Problem 4

Ahmad Fathul Adzmi

405130213
Gastrointestinal System Block
Acute Abdomen
 Definition
• Acute abdomen  sign and symptoms of
abdominal pain and tenderness, a clinical
presentation that often requires emergency
surgical therapy.
 ETIOLOGY
(ACCORDING TO AGE)
Neonatal causes of Abdominal
Pain
– Colic
– Milk Protein Allergy
– Gastroesophageal reflux
– Malrotation or Midgut volvulus
– Necrotizing Enterocolitis
– Hirschprung's Enterocolitis
Infant causes of Abdominal Pain
– Intussusception
– Infantile colic
– Bowel Obstructionn
• Pyloric stenosis
• Incarcerated Herniaa
• Internal hernia
• Omphalomesenteric band
• Hirschprung's Diseasee
– Battered Infant
• Jejunum perforation
• Duodenal hematoma
– Gastroenteritis
– Constipation
– Urinary Tract Infection
 ETIOLOGY
(ACCORDING TO AGE)
Child causes of Abdominal Pain Adolescent
– Constipation – Appendicitis
– Lactose Intolerance – Gastroenteritis
– Lead Poisoning
– Constipation
– Helicobacte pylori
– Urinary Tract Infection – Gynecologic cause
– Pneumonia • Pregnancy (or Ectopic Pregnancy)
– Pancreatitis • Mittelschmerz
– Appendicitis • Dysmenorrhea
– Mesenteric Lymphadenitis • Pelvic Inflammatory Disease
– Gastroenteritis • Ovarian torsion
– Intussusception or Volvulus (children – Testicular Torsion
under age 6) – Drug and Alcohol use
– Abdominal trauma
– Sexual abuse
– Pharyngitis (e.g. Strep Throat)
– Sickle Cell Crisis – Gallbladder disease
– Henoch-Schonlein Purpura – Neoplasm
– Inflammatory Bowel Disease
 ETIOLOGY/CAUSES/DIFFERENTIAL DIAGNOSIS
OF ACUTE ABDOMEN
• Gastrointestinal
– Appendisitis
– Perforated peptic ulcer
– Intestinal ischemia
– Diverticulitis
– Inflammatory bowel disease
– Meckel’s diverticulitis
• Pancreaticobiliary tract, liver,
spleen
– Acute pancreatitis
– Calculous cholecystitis
– Acalculous cholecystitis
– Acute cholangitis
– Hepatic abscess
– Ruptured hepatic tumor
– Splenic rupture
• Urinary tract
– Renal/ureteral stone
• Gynecologic
– Ectopic pregnancy
– Tuboovarian abscess
– Ovarian torsion
– Uterine rupture
– Ruptured ovarian cyst or follicle
• Retroperitoneum
– Abdominal aortic aneurysm
• Supradiaphragmatic
– Pneumothorax
– Pulmonary embolus
– Acute pericarditis
– Empyema
 Nonsurgical Causes of
Acute Abdomen
Endocrine and Metabolic Causes
Uremia
Diabetic crisis
Addisonian crisis
Acute intermittent porphyria
Hereditary Mediterranean fever
Hematologic Causes
Sickle cell crisis
Acute leukemia
Other blood dyscrasias
Toxins and Drugs
Lead poisoning
Other heavy metal poisoning
Narcotic withdrawal
Black widow spider poisoning
 Surgical Acute Abdominal Conditions
Hemorrhage
Solid organ trauma
Leaking or ruptured arterial aneurysm
Ruptured ectopic pregnancy
Bleeding gastrointestinal deiverticulum
Arteriovenous malformation of gastrointestinal tract
Intestinal ulceration
Aortoduodenal fistula after aortic vascular graft
Hemorrhagic pancreatitis
Mallory – Weiss syndrome
Spontaneous rupture of spleen
Infection
Appendicitis
Cholecystitis
Meckel’s diverticulitis
Hepatic abscess
Diverticular abscess
Psoas abscess
Perforation
Perforated gastrointestinal ulcer
Perforated gastrointestinal cancer
Boerhaave’s syndrome
Perforated diverticulum
Obstruction
Adhesion related small or large bowel obstruction
Sigmoid volvulus
Cecal volvulus
Incarcerated hernias
Inflammatory bowel disease
Gastrointestinal malignancy
Intussusception
Ischemia
Buerger’s disease
Mesenteric thrombosis or embolism
Ovarian torsion
Ischemic colitis
Testicular torsion
Strangulated hernias
 Some mechanisms of pain originating
in abdomen
• Inflammation of the parietal peritoneum
– Pain of parietal peritoneal inflammation is steady and aching in
character and is located directly over the inflamed area 
transmitted by somatic nerves supplying the parietal
peritoneum
– Pain intensity  type and amount of material to which the
peritoneal surfaces are exposed in a given time period
– The pain of peritoneal inflammation is invariably accentuated by
pressure or changes in tension of the peritoneum
• Produced by palpation or by movement, as in coughing or sneezing
• Lies quietly in bed, preferring to avoid motion,
• In contrast to the patient with colic, who may writhe incessantly
– Tonic reflex spasm of the abdominal musculature, localized to
the involved body segment
• Obstruction of hollow viscera
– Intermittent, or colicky
• Distention of a hollow viscus  steady pain + very occasional
exacerbations
• The colicky pain of obstruction of the small intestine 
periumbilical or supraumbilical, poorly localized
• Acute distention of the gallbladder  pain in the right upper
quadrant with radiation to right posterior region of the
thorax / to the tip of the right scapula
• Distention of the common bile duct  pain in the
epigastrium radiating to the upper part of the lumbar region
• Obstruction of the urinary bladder  dull suprapubic pain,
usually low in intensity
– In contrast, acute obstruction of the intravesicular portion of the
ureter  severe suprapubic and flank pain radiates to penis,
scrotum, or inner aspect of the upper thigh
• Vascular Disturbances
– Pain associated with intraabdominal vascular disturbances
is sudden and catastrophic in nature
• Embolism or thrombosis of the superior mesenteric artery
– Severe & diffuse; only mild continuous diffuse pain for 2 or 3 days before
vascular collapse or findings of peritoneal inflammation appear
• Impending rupture of an abdominal aortic aneurysm
– Abdominal pain with radiation to the sacral region, flank, or genitalia;
persist over a period of several days before rupture and collapse occur
• Abdominal wall
– Pain from the abdominal wall  constant & aching
– e/ Movement, prolonged standing, and pressure
accentuate the discomfort and muscle spasm
• Ex: hematoma of the rectus sheath
 Classification

Visceral
pain
Abdominal Parietal
Pain pain
Reffered
pain
 Classification
• Visceral pain
– Tends to be vague, poorly localized to the epigastrium,
periumbilical region, or hypogastrium
– Depending on its origin from the primitive foregut, midgut,
or hindgut
– Mediated by autonomic nerves (sympathetic and
parasympathetic)

• Parietal pain
– Coorresponds to the segmental nerve roots innervating
the peritoneum
– Tends to be sharper and better localized
• Referred pain
– Perceived at a site that is distant from the
sourced of stimulus
– For example  irritation of the diaphragm may
produce pain in the shoulder

Locations of Reffered Pain and Its Causes

Right Shoulder
Liver
Gallbladder
Right hemidiaphragm
Left Shoulder
Heart
Tail of pancreas
Spleen
Left hemidiaphragm
Scrotum and Testicles
Ureter
 PHYSICAL EXAMINATION
• Patient overall appearance
– Ability to communicate and habitus ?
– Lie quietly in bed or active move ?
– Lie on his or her side with knees and hips flexed?
– Appear dehydrated with dry mucous membranes?
• Patient lying quietly in bed, avoiding motion, and
complaining of abdominal pain -> serious intra-
abdominal disease
 PHYSICAL EXAMINATION
• Evaluation of the vital signs
– Low fever (37.2 ⁰ C – 37.8⁰ C)  diverculitis,
appendicitis, acute cholecystitis
– High fever (> 37.8⁰ C) pneumonia, urinary tract
infection, septic cholangitis, or gynecologic
infection
– Rapid heart rate and hypotension  complicated
disease with peritonitis
 PHYSICAL EXAMINATION
Inspection
• Scars
• Hernias
• Masses
• Abdominal wall defect
• Contour abdomen scaphoid, flat, distended
– Abdominal distention  intestinal obstruction,
ileus, or fluid including ascites, blood, or bile
– Peristaltic movement  intestine obstruction
– Contraction abdomen  perforation
 PHYSICAL EXAMINATION
Auscultation
• Bowel sounds ↑  obstruction of small
intestine, early acute pancreatitis
• Bowel sound ↓  chronic obstruction of
intestine, difuse peritonitis, ileus
 PHYSICAL EXAMINATION
Palpation
• Localized tenderness in :
– McBurney poin  appendicitis
– RUQ  inflamed gallbladder
– LLQ  diverticulitis
– Throughout abdomen  diffuse peritonitis
– Rebound tenderness  peritonitis
• Deep palpation can detect abdominal masses (Acute
cholecystitis, acute pancreatitis, abdominal aneurysm,
diverticulitis)
 PHYSICAL EXAMINATION
Percussion
• Hyperresonance or tympany  gaseous
distention of the intestine or stomach
• Resonance over the liver  free
intraabdominal gas
• Percussion pain which has the same located
with rebound tenderness  peritoneal
irritation
• Shiffting dullness +  fluid on peritoneal
Differential diagnose
 Approach to the patient
• Only those patients with exsanguinating
intraabdominal hemorrhage (e.g., ruptured
aneurysm)  operate
• But in such instances only a few minutes are
required to assess the critical nature of the
problem

• Orderly, painstakingly detailed history

• Even though a reasonably accurate diagnosis can
be made on the basis of the history alone in the
majority of cases
Intussusception
 Definition
• The sliding of one part of the intestine into
another
 Etiology
• The cause of intussusception is not known,
although viral infections may be responsible in
some cases
• Sometimes a lymph node, polyp, or tumor can
trigger the problem
• The older the child, the more likely such a
trigger will be found
 Epidemiology
• The male-to-female ratio is approximately 3:1.
With advancing age, gender difference
becomes marked; in patients older than 4
years, the male-to-female ratio is 8:1
• Intussusception is the most common cause of
intestinal obstruction in patients aged 5
months to 3 years
• In Great Britain, incidence varies from 1.6-4
cases per 1000 live births
 Signs and Symptoms
• The first sign of intussusception is usually sudden, loud
crying caused by abdominal pain  the pain is colicky
and not continuous (intermittent), but it comes back
often, increasing in both intensity and duration
• An infant with severe abdominal pain may draw the
knees to the chest while crying
• Bloody, mucus-like bowel movement
• Fever
• Shock
• Stool mixed with blood and mucus
• Vomiting
 Risk factors
• Age. Children are much more likely to develop intussusception than
adults are. It's the most common cause of bowel obstruction in
children between the ages of 6 months and 3 years.
• Sex. Intussusception more often affects boys.
• Abnormal intestinal formation at birth. A condition present at birth
(congenital) in which the intestine doesn't develop correctly
(malrotation) also is a risk factor for intussusception.
• A prior history of intussusception. Once you've had intussusception,
you're at increased risk to develop it again.
• AIDS. There is some evidence of an increased incidence of
intussusception in people with acquired immune deficiency
syndrome.
 Clinical Assessment
• Upon physical examination, the patient is usually
chubby and in good health
• The infant can be pale, diaphoretic, and hypotensive if
shock has occurred
• The hallmark physical findings in intussusception are a
right hypochondrium sausage-shaped mass and
emptiness in the right lower quadrant (Dance sign).
This mass is hard to detect and is best palpated
between spasms of colic, when the infant is quiet
• Abdominal distention frequently is found if obstruction
is complete
 Treatment
• Barium enema and air enema
– Barium enema should not be attempted if signs of
strangulated bowel, perforation, or toxicity are
present
• Surgery
– Extremely ill patients
– Patients with evidence of bowel perforation
– Patients whom hydrostatic or pneumatic
reduction has been unsuccessful
 Complication
• A hole (perforation) is a serious complication
due to risk of infection
• If not treated, intussusception is almost
always fatal for infants and young children
 Prognosis
• The outcome is good with early treatment
• There is a risk the condition will come back
 Acute Abdominal Pain in Child
-Causes-
• Your child mostly likely is having
abdominal pain from something that
is not life threatening. For example,
your child may have:
• Constipation
• Gas
• Food allergy or intolerance
• Heartburn or acid reflux
• Stomach flu or food poisoning
• Strep throat or mononucleosis
("mono")
• Colic
• Air swallowing
• Abdominal migraine
• Pain caused by anxiety or depression
• Your child may have something more
serious if the pain does not get better
in 24 hours, gets worse or gets more
frequent. Abdominal pain can be a sign
of:
• Appendicitis
• Gallstones
• Stomach ulcers
• Hernia or other bowel twisting,
blockage or obstruction
• Inflammatory bowel disease (Crohn's
disease or ulcerative colitis)
• Intussusception, caused by part of the
intestine being pulled inward into itself
• Tumors or cancers
• Urinary tract infections
• Sickle cell disease crisis
Appendicitis
 Appendicitis
Inflammation & obstruction of the vermiform appendix

http://www.privatehealth.co.uk/EasysiteWeb/getresource.axd?AssetID=2683&type=full&servicetype=inline&customSizeId=0
 EPIDEMIOLOGY
• In USA > 250.000 appendectomies/year that
has been done & it is the common abdominal
emergency surgery

• Predilection of age is 5-30 years old

• < 2 years old  its incidens is 70-80% for

perforation & the common peritonitis because
of the delaying diagnostic
 Etiology
• Mucosal ulceration
• Fecal mass
• Stricture
• Infection
 Patophysiology Necrosis
I
f
Mucus, stool, or The blood supply to Perforation
Reduced
parasites the appendix is cut
blood flow
off
Appendicular Peritonitis
Inflammation abcsess

Obstructs the Obstruction of Pressure in

appendix mucus outflow appendix
increases

Multiplying bacteria,
Restricting blood flow inflammation and Appendix
to the organ pressure continue to contracts
increase

Severe abdominal pain

Rowsing Sign: “Pain in the
right lower quadrant when
pressure is exerted on the left
lower quadrant
Psoas Sign
“Pain on flexion of the thigh”
 Obturator Sign
“Pain on flexion and rotation of the thigh”
 Prognosis & Complication
• Most people recover quickly after surgery if
the appendix is removed before it ruptures.
• If appendix ruptures before surgery, recover
may take longer. You are also more likely to
develop or problems, such as:
– An abscess
– Blockage of the intestine
– Infection inside the abdomen (peritonitis)
– Infection of the wound after surgery
Peritonitis
ACUTE PERITONITIS
 Definition
• Peritonitis is an inflammation of the
peritoneum This is the thin tissue that lines
the inner wall of the abdomen and covers
most of the abdominal organs.
Etiology
Pathofisiology
 Symptoms
• The belly (abdomen) is very painful or tender. The
pain may become worse when the belly is
touched or when you move.
• Your belly may look or feel bloated. This is called
abdominal distention. Other symptoms:
– Fever and chills
– Passing little or no stools or gas
– Excessive fatigue
– Passing less urine
– Nausea and vomiting
– Racing heartbeat
– Shortness of breath
 Diagnosis
• Clinical manifestation
– Fever (80%)
– Acites  predates infection
– Abdominal pain, an acute onset of symptoms, and peritoneal irritation
(physical examination)
– Nonlocalizing symptoms  malaise, fatigue, or encephalopathy

• Other examination
– >250 PMNs/L is diagnostic for PBP
– Blood culture
• enteric gram-negative bacilli (Escherichia coli)  most commonly encountered
• gram-positive organisms (streptococci, enterococci, or even pneumococci)  sometimes
found
• Aerobic bacteria
– Contrast-enhanced CT  intraabdominal source for infection
– Chest & abdominal radiography  to exclude free air
 Treatment and Prevention
• Treatment
– Third-generation cephalosporins (cefotaxime 2 g q8h,
administered IV)  initial coverage in moderately ill patients
– Broad-spectrum antibiotics, such as penicillin/β-lactamase
inhibitor combinations (piperacillin/tazobactam 3.375 g q6h IV
for adults with normal renal function); ceftriaxone (2 g q24h IV)
• Prevention
– Up to 70% of patients experience a recurrence within 1 year
– Antibiotic prophylaxis reduces this rate to <20%
– Prophylaxis agents
• fluoroquinolones (ciprofloxacin, 750 mg weekly; norfloxacin, 400
mg/d)
• trimethoprim-sulfamethoxazole (one double-strength tablet daily)
 Prognosis
• Mortality rates are <10% for uncomplicated
peritonitis associated with a perforated ulcer or
ruptured appendix or diverticulum in an
otherwise healthy person. Mortality rates of 40%
have been reported for elderly people, those with
underlying illnesses, and when peritonitis has
been present for >48 h.
 Secondary peritonitis
• Develops when bacteria contaminate the peritoneum
as a result of spillage from an intraabdominal viscus 
chemical irritation and/or bacterial contamination
• Found almost always constitute a mixed flora in which
– facultative gram-negative bacilli
– anaerobes predominate, especially when the
contaminating source is colonic
• Early death in this  gram-negative bacillary sepsis
and to potent endotoxins circulating in the
bloodstream
– E. coli, are common bloodstream isolates, but Bacteroides
fragilis bacteremia also occurs
• Clinical manifestation
– local symptoms may occur in secondary peritonitis, ex:
• Epigastric pain from a ruptured gastric ulcer
• Appendicitis  vague, with periumbilical discomfort and nausea;
number of hours  pain localized right lower quadrant
– lie motionless
– knees drawn up to avoid stretching the nerve fibers of the
peritoneal cavity
– Coughing and sneezing  increase pressure within the
peritoneal cavity  sharp pain
• Physical examination
– voluntary and involuntary guarding of the anterior abdominal
musculature
– tenderness, especially rebound tenderness
• Treatment
– antibiotics aimed particularly at aerobic gram-negative
bacilli and anaerobes
– penicillin/β-lactamase inhibitor combinations
(ticarcillin/clavulanate, 3.1 g q4–6h IV); cefoxitin (2 g q4–6h
IV)
– Patients in the intensive care unit  imipenem (500 mg
q6h IV), meropenem (1 g q8h IV), or combinations of
drugs, such as ampicillin plus metronidazole plus
ciprofloxacin
– Surgical intervention + antibiotics (bacteremia) 
decrease incidence of abscess formation & wound
infection; prevent distant spread of infection
Illeus Obstruction
 Definition

• Intestinal obstruction is a partial or complete

blockage of the bowel that results in the
failure of the intestinal contents to pass
through.
 Causes

a. Mechanical obstructions
b. Non-mechanical obstruction (ileus or
paralytic ileus)
COMMON CAUSES OF INTESTINAL
OBSTRUCTION ACCORDING TO AGE
 Gallstone colic Volvulus Diverticulosis

Hernia incarcerate Intussusception Hirschprung’s disease

PATOPHYSIOLOGY
 Intestinal Obstruction
a. Mechanical obstructions
• Occur because the bowel is physically blocked and its
contents can not pass the point of the obstruction.
• Mechanical causes of intestinal obstruction may include:
– Abnormal tissue growth
– Adhesions or scar tissue that form after surgery
– Foreign bodies (ingested materials that obstruct the intestines)
– Gallstones
– Hernias
– Impacted feces (stool)
– Intussusception
– Tumors blocking the intestines
– Volvulus (twisted intestine)
 Intestinal Obstruction
b. Non-mechanical obstruction (ileus or paralytic ileus)
• Occurs because peristalsis stops. Peristalsis is the rhythmic
contraction that moves material through the bowel.
• Causes of paralytic ileus include:
– Chemical, electrolyte, or mineral disturbances (such as decreased
potassium levels)
– Complications of intra-abdominal surgery
– Decreased blood supply to the abdominal area (mesenteric artery
ischemia)
– Injury to the abdominal blood supply
– Intra-abdominal infection
– Kidney or lung disease
– Use of certain medications, especially narcotics . Example :
chemotherapy drugs such as vinblastine (Velban, Velsar) and
vincristine (Oncovin, Vincasar PES, Vincrex)
Intestinal Obstruction
 Intestinal Obstruction
Location Causes
Colon Tumors (usually in left colon),
diverticulitis (usually in sigmoid), volvulus
of sigmoid or cecum, fecal impaction,
Hirschsprung's disease
Duodenum
a. Adult Cancer of the duodenum or head of
pancreas, ulcer disease
b. Neonates Atresia, volvulus, bands, annular
pancreas
Jejunum and Ileum
a. Adult Hernias, adhesions (common), tumors,
foreign body, Meckel's diverticulum,
Crohn's disease (uncommon), Ascaris
infestation, midgut volvulus,
intussusception by tumor (rare)
b. Neonates Meconium ileus, volvulus of a malrotated
gut, atresia, intussusception
 Pathophysiology
A. Mechanical obstruction
Ingested fluid and food, digestive secretions, and gas accumulate
above the obstruction

The proximal bowel distends, and the distal segment collapses

The normal secretory and absorptive functions of the mucosa are
depressed

The bowel wall becomes edematous and congested.

• Severe intestinal distention is self-perpetuating and progressive,

intensifying the peristaltic and secretory derangements and
increasing the risks of dehydration and progression to strangulating
obstruction.
 Pathophysiology
B. Non mechanical obstruction (Ileus)
Ileus is mediated via activation of inhibitory spinal
reflex arcs.
Anatomically, 3 distinct reflexes are involved:
1.Ultrashort reflexes confined to the bowel wall
2.Short reflexes involving prevertebral ganglia
3.Long reflexes involving the spinal cord
 Intestinal Obstruction
Ileus Pseudo-obstruction Mechanical
Obstruction (Simple)
Symptoms Mild abdominal pain, Crampy abdominal Crampy abdominal
bloating, nausea, pain, constipation, pain, constipation,
vomiting, obstipation, obstipation, nausea, obstipation, nausea,
constipation, vomiting, anorexia vomiting, anorexia

Physical Silent abdomen, Borborygmi, tympanic, Borborygmi, peristaltic

Examination distension, tympanic peristaltic waves, waves, high-pitched
Findings hypoactive or bowel sounds, rushes,
hyperactive bowel distension, localized
sounds, distension, tenderness
localized tenderness

Plain Radiographs Large and small bowel Isolated large bowel Bow-shaped loops in
dilatation, diaphragm dilatation, diaphragm ladder pattern, paucity
elevated elevated of colonic gas distal to
lesion, diaphragm
mildly elevated, air-
fluid levels
 Exams and Tests

• Listening bowel sound

– If the obstruction has persisted for long time or the bowel has been
significantly damaged bowel sounds decrease or silent
– Paralytic ileus decreased or absent bowel sound.
• Tests that show obstruction include:
– Abdominal CT scan
– Abdominal x-ray
– Barium enema
• Barium enema is a special x-ray of the large intestine, which includes the colon
and rectum.
• The liquid called barium sulfate is placed in the rectum that use for contrast
.Contrast highlights specific areas in the body, creating a clearer image.
– Upper GI and small bowel series
• An upper GI and small bowel series is a set of x-rays taken to examine the
esophagus, stomach, and small intestine.
 Treatment
Initial assessment
• The first step in treatment is inserting a nasogastric tube to suction
out the contents of the stomach and intestines.
• The patient is then given intravenous fluids to prevent dehydration
and correct electrolyte imbalances.

Nonsurgical approaches
• In some cases of volvulus, guiding a rectal tube into the intestines
will straighten the twisted bowels.
• In infants, a barium enema may reverse intussusception in 50-90%.
• An air enema is sometimes used instead of a barium enema. The
treatment can relieves the obstruction in many infants.
• In patients with only partial obstruction, a barium enema may
dissolve the blockage.
 Treatment
Surgical treatment
• If these efforts fail, surgery is necessary.
• The obstructed area is removed and part of the
bowel is cut away.
• If the obstruction is caused by tumors, polyps, or scar
tissue, they are removed.
• Hernias, if present, are repaired.
• Antibiotics are given to reduce the possibility of
infection.
 Prevention

• Most cases of intestinal obstruction are not

preventable.
• Surgery to remove tumors, polyps, or
gallstones helps prevent recurrences.
 Prognosis
Mortality
• Delayed diagnosis of volvulus in infants has a mortality rate of 23-33%
with prompt diagnosis and treatment the mortality rate is 3-9%.
• The bowel either strangulates or perforates, causing massive infection.
• With prompt treatment, most patients recover without complications.

Recurrence
• As many as 80% of patients whose volvulus is treated without surgery
have recurrences.
• Recurrences in infants with intussusception are most likely to happen
during the first 36 hours after the blockage has been cleared.
• The mortality rate for unsuccessfully treated infants is 1-2%.
EXAMPLES OF CAUSES OF INTESTINAL
OBSTRUCTION

Obstruction due to Obstruction due to Obstruction due

adhesions mesenteric occlusion to hernia

Obstruction due to Obstruction due to Obstruction due to

intussusception tumor volvulus
Illeus Paralytic
• Ileus (paralytic ileus, adynamic ileus) is
temporary absence of the normal contractile
movements of the intestinal wall.

• bloating,
• vomiting,
• constipation,
• cramps,
• loss of appetite occur.

People are given nothing to eat or drink, and

a thin suction tube is passed through the nose
into the stomach by NGT
 Paralitic Ileus
• Ileus is the failure of intestinal peristalsis
without evidence of mechanical obstruction.
• Lack of normal gut motility interferes with
abnormal movement of intestinal contents
and in children is most often associated with
abdominal surgery or infection (pneumonia,
gastroenteritis, peritonitis).
• Ileus also accompanies metabolic
abnormalities, such as uremia, hypokalemia,
or acidosis, and occurs with administration of
certain drugs, such as opiates and vincristine.
• Ileus may also occur when antimotility drugs
such as loperamide are used during episodes
of gastroenteritis.
• Clinical features
– Increasing abdominal distention and
initially minimal pain
– Pain increases with increasing distention
• Examination
– Bowel sounds are minimal or absent, in
contrast to early mechanical obstruction,
when they are hyperactive.
• Radiographs
– Plain abdominal many air-fluid levels
throughout the abdomen.
– Serial do not show progressive
distention as they do in mechanical
obstruction.
– Contrast slow movement of the barium
through a patent lumen.
• Treatment
– Correction of underlying abnormality.
– Nasogastric decompression is used if
abdominal distention is associated with pain or
to relieve recurrent vomiting.
– Ileus after abdominal surgical procedures
usually results in return of normal intestinal
motility within 24-72 hr.
– Prokinetic agents such as metoclopramide or
erythromycin may stimulate the return of normal
bowel motility and be of assistance to children
with prolonged ileus.
– Oral administration of drugs that block
gastrointestinal opiate receptors but do not
block central nervous system opiate action may
reduce the ileus in postoperative patients
receiving narcotics
Complications and sequelae of Paralytic ileus:

•Hypovolaemic shock
•Constipation
•Abdominal pain
•Bowel obstruction
•Renal failure
•Nausea and vomiting
Abdominal Hernia
 Abdominal Hernia
• Abdominal wall hernias are among the most
common of all surgical problems. Knowledge of
these hernias (usual and unusual) and of
protrusions that mimic them is an essential
component of the armamentarium of the general
and pediatric surgeon. More than 1 million
abdominal wall hernia repairs are performed
each year in the United States, with inguinal
hernia repairs constituting nearly 770,000 of
these cases; approximately 90% of all inguinal
hernia repairs are performed on males
 Signs and symptoms
• Hernias may be detected on routine physical examination, or
patients with hernias may present because of a complication
associated with the hernia.
• Characteristics of asymptomatic hernias are as follows:
– Swelling or fullness at the hernia site
– Aching sensation (radiates into the area of the hernia)
– No true pain or tenderness upon examination
– Enlarges with increasing intra-abdominal pressure and/or standing
• Characteristics of incarcerated hernias are as follows:
– Painful enlargement of a previous hernia or defect
– Cannot be manipulated (either spontaneously or manually) through
the fascial defect
– Nausea, vomiting, and symptoms of bowel obstruction (possible)
• Characteristics of strangulated hernias are as follows:
– Patients have symptoms of an incarcerated hernia
– Systemic toxicity secondary to ischemic bowel is possible
– Strangulation is probable if pain and tenderness of an incarcerated hernia
persist after reduction
– Suspect an alternative diagnosis in patients who have a substantial amount of
pain without evidence of incarceration or strangulation
• When attempting to identify a hernia, look for a swelling or mass in the
area of the fascial defect, as follows:
– For inguinal hernias, place a fingertip into the scrotal sac and advance up into
the inguinal canal
– If the hernia is elsewhere on the abdomen, attempt to define the borders of
the fascial defect
– If the hernia comes from superolateral to inferomedial and strikes the distal
tip of the finger, it most likely is an indirect hernia
– If the hernia strikes the pad of the finger from deep to superficial, it is more
consistent with a direct hernia
– A bulge felt below the inguinal ligament is consistent with a femoral hernia
 Characteristics of various hernia types
include the following:
• Inguinal hernia - Bulge in the inguinal region or scrotum, sometimes intermittent; may be
accompanied by a dull ache or burning pain, which often worsens with exercise or straining (eg,
coughing)
• Spigelian hernia - Local pain and signs of obstruction from incarceration; pain increases with
contraction of the abdominal musculature
• Interparietal hernia - Similar to spigelian hernia
• Internal supravesical hernias - Symptoms of gastrointestinal (GI) obstruction or symptoms
resembling a urinary tract infection
• Lumbar hernia - Vague flank discomfort combined with an enlarging mass in the flank
• Obturator hernia - Intermittent, acute, and severe hyperesthesia or pain in the medial thigh or in
the region of the greater trochanter, usually relieved by thigh flexion and worsened by medial
rotation, adduction, or extension at the hip
• Sciatic hernia - Tender mass in the gluteal area that is increasing in size; sciatic neuropathy and
symptoms of intestinal or ureteral obstruction can also occur
• Perineal hernias - Perineal mass with discomfort on sitting and occasionally obstructive symptoms
with incarceration
• Umbilical hernia - Central, midabdominal bulge
• Epigastric hernia - Small lumps along the linea alba reflecting openings through which preperitoneal
fat can protrude; may be adjacent to the umbilicus (umbilical hernia) or more cephalad (ventral
hernia [epiplocele])
 Diagnosis
• History and physical examination remain the best
means of diagnosing hernias. The review of systems
should carefully seek out associated conditions, such as
ascites, constipation, obstructive uropathy, chronic
obstructive pulmonary disease, and cough.
• Laboratory studies include the following:
– Stain or culture of nodal tissue
– Complete blood count (CBC)
– Electrolytes, blood urea nitrogen (BUN), and creatinine
– Urinalysis
– Lactate
• Imaging studies are not required in the normal workup
of a hernia. However, they may be useful in certain
scenarios, as follows:
– Ultrasonography can be used in differentiating masses in
the groin or abdominal wall or in differentiating testicular
sources of swelling
– If an incarcerated or strangulated hernia is suspected,
upright chest films or flat and upright abdominal films may
be obtained
– Computed tomography (CT) or ultrasonography may be
necessary if a good examination cannot be obtained,
because of the patient’s body habitus, or in order to
diagnose a spigelian or obturator hernia
 History and physical examination remain the best means of
diagnosing hernias. The review of systems should carefully seek
out associated conditions, such as the following:

• Ascites
• Constipation
• Chronic obstructive pulmonary disease
• Cough
• Groin abscess
• Hematoma
• Lipoma
• Lymphadenitis
• Obstructive uropathy
• Pseudoaneurysm
• Spermatocele
• Tumor
• Undescended or retracted testes
• Varicocele
 Differential Diagnoses
• Acute Epididymitis
• Hidradenitis Suppurativa in Emergency
Medicine
• Hydrocele in Emergency Medicine - DELETE
• Lymphogranuloma Venereum in Emergency
Medicine
• Testicular Torsion in Emergency Medicine
 Management
• Nonoperative therapeutic measures include the following:
– Trusses
– Binders or corsets
– Hernia reduction
– Topical therapy
– Compression dressings
• Surgical options depend on type and location of hernia.
Basic types of inguinal hernia repair include the following:
– Bassini repair
– Shouldice repair
– Cooper repair
– Simple inguinal hernia repair in children
 Surgical approaches to other hernia
types may vary, as follows:
• Umbilical hernia - After exposure of the umbilical sac, a plane is created to encircle the sac at the level of the
fascial ring, and the defect is closed transversely with interrupted sutures; if the defect is very large, mesh may be
required
• Epigastric hernia - A small vertical incision directly over the defect is carried to the linea alba, and incarcerated
preperitoneal fat is either excised or returned to the properitoneum; the defect is closed transversely with
interrupted sutures
• Spigelian hernia - A transverse incision over the hernia to the sac allows dissection to the neck, and clean
approximation of the internal oblique muscle and the transversus abdominis completes the repair
• Interparietal hernia - The spermatic cord is identified; orchiopexy or orchiectomy is performed as indicated; a
properitoneal indirect inguinal hernia repair is taken
• Supravesical hernia - The standard techniques for inguinal and femoral hernias are used, usually via a paramedian
or midline incision
• Lumbar hernia - A skin-line oblique incision is made from the 12th rib to the iliac crest; a layered closure or mesh
onlay for large defects is successful
• Obturator hernia - Generally approached abdominally and often amenable to laparoscopic repair; mesh closure is
necessary for a tension-free repair
• Sciatic hernia - A transperitoneal approach is used in the event of incarceration; a transgluteal repair can be used
if the diagnosis is established and the intestine is clearly viable
• Perineal hernia - A transabdominal approach with prosthetic closure is preferred
• Gastroschisis and omphalocele - Primary closure of fascia and skin is usually best; nonoperative management of
gastroschisis (plastic closure) is an alternative to conventional primary operative closure or staged silo closure
 Technical factors that increase the likelihood of
recurrence include the following:
• Unrecognized tear in the sac
– Failure to repair a large internal inguinal ring
– Damage to the floor of the inguinal canal
– Infection or other postoperative complications
– In some cases, a direct hernia may result from vigorous dissection; in others, it may be a simultaneous
hernia that was initially unrecognized.
• Other hernia types
– Recurrence, bleeding, infection, and persisting pain are potential complications for the other types of
abdominal wall hernia. The rate of recurrence for incisional hernias may be as high as 30%. The addition of
mesh to most abdominal wall hernia repairs is decreasing the incidence of recurrence.
• Gastroschisis and omphalocele
– Infants with uncomplicated gastroschisis and omphalocele generally fare well, with a mortality of less than
5%.[25] Complications arising from the prolonged time required to reduce the contents into the abdomen
include the following:
• Infection
– Dislodgment of the prosthesis
– Prolonged mechanical ventilation
– Intestinal obstruction
– Budd-Chiari syndrome (due to kinking of the suprahepatic inferior vena cava)
– However, mortality among infants with gastroschisis or omphalocele who have intestinal atresia or severe
associated anomalies is substantially higher, in the range of 15-50%.
 Crohn Disease
• Chronic granulomatous inflammatory disease
of the GI tract.
• Can involve any part of GI tract from mouth to
anus
• Ileum is involved in majority of cases
 Crohn Disease
• Etiology and pathogenesis are unknown.
• Infectious, genetic, environmental factors
have been implicated.
• Autoimmune destruction of mucosal cells as a
result of cross-reactivity to antigens from
enteric bacteria.
 Crohn Disease
• Cytokines,including IL and TNF have been
implicated in perpetuating the inflammatory
response.
• Anti-TNF(remicade) drugs have shown efficacy
in treating Crohn disease
 Crohn Disease
• Epidemiology: peak incidence is 15-22 years
old with a second peak 55-66years
• 20-30% increase in women
• More common in European
• 4 times more common in Jews than non-Jews
• More common in whites vs blacks
• 10-15% have family hx
 Crohn Disease
• Pathology: most important is the involvement of all
layers of the bowel and extension into mesenteric
lymph nodes
• Disease has skip areas between involved areas
• Longitudinal deep ulcers and cobblestoning of
mucosa are characteristic
• These result in fissures, fistulas, and abscesses
 Crohn Disease
• Clinical features: variable and unpredictable
• Abd pain, anorexia, diarrhea, and weight loss
are present in most cases
• 1/3 of patients develop perianal fissures or
fistulas, abscesses, or rectal prolapse
 Complications
• PERFORATION
• PERITONITIS
• ABSCESS
• ILEUS
Perforation of the Acute Appendicitis
 References
• Kliegman: Nelson Textbook of Pediatrics, 18th ed. 2007
• Fauci. Braunwald. Dkk. Harrison’s Principles of Internal
Medicine. 17th edition. United State: The McGraw-Hills;
2008
• Nelson Textbook of Pediatric, 19th edition
• Evers BM. Small intestine. In: Townsend CM, Beauchamp
RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery.
18th ed. St. Louis, Mo: WB Saunders; 2008:chap 48.
• http://www.ucsfhealth.org/education/nutrition_tips_for_in
flammatory_bowel_disease/
• http://emedicine.medscape.com/article/179037-
overview#aw2aab6b2b2