Problem 4 GIT

7/23/2019 Problem 4 GIT

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Ileus paralitik/obstruksi Apendisitis perforasi/akut Peritonitis primer/skunder Hernia

Invaginasi/intusepsi Volvulus/malrotasi Perforasi intestinal


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Hernia

A hernia is de ned as anabnormal protrusion of anorgan or tissue through adefect in its surroundingwalls

Although a hernia canoccur at various sites ofthe body, these defectsmost commonly involvethe abdominal wall,particularly the inguinalregion


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Hernia Inguinal !lassi ed as direct or indirect "he sac of an indirect inguinal hernia passes from the internal inguinal

ring obli#uely toward the e$ternal inguinal ring and ultimately into thescrotum

As indirect hernias enlarge, it sometimes can be di%cult to distinguishbetween 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 epigastricvessels &en are '( times more likely to have a groin hernia than women Indirect inguinal and femoral hernias occur more commonly on the right

side "he predominance of right)sided femoral hernias is thought to be caused

by the tamponading e*ect of the sigmoid colon on the left femoral canal


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+trangulation, the most common serious complicationof a hernia, occurs in only - to .- of groin hernias andis more common at the e$tremes of life

&ost strangulated hernias are indirect inguinal hernias


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Diagnosis "here may be associated pain or vague discomfort in the region, but groin

hernias are usually not e$tremely painful unless incarceration or strangulationhas occurred

patients may e$perience paresthesias related to compression or irritation of theinguinal nerves by the hernia

"he inguinal region is e$amined with the patient in the supine and standingpositions

Inspects and palpates the inguinal region, looking for asymmetry, bulges, or amass

Valsalva maneuver can facilitate identi cation of a hernia A bulge moving lateral to medial in the inguinal canal suggests an indirect

hernia If a bulge progresses from deep to super cial through the inguinal oor, a direct

hernia is suspected 0ltrasonography also can aid in the diagnosis 1!"2 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 challengingcases


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Acute Appendisitis

Appendicitis occurs more fre#uently in 3esterni4edsocieties Acute appendicitis remains the most common

emergency general surgical disease a*ecting theabdomen

Appendicitis occurs most commonly in 5) to 6)year)olds 7ne of the more common complications and most

important causes of e$cess morbidity and mortality isperforation


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Pathogenesis 8ecaliths, incompletely digested food residue, lymphoid

hyperplasia, intraluminal scarring, tumors, bacteria, viruses, andin ammatory bowel disease have all been associated with

in ammation of the appendi$ and appendicitis 7bstruction lumen appendicitis luminal distention, bacterial

overgrowth inhibit dlow of lymph and blood thrombosis,ischemic necrosis perforation distal appendi$

+ome cases of simple acute appendicitis may resolvespontaneously or with antibiotic therapy, and recurrent disease is

remotely possible 3hen perforation occurs, the resultant leak may be contained by

the omentum or other surrounding tissues to form an abscess 8ree perforation normally causes severe peritonitis infective

suppurative thrombosis portal vein intrahepatic abscesses "he prognosis of the develop this dreaded complication is very

poor


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Clinical Manifestation


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Laboratory Testing 9oes not identify patients with appendicitis but can help the clinician

work through the di*erential diagnosis 3hite blood cell count is only mildly to moderately elevated in

appro$imately :5- of patients with simple appendicitis 1with aleukocytosis of 5,555; 2

A ?left shift@ toward immature polymorphonuclear leukocytes ispresent in 6(- of cases

0rinalysis is indicated to help e$clude genitourinary conditions thatmay mimic acute appendicitis

In amed appendi$ that abuts the ureter or bladder may cause sterilepyuria or hematuria

!ervical cultures are indicated if pelvic in ammatory disease issuspected

Anemia and guaiac)positive stools should raise concern about thepresence of other diseases or complications such as cancer


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Imaging Plain lms of the abdomen not routinely obtained unless

the clinician is worried about other conditions such asintestinal obstruction, perforated viscus, or ureterolithiasis

Presence of a fecalith is not diagnostic of appendicitis "he e*ectiveness of ultrasonography as a tool to diagnosis

appen)dicitis is highly operator dependent 0ltrasonography may facilitate early diagnosis

0ltrasonographic ndings suggesting the presence ofappendicitis include wall thickening, an increasedappendiceal diameter, and the presence of free uid

!" imaging may be very helpful, although it is importantnot to be overly cautious and delay operative interventionfor those patients who are believed to have appendicitis


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Treatment In the absence of contraindications, a patient who has a strongly

suggestive medical history and physical e$amination with supportivelaboratory ndings 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 !" may accurately indicate the presence of appendicitis or other

intraabdominal processes Barcotics can be given to patients with severe discomfort, especially if

the rst abdominal e$amination is completed before drugs areadministered

All patients should be fully prepared for surgery and have any uid andelectrolyte abnormalities corrected

Cither laparoscopic or open appendectomy is a satisfactory choice forpatients with uncomplicated appendicitis


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+uch patients are best served by treatment with broad)spectrum antibiotics, drainage if there is an abscess . cmin diameter, and parenteral uids and bowel rest if theyappear to respond to conservative management

"he appendi$ can then be more safely removed D; 'weeks later when in ammation has diminished >aparoscopic appendectomy is associated with less

postoperative pain and, possibly, a shorter length of stayand faster return to normal activity

have fewer wound infections, although the risk ofintraabdominal abscess formation may be higher Absent complications, most patients can be discharged

within 'E;E5h of operation most common postoperative complications are fever and

leukocytosis


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Acute Peritonitis Acute peritonitis, or in ammation of the visceral and parietal

peritoneum, is most often but not always infectious in origin,resulting from perforation of a hollow viscus

"his is called secondary peritonitis, as opposed to primary orspontaneous peritonitis, when a speci c intraabdominal sourcecannot be identi ed

In either instance, the in ammation can be locali4ed or di*use Infective organisms may contaminate the peritoneal cavity after

spillage from a hollow viscus, because of a penetrating wound ofthe abdominal wall, or because of the introduction of a foreignobFect like a peritoneal dialysis catheter or port that becomesinfected


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+econdary peritonitis mostcommonly results fromperforation of the appendi$,

colonic diverticuli, or thestomach and duodenum It mayalso occur as a complication ofbowel infarction or incarceration,cancer, in ammatory boweldisease, and intestinal

obstruction or volvulus 7ver 65- of the cases of

primary or spontaneousbacterial peritonitis occur inpatients with ascites orhypoproteinemia 1G g/>2


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Aseptic peritonitis is most commonly caused by theabnormal pres)ence of physiologic uids like gastric

Fuice, bile, pancreatic en4ymes, blood, or urine "he chemical irritation caused by stomach acid and

activated pancreatic en4ymes is e$treme and secondarybacterial infection may occur


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Clinical Features "he cardinal signs and symptoms of peritonitis are acute, typically severe,

abdominal pain with tenderness and fever Clderly and immunosuppressed patients may not respond as aggressively to

the irritation 9i*use, generali4ed peritonitis is most often recogni4ed as di*use

abdominal tenderness with local guarding, rigidity, and other evidence ofparietal peritoneal irritation

owel sounds are usually absent to hypoactive &ost patients present with tachycardia and signs of volume depletion with

hypotension

>aboratory testing typically reveals a signi cant leukocytosis, and patientsmay be severely acidotic adiographic studies may show dilatation of the bowel and associated

bowel wall edema 8ree air, or other evidence of leakage, re#uires attention and could

represent a surgical emergency


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Treatment &ortality rates can be less than 5- for reasonably

healthy patients with relatively uncomplicated, locali4edperitonitis

&ortality rates E5- have been reported for the elderlyor immunocompromised

+uccessful treatment depends on correcting anyelectrolyte abnormalities, restoration of uid volumeand stabili4ation of the cardiovascular system,appropriate antibiotic therapy, and surgical correction ofany underlying abnormalities


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Intussuception ac#uired invagination of the bowel into itself, usually involving

both small and large bowel "he more pro$imal bowel that invaginates into more distal bowel

is termed the intussusceptum, whereas the recipient bowel thatcontains the intussusceptum is termed the intussuscipiens

Invagination of the bowel leads to edema, and ischemic changeseventually superveneJ thus intussusception is an urgent condition,but prolonged delay in diagnosis is not uncommon, resulting inincreased risk for patients to present with obstruction, necrosis,and bowel perforation

!lassic pediatric intussusception involves invagination of the distalileum into the colon, as ileocolic or ileoileocolic intussusceptionJhowever, intestinal intussusception may occur along the entirelength of the bowel from the duodenum to the colon


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Etiology &ost cases of ileocolic intussusception occurring in

children are idiopathic

+ome reports suggest a viral etiology, most commonlyadenovirus, but enterovirus, echovirus, and humanherpes virus D also have been implicated


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Clinical Presentation Idiopathic intussusception occurs most commonly in infants

between ' months and . years of age, with a peak at age ( to 6months

"he classic clinical presentation of the child with intussusceptionis colicky abdominal pain, vomiting, bloody stools, and a palpableabdominal mass

!hildren with intussusception should be diagnosed as early aspossible to avoid bowel ischemia, necrosis, and surgery

"he clinical signs and symptoms of intussusception are often

nonspeci c and may overlap with those of gastroenteritis,malrotation with volvulus, and in older children, Henoch)+chKnleinpurpura

Venous hypertension leads to hematoche4ia, with a typicalmi$ture of stool, blood, and blood clots described as ?currant Fellystools,@ a nding highly suggestive of intussusception

Intussuscepted bowel may prolapse through the rectum


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Diagnosis & Imaging

Treatment


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Treatment Cnema reduction should be

undertaken in children withintussusception after surgical

consultation the only absolute

contraindications to enemareduction are signs ofperitonitis on clinical

e$amination or free air onabdominal radiographs


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Intestinal 7bstruction L &alrotation


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Clinical Presentation


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Clinical Presentation Patients with obstruction may e$hibit severe pain, abdominal

distension 1unless involvement is in the pro$imal MI tract2,diaphoresis, stigmata of dehydration, and vomiting with inability totolerate oral input

may be tachycardic 1both from pain and hypovolemia2 8ever raises concerns for intestinal ischemia, perforation, and

peritonitis +mall 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 7n rectal e$amination, if the obstruction is high in the colon, the

rectum will be devoid of stool, but hard stool in the rectum may bepresent if the patient has fecal impaction


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Evaluation & Management


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Evaluation & Management initial evaluation in the emergency department is to determine the acuity

and severity of the childNs illness "he rst pass on physical e$amination should #uickly ac#uire information

regarding the patientNs critical features, beginning with the A !s Vital signs should be evaluated for fever 1in the setting of obstruction,

concerning for ischemia2, tachycardia, hypotension 1worrisome fordecompensated shock2, and lownormal blood pressure with widened pulsepressure 1concerning for compensated shock2

Patients with vomiting should receive nothing by mouth 1BP72 and shouldhave an intravenous 1IV2 line started for maintenance uids

If there are signs of dehydration, isotonic uid boluses are appropriateuntil the patient is hemodynamically stable

If the patient is ill appearing or has fever in the conte$t of suspectedobstruction, the physician should strongly consider initiating IV antibiotictherapy with ade#uate coverage for common gut ora 1gram)negative andanaerobic organisms2 after obtaining a blood culture

Laboratory Finding


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Laboratory Finding If the patient is ill appearing or has fever in the conte$t

of suspected obstruction, the physician should stronglyconsider initiating IV antibiotic therapy with ade#uatecoverage for common gut ora 1gram)negative andanaerobic organisms2 after obtaining a blood culture

If the patient is ill appearing and has a fever, a bloodculture should be done before administration ofantibiotics

Radiologic Test


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Radiologic Test 8luoroscopic arium water)soluble contrast agent O perforation

In patients who are medically unstable, who have ahistory of trauma, or who have a suspected perforation,the study of choice is the !" scan

I endosco!y is a useful tool for diagnosing mucosaldisorders that may not be

obvious on radiologic imaging After enough clinical information is available to

determine whether the child should go to the operatingroom, laparotomy or, at some centers, laparoscopy


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eference >ongo 9>, asper 9>, Qameson Q>, 8auci A+, Hauser +>, >oscal4o Q, editors HarrisonNs Principle of Internal &edicine 6 th

&cMraw)HillJ '5 ( "anto !, >iwang 8, Hanifati +, Pradipta CA, editors apita

+elekta edokteran Cdisi E QakartaO &edia AesculapiusJ '5 E Intussusception !hapter imberly C Applegate !a*eyRs

Pediatric 9iagnostic Imaging, !hapter 5

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Problem 4 GIT