incidence : 75%
o Mortality : < 10%
LIVER INJURIES
 Grade III
 Subcapsular hematoma, > 50% of surface area,
expanding or ruptured with bleeding
 Intraparenchymal hematoma, > 10 cm or
expanding
 Laceration > 3 cm deep
 Incidence : 15%
 Mortality : 25%
 LIVER INJURIES

 Grade IV
 Ruptured intraparenchymal hematoma with
bleeding
 Parenchymal disruption involving 25% to 75% of
lobe or 1 to 3 segments
 Incidence : 7%
 Mortality : 40%
 LIVER INJURIES

 Grade V
 Parenchymal
disruption of > 75%
of lobe or more
than 3 segments
 Juxtahepatic
venous injury
 Incidence : 3%
 Mortality > 80%
LIVER INJURIES

 Grade VI
 Hepatic avulsion
 Incidence : Rare
 Mortality : near 100%
 Take home : no change over time
 Non operatif management

 Stable Haemodynamic
 Trauma grade I and grade II
 Key for sucsess; close monitor, CT serial
 Compliction: “biloma”, abcses, fistel
vaskuler-bilier
OPERATIVE

 INDICATION;
1. Shock haemorrhagic
2. Non operative failure
3. Based on physic diagnostic,
haemodinamic stabillity, imaging result,
clinical experiences (surg).
FLUIDS RESUSITATION RESPONS IN BLEEDING CASES

RAPID RESPONSE

TRANSIENT RESPONSE

NO RESPONSE
 Operative management
abdominal penetrating injury

 Haemodinamyc instability
 Eviserasi intraperitonial organ
 Sign of peritonitis
 PERITONEAL IRRITANT
Abnormal Fluids in abdominal cavity(Lowenfels, 1975)

Pankreas Fluids

Intetine Content

Gastric Juices
Blood

Urine

Pus
Bile

Mild Severe
FRESH BLOOD IS NOT A
PERITONEAL IRRITANT !
1. STOP INTAKE ORAL 2. NASOGASTRIC TUBE

3. IV LINES 4. ANTIBIOTIK

5. KATETER / URINE OUT PUT MONITOR

EVIDENCE-BASED GUIDELINES FOR NON-OPERATIVE
MANAGEMENT OF ABDOMINAL INJURY

Boffard KD: Abdominal Trauma in

Core Topics in General and
Emergency Surgery, 3rd edit, Simon
Patterson Brown Elsevier-
Saunders.2005
Boffard KD: Abdominal Trauma in Core Topics in General and Emergency
Surgery, 3rd edit, Simon Patterson Brown Elsevier-Saunders.2005
 http://www.nature.com/gimo/contents/pt1/full/gimo6.html

https://sites.google.com/a/mtlstudents.net/the-digestive-
system/home/the-pharynx-and-the-esophagus/2-esophagus

Dr.Muhammad Nuralim Mallapasi.MD

SUB BAGIAN BEDAH TORAKS KARDIOVASKULAR
FAK KEDOKTERAN UNIVERSITAS HASANUDDIN
MAKASSAR

Warko Karnadihardja, Sp.B-KBD,FINACS

Sub Bag Bedah Digestif, RS. Hasan Sadikin
Fakultas Kedokteran UNPAD
Bandung
P2B2 PABI, 6-10 November 2007 Solo

Gerard M. Doherty; current surgical diagnosis and treatment 12th ed. P;472-6
Boffard KD: Abdominal Trauma in Core Topics in General and Emergency
Surgery, 3rd edit, Simon Patterson Brown Elsevier-Saunders.2005