PBL REPORT MODULE 4

BOWEL OBSTRUCTION
SYSTEM GASTROENTEROHEPATOLOGI

TUTOR : dr. Zulfahmidah

BY : KELOMPOK 1

FITRIANI 11020180128
INAYAH AL FATIHA 11020180136
FERYANSYAH AKBAR SYAMSIR 11020180151
IFA LATIFAH 11020180156
RAFIKA JUNIARTI H. MANSYUR 11020180162
DWI HIKMAH 11020180181
ANDI WE YADA TENRIBALI 11020180188
NURUL MAGFIRATUL IFFAH 11020180216
NIDYA CARRISA WAHYUNI 11020180226
AGHNIA ULYA AFTHA 11020180124

FACULTY OF MEDICINE
UNIVERSITAS MUSLIM INDONESIA
MAKASSAR
2020
Preliminary
This module is given to third semester Medical Faculty students who are
part of the Respiration System course. The purpose of giving this module is to train
students' abilities in handling diseases of the respiratory system, where in this module
two types of scenarios that show a clinical symptom of respiratory system diseases are
found, namely coughing. Students are expected to discuss not only the core of the
problem but also all matters related to the problem, for example the pathomechanism
of diseases which must be discussed about anatomy, histology, physiology, and
biochemical processes that occur. What is important here is how to solve the problem
given and not the diagnosis.
Before using this module, tutors and students must first read TIU & TIK so
that the discussion is expected not to deviate from the learning objectives of the module
and to achieve the expected competencies. The role of the tutor in directing the tutorial
is very important. Material for discussion can be obtained from lecture materials that
have been given as well as references given by each lecturer giving lecturers.
The author hopes this module can help students in establishing the diagnosis of
respiratory system diseases and how to handle them.

Compiler
Scenario 1
A 60 years old man came to the hospital complaining of defecation in the last 2 weeks.
In the past week the complaint was felt to be burdensome. BAB accompanied by blood and
mucus. The stomach feels bloated. Patients complain of dissatisfaction after bowel movements.
In the RT obtained a lump in the direction of 9o’clock, hard consistency, there is mucus on the
handschoen

Hard word : -

Key words :
1. A 60 years old man
2. Constipation 2 weeks
3. Accompanied by blood & mucus defecation
4. Bloated (+)
5. Dissatisfaction after bowel movements
6. In the RT obtained a lump in the direction of 9 o’clock
7. Hard consistency
8. There is mucus on the hand schoen

Questions :
1. What is the mechanism of the normal defecation ?
2. What is the mechanism of the constipation ?
3. What is the patomechanism of defecation accompanied by blood and mucus ?
4. How can bloating occur ?
5. Why the patients dissatisfaction after bowel movements ?
6. What is the diagnostic procedure of the scenario ?
7. What is the deferensial diagnose from the scenario ?
8. What is the perspektif islam based on the scenario ?
 The answer
1. Mechanism of the normal defecation
Defecation is expenditure feces from the anus and rectum. It is also called the
bowel movement. The defecation frequency varies widely from a few times a day to 2
or 3 times a week. The amount of feces also varies every person. When the peristaltic
waves push the feces into the sigmoid colon and rectum, rectal sensory nerve is
stimulated and the individual becomes aware of the need to defecate.
Defecation reflex is usually started by two defecation, namely:
 Intrinsic defecation reflex
When feces into the rectum, the development of the rectal wall to give a signal
that propagates through plexus mesentrikus to start the peristaltic wave in
descending colon, sigmoid colon and in the rectum. These waves pressing stool
toward the rectum. Once the peristaltic wave approaches the anus, the internal anal
spingter not close and when the external spingter calm the feces out.
 Defecation reflex parasympathetic
When the nerve fibers in the rectum is stimulated, the signal is forwarded to the
spinal cord (sacral 2-4) and then back to the descending colon, sigmoid colon and
rectum. The parasympathetic signals increase peristaltic waves, relaxes the internal
anal spingter and increase the intrinsic defecation reflex. Spingter anus individuals
sitting ditoilet or bedpan, spingter external anus stool Spending quiet itself aided
by the contraction of the abdominal muscles and diaphragm which will increase
abdominal pressure and by the contraction of the levator ani muscles on the pelvic
floor move stool through the anal canal.

Normal defecation easy with thigh reflection that increase pressure in the
abdomen and a sitting position that increases the downward pressure toward the rectum.

If the defecation reflex is ignored or if defecation intentionally inhibited by

contracting the muscle of the external spingter, the sense of urgency to defecate
repeatedly can result in the rectum expands to accommodate a collection of feces.
 Image 1 : Pathomechanism of defecation

Defecation defecation reflex caused by one reflex is a reflex intrinsic mediated

by local enteric nervous system within the wall of the rectum. It apat explained that
when faeces enters rekrum, distention of the rectum wall causing afferent signals which
spread through plexus mienterikus for peristaltic waves in the descending colon,
sigmoid and rectum, push the stool toward the rectum. As paristaltik wave approaching
the intestine, the internal anal sphincter direlaksasikan by inhibitory signals from
mienterikus plexus, if the external anal sphincter is also conscious and voluntarily
relaxation at the same time, there was defecation.

Reference: Guyton & Hall, Medical Physiology. edition 11

2. Mechanism of the constipation
Constipation is the infrequent passage of stool. It is generally defined as ≤ 3
bowel movements per week, which may be associated with straining to defecate, the
passage of hard stools, tenesmus, or the need for self-digitation to evacuate stool. It may
be primary or secondary.
Types of primary constipation (i.e., no identifiable organic cause) include
normal transit constipation (e.g., due to inadequate calorie, fiber, or water intake), slow
transit constipation, and pelvic floor dyssynergia. Secondary constipation may be drug-
induced (e.g., opioid-induced constipation) or due to metabolic disorders (e.g.,
hypothyroidism), neurological disorders (e.g., spinal cord lesion), or mechanical
obstruction of the bowel (e.g., colon cancer)
Both primary and secondary constipation can cause changes in stool consistency
and defecation habits.

Mechanism of altered stool consistency :

External factors such as lack of exercise or inadequate fluid and fiber intake
(primary constipation)/internal factors such as changes within the colon or rectum
(secondary constipation) → slow passage of stool → prolonged absorption of water by
the bowel → dry, hard stool → painful defecation → sensation of incomplete and
irregular bowel emptying → constipation

Mechanism of altered bowel motility

 Effective peristalsis of the bowel is controlled by intrinsic (e.g., myenteric plexus)
and extrinsic (e.g., sympathetic and parasympathetic) innervation.
 Any alteration in bowel innervation may lead to ineffective peristalsis.
 Drugs (e.g., calcium channel blockers, opiates, antispasmodics,
antidepressants) → altered autonomic outflow and bowel muscle contraction
 Endocrine pathology (e.g., hypothyroidism) → downregulated bowel motility
 Neurological pathology (e.g., spinal injury, enteric neuropathy) → disease or
trauma of bowel innervation
 Ineffective peristalsis → difficult passage of stool regardless of stool consistency
→ sensation of incomplete and irregular bowel emptying

The causes of constipation can be divided into congenital, primary, and

secondary. The most common kind is primary and not life-threatening. It can also be
divided by the age group affected such as children and adults.
Primary or functional constipation is defined by ongoing symptoms for greater
than six months not due to an underlying cause such as medication side effects or an
underlying medical condition.It is not associated with abdominal pain, thus
distinguishing it from irritable bowel syndrome. It is the most common kind of
constipation, and is often multifactorial. In adults, such primary causes include: dietary
choices such as insufficient dietary fiber or fluid intake, or behavioral causes such as
decreased physical activity. In the elderly, common causes have been attributed to
insufficient dietary fiber intake, inadequate fluid intake, decreased physical activity,
side effects of medications, hypothyroidism, and obstruction by colorectal cancer.
Evidence to support these factors however is poor.
Secondary causes include side effects of medications such as opiates, endocrine
and metabolic disorders such as hypothyroidism, and obstruction such as from
colorectal cancer. Celiac disease and non-celiac gluten sensitivity may also present with
constipation.Cystocele can develop as a result of chronic constipation.
 Diet
Constipation can be caused or exacerbated by a low-fiber diet, low liquid intake,
or dieting.Dietary fiber helps to decrease colonic transport time, increases stool bulk
but simultaneously softens stool. Therefore, diets low in fiber can lead to primary
constipation.
 Medications
Many medications have constipation as a side effect. Some include (but are not
limited to) opioids, diuretics, antidepressants, antihistamines, antispasmodics,
anticonvulsants, tricyclic antidepressants, antiarrythmics, beta-adrenoceptor
antagonists, anti-diarrheals, 5-HT3 receptor antagonists such as ondansetron, and
aluminum antacids.Certain calcium channel blockers such as nifedipine and
verapamil can cause severe constipation due to dysfunction of motility in the
 rectosigmoid colon. Supplements such as calcium and iron supplements can also
have constipation as a notable side effect.

 Medical conditions
Metabolic and endocrine problems which may lead to constipation include:
hypercalcemia, hypothyroidism, hyperparathyroidism, porphyria, chronic kidney
disease, pan-hypopituitarism, diabetes mellitus, and cystic fibrosis. Constipation is
also common in individuals with muscular and myotonic dystrophy. Systemic
diseases that may present with constipation include celiac disease and systemic
sclerosis.
Constipation has a number of structural (mechanical, morphological, anatomical)
causes, namely through creating space-occupying lesions within the colon that stop the
passage of stool, such as colorectal cancer, strictures, rectocoles, anal sphincter damage
or malformation and post-surgical changes. Extra-intestinal masses such as other
malignancies can also lead to constipation from external compression.
Constipation also has neurological causes, including anismus, descending perineum
syndrome, and Hirschsprung's disease. In infants, Hirschsprung's disease is the most
common medical disorder associated with constipation. Anismus occurs in a small
minority of persons with chronic constipation or obstructed defecation.
Spinal cord lesions and neurological disorders such as Parkinson's disease and
pelvic floor dysfunction can also lead to constipation.
 Tabel 1 : Pathomechanism of constipation

Refrence :
1. Chatoor D, Emmnauel A (2009). "Constipation and evacuation disorders". Best
Pract Res Clin Gastroenterol. 23 (4): 517–30.
2. Locke GR, Pemberton JH, Phillips SF (December 2000). "American
Gastroenterological Association Medical Position Statement: guidelines on
constipation". Gastroenterology. 119 (6): 1761–6.
3. Hsieh C (December 2005). "Treatment of constipation in older adults". Am Fam
Physician. 72 (11): 2277–84.
 4. Basilisco, Guido; Coletta, Marina (2013). "Chronic constipation: A critical
review". Digestive and Liver Disease. 45 (11): 886–893.
5. Leung FW (February 2007). "Etiologic factors of chronic constipation: review
of the scientific evidence". Dig. Dis. Sci. 52 (2): 313–6. doi:10.1007/s10620-006-
9298-7.
6. "Symptoms & Causes of Celiac Disease | NIDDK". National Institute of Diabetes
and Digestive and Kidney Diseases. June 2016.
7. "Celiac disease". World Gastroenterology Organisation Global Guidelines. July
2016.

3. Patomechanism of defecation accompanied by blood and mucus

The blood feces is caused by rupture of blood vessels in the wall of the
gastrointestinal tract. The blood vessels in the gastrointestinal tracts have begun to be
found in the promen's mucosal lamina but the amount of blood vessels that are
discovered in the submucous tunic. This means that if there are ulcers that are about

Tabel 2: Pathomechanism of Hematokezia accompany with mucous

mucosal tunic, it can manifest as a feces with blood. Blood can manifest as
Melena or Hematokezia. Darker-coloured blood occurs due to the oxidation of
hemoglobin by intestinal bacteria. Melena or "Black blood" indicates that the bleeding
of the gastrointestinal tract occurs in the intestinal proximal part or the distal intestinal
part with a long transit period thus giving the bacteria the opportunity to oxidize
hemoglobin. While Hematokezia or "fresh blood" can be caused by bleeding of the
distal part of the gastrointestinal tract (e.g. rectum) or in the intestinal proximal but with
a short transit period that does not give the chance of intestinal bacteria to oxidize
Maximum hemoglobin.

Hematochezia is caused by bleeding in the lower digestive tract, especially in

the colon. Some conditions that may result in the lower gastrointestinal bleeding are:
Diverticulitis. Diverticulitis is an inflammation or infection of the diverticula (abnormal
small pockets are formed in the gastrointestinal tract).
 Inflammation of the intestine. Inflammation of the intestine is a condition of
intestinal inflammation. Inflammation of the intestines can also refer to two
digestive tract disorders, namely Crohn's disease and ulcerative colitis.
 Polyps. Polyps is a stemmed and small-sized growth of abnormal tissues, less than
1.5 cm.
 Benign tumors. Benign tumors that grow in the colon and rectum can cause
bleeding.
 Colon cancer. Colon cancer is a cancer that grows in the colon (colon).
 ANI fissure. The anal fissure is an open wound on the anus or anus canal.
 Hemorrhoids or piles. Hemorrhoids are the widening of blood vessels in the anus
area at risk of bleeding.
 Bacterial infections – bacterial infections can cause different types of inflammation
in the gastrointestinal tract. The most common bacteria causing infections of the
gastrointestinal tract are Helicobacter pylori.
 Peptic ulcer – peptic ulcer, which is often characterized by open wounds in the
lining of the stomach or the upper end of the small intestine, may also cause
bleeding. A common cause of peptic ulcer is to consume anti-inflammatory drugs,
such as ibuprofen and aspirin, in the long term or excessively.
In Hematochezia, blood that comes out with feces will appear red. This is
because bleeding occurs in areas not far from the anus, so that the blood comes out in
a still fresh state. Hematochezia is sometimes accompanied by diarrhea, fever, changes
in bowel frequency, abdominal pain, and weight loss. In addition to being able to exit
with feces, blood can also drip from the anus. And as for the slimy chapter i.e., when
the mucous membranes of the intestines (especially in the mucosa of the colon) are
irritated, it can cause goblet cells to become more active. The goblet cells produce a lot
 of mucus that serves for mucosal protection. When the mucus is too excessive, it can
appear in the feces and manifests a slimy feces.

Reference :
• Guyton & Hall, Fisiologi Kedokteran. Edisi 11
• Siti setiati dkk. 2014. Buku Ajar Ilmu Penyakit Dalam Jilid II Edisi VI. Jakarta :
Interna Publishing. Hal 1894-1895

4. The process of bloating

There are several elements that contribute to bloating. First are physical factors
that affect the volume of contents in the abdomen. To understand how this works, it
may be useful to imagine two rubber tubes, one within the other one.
If the inner tube is the intestines and the outer tube represents the wall of the
abdomen, any change in the volume and pressure of the inner tube would affect the
outer tube. Though this may be simplistic, only two sections of the outer tube, the front
and side muscles of abdomen and the diaphragm (the muscle under the lungs that
separates the chest and abdomen and facilitates breathing movements) actually have
room to expand. When the contents in the inner tube (intestines) increase due to solid
(hard stool), gas or liquid (liquid stool), three things can happen: the abdomen can
expand, the diaphragm can be pushed up higher into the chest, and the pressure in the
abdomen can increase.
Some problems -- such as swallowing large amounts of air, delayed emptying
of the stomach because of dyspepsia, slow gas transport in the intestines with gas
accumulation associated with IBS, and retention of stools due to constipation -- can
cause a change in volume of the GI tract (the inner tube) that in turn produces a change
in the outer tube, causing the abdomen to be distended. But, in real life, the body tends
to counteract this change in volume by either contracting the abdominal muscles
(stiffening the abdominal wall) or doing the opposite -- relaxing the muscles to
accommodate this increase in volume. This is called the viscerosomatic reflex.
The other key element in causing the symptom of bloating is visceral
hypersensitivity or heightened perception of sensations arising in the gut. This
hypersensitivity, which is common in IBS, can cause ordinary small changes in the
volume of the GI tract to be perceived as bloating, and the accompanying tightening or
relaxation of abdominal muscles can also be sensed that way. For these reasons, one
 may have the sensation of bloating and not have the distension (the abdomen sticking
out), depending on how much volume change there is and how the abdominal wall
responds to it. Also, some very sensitive people might perceive the sensation of bloating
without any volume change in the GI tract at all, for example, merely in response to
normal contractions of the gut. Similarly, people with eating disorders such as Bulimia
and Anorexia may suffer from bloating that is related to enhanced awareness of normal
gut regulatory signals at the level of the brain.
Finally, any increase in the volume between the inner and the outer tube, such
as fluid accumulation due to certain conditions such as congestive heart failure or
kidney disease where fluid accumulates in the abdomen and legs, can cause bloating
with or without distension, or even distension with or without bloating. Occasionally,
patients have excessive forward curvature of the lower back (Lumbar spine), giving the
appearance of a distended abdomen.

Refrence :
Thiwan.2016.Abdominal Bloating.UNC School Of Medicine

5. Why the patients dissatisfaction after bowel movements

Because the scenario says the consistency of feces is hard, the patient can
automatically increase constipation and the patient has difficulty getting sick can reduce
the possibility of the patient removing his feces. The feces consistency of the patient is
hard because it is difficult to eat foods low in fiber, maybe it is according to the patient's
wishes say the chapter is incomplete, so the patient at the time is convinced that the
stool is all out but there is still a feeling of discomfort because the feces is incomplete
Refrence :
Jurnal unnisula.ac.id

6. Diagnostic procedure
1) Anamnesis Patient
 Personal Data include:
a. Name:
b. Age :
c. Gender :
d. Profession :
e. Address :
  The main complaints
 Current disease history
 History of other diseases
 History before illness
a. Past medical history:
b. History of trauma :
c. Treatment history:
d. Surgery history :
 History of other body system
Anamnesis: Important for diagnosis, chapter history (Frequency, size,
consistency of stool, difficulty in chapters, bloody chapters, pain in the chapter),
Food history, psychological problems, and other symptoms such as abdominal
pain.
2) EXAMINATION PHISYCS
Physical examination: Can be touched by the mass of feces in the left
abdomen, in the absence of an anorectal examination of the anus, prolapse,
inflammation of the perianus, Fissura, and tonus of the urinary tract
 Abdominal inspection
 Skin
inspection of lesions on the surface of the abdominal skin that
corresponds to the lesions of a particular disease. E.g: Icterus on
hepatitis
 Rose spots in fever typhoid
Note that there are veins that are dilated on the abdominal
surface. Usually due to dam process. Determine the direction of the flow
of the widened veins. If the vein is obtained over umbilicus, when the
upward flow, the possibility of portal hypertension. If the flow is down
then it is likely a dam in the superior vein cava. When obtained widening
in the vein of umbilicus, if the blood flow down then it is likely a portal
hypertension, preferably when the upward flow then the likelihood of a
dam in the inferior vein cava. In the dam caused by portal hypertension,
can be found an overview of the Caput medusae, is a rapidly-running
 venous dilation of the lower and upper Umbilicus. The overview of
caput medusa is rare in get.
 Umbilicus
Pay attention to the shape whether or not the little bial small
stand may be due to cough or increased pressure in the abdominal cavity.
Large bulges can be caused by umbilicaliser hernia when accompanied
by harsh consistency usually due to violence.
 Abdominal wall Movement
Normal abdominal wall movement, orderly at breathing time and
freely moving. If the abdominal wall is too late during breathing, it can
be caused by:
1) If some late may result in the process of inflammation of the organs
that are dependent on the location of the organ.
2) If the entire abdomen appears to be left behind in the usual
movement of peritonitis generalisata.
3) movement in the epigastric region corresponding to cardiac pulsation
is found in the right heart-crappy.
4) In the skinny people often see the pulsation of abdominalist aortic.
5) Sometimes the intestinal movement is seen which is a mass that is
found in the Obstructives ileus.
 Abdominal form
1) If the stomach is enlarged and symmetrical, caused by:
A. Overweight
B. Ascites
C. Air outflow in the intestines
2) If the stomach enlargement is not symmetric possible:
A. Pregnancy
B. Tumors in the abdominal cavity
3) Local enlargement can be caused by liver enlargement, spleen or
tumors.
4) The concave stomach in the form:
A. Skinny people
B. TUBERCULOSIS Meningitis
The purpose of auscultation of the abdomen is to determine:
1) The presence or absence of intestinal peristaltic.
The normal sound heard is caused by the movement of water and idara
in the intestinal lumen. If there is a blockage in the intestinal lumen. If
there is intestinal obstruction, a high-pitched and loud metallic sound
will be heard. This increase in sound is also known as borborigmie. In
paralytic ileus states weaken or disappear.
2) Fluid movement
Fluid can be heard for example in stenosa pyloris movements. The
sound of fluid in the epigastrium after the patient drinks liquid, when
the pylorus rocked while listening with a stethoscope in the epigastric
region. This sound is called succution flash.
3) Noisy blood vessels
Vascular sounds that arise can be clearly audible noise in the aortic
aneurysma or in hepatomas that can be heard in certain places =. In
portal hypertension, there may be a "venous hum" venous noise that is
located between the epigastrium and the umbilicus. 3. Abdominal
palpation Palpate with both hands ie the left hand is placed at the
bottom of the right or left hip and lifts the patient's waist up. The right
hand palpates the upper abdomen. In this way the lat-tool in the
abdominal cavity is more easily palpated. This way of palpation is
called bimanual palpation. When abdominal palpation should be
noted:
a) Is there a wall of the abdominal wall and if there is in which region.
The existence of tension in the abdominal wall is a reaction of the
abdominal wall to protect the area underneath. This symptom is called
defance musculair. In general, areas that show tenderness will strain
the abdominal wall. Defender musculair is found in:
1. Local; in acute cholecystisisl, acute appendicitis
2. Comprehensive; in generalist peritonitis.
3. Pressure pain
Abdominal tenderness indicates an inflammatory process under
the abdominal wall, both in the peritoneum and in the organs in the
 abdominal cavity. Localization of tenderness is important to determine
diseased organs such as tenderness in the right hypocondrium, usually
caused by cholisistisis or acute hepatitis.
4. Hyperastesia
By palpating with a small touch on the surface of the stomach, the
sufferer feels extreme pain. This is determined in patients with peritonitis,
post herpetic neuralgia.
5. Enlargement of the abdominal cavity
a) Palpate the liver
b) Palpate the gallbladder
c) Renal palpation
d) Palpation of the spleen
e) Palpation of the bladder
f) Gastric palpation
g) Palpate the tumor

 Auscultation of the abdomen

The purpose of auscultation in the abdomen is to determine:
1. Absence of intestinal peristaltic
Normal sound is heard due to the movement of water and joy in
the intestinal lumen. If there is obstruction in the intestinal lumen. If
there is a bowel blockage it will be heard a high-pitted sound and a loud
"metallic sound". This voice enhancement is also known as
Borborigmie. In the turn paralitic ileus weakened or disappeared.
2. Fluid Movement
The fluid can be heard in such a stenosa pyloris. In the epigastric
fluid is heard after the sufferer drank the fluid, when the pylorus was
shaken while hearing with a stethoscope in the Epigastric region. This
sound is called succution Flash.
3. Noisy blood vessels
The sound of blood vessels can be a clear noise in the aortic
aneurysma or in the hepatoma that can be heard at a particular place =.
At the portal hypertension, it may sound noisy "venosus hum" which is
located between Epigastric and Umbilicus.
 Abdominal palpation
Perform superficial palpation with a depth of 1 cm in the abdominal wall
to see the tenderness and mass.
Perform deep palpation with a depth of 4-5 cm to see the tenderness and
mass. If the tumor mass is positive bimanual palpation is performed.
At the time of palpation and mass discovered, an assessment was made
in terms of: location, size, size, consistency, suppleness, mobility, and pulp.
 Special palpation
 Plug in the rectal / rectal touche
 This examination is very important so we can get important
information to establish the diagnosis. But this examination is often
overlooked. So important that it has been stated that there are no
index fingers for rectal plugs, toe can be used for rectal plugs.
 There are several positions to plug in the rectum:
1) Left lateral (Sims) position. Routine is used for women or standard
male procedures. Patients are tilted to the left, with the upper right
leg flexed, while the lower left leg is semi-extension. The pelvis
should be menungging and parallel to the edge of the bed.
2) Knee-elbow position. Good for prostate palpation and seminal
vesicles.
3) Dorsal position. The patient sleeps in a half-sitting position with
the knees bent (flexed).
4) The patient's right forefinger goes into the grave by crossing under
the patient's right thigh. For bimanual palpation of the left hand
above the supra pubis.
5) Lithotomy position. Performed on the operating table. Manually
with the right index finger on the rectum while the left hand on the
supra pubis.
 Touch and value: surface / rectal mucosa, enlargement (pole
palpable / not), consistency (hard / soft), symmetrical / not,
bumpy / not, fixed / not, tenderness / no, no crepitus / no.
 When the finger is removed if there is blood, mucus, or feces
on the handscoen.
 Abdominal percussion
Useful for assessing the results of palpation and percussion examination
with percussion can be known:
a) Enlargement of the organs (when the liver and spleen enlarges in the
percussion).
b) The existence of free air when in this area sounds tympani there is free
air in The abdominal cavity due to intestinal perforation
c) Free fluid or percutaneous ascents there are three ways depending on
the amount of liquid:
1) Percussion fluid sites are percussion in areas containing dull
sounds and then the patient is instructed to lie down then fluid
will collect on the left and right sides of the abdomen (lowest
area). Percussion in both places will sound deaf and then the
patient is told to tilt to one side, the percussion sound of Peke on
one of the highest sides will change to tympani.
2) Percussion of many ascitic fluids. The examiner's hand is placed
on one side of the abdomen, the other hand taps the abdominal
wall, there will be waves of fluid felt on the hand on the opposite
side. To differentiate from large ovarian tumors, the surface of
convex ovarian tumor fluid is convex in patients with concave
surface concave.
3) For small amounts of liquid. Percussion is done by asking the
patient to lie on his stomach or menungging position. After a
while percussion in the lowest area, if there is liquid it will sound
deaf. You can also use a stethoscope in the lowest area. By
performing percussion on the side of the abdomen, there will be
a difference in sound through the stethoscope if the stethoscope
is moved through the abdomen to the other side (puddle sign)
d) The phenomenon of a chessboard
In the abdominal wall percussion found tympani sound and deaf
alternating conditions are found in tuberculous peritonitis
 Supporting examination
Supporting examination: Simple radiography of the abdomen, barium
enema, anorectal manometry, bowel transit time, and rectum biopsy
1. Radiology
Barium Meal Double-contrastaadditional defect, iregularity of the
mucosa of the primary tumor or the spread of tumors to the
oesophagus/duodenum.
Abdominal-> ultrasonography to detect liver metastases.
2. Colon in loop screening
It is a radiological examination of the colon using a retrograde contrast
medium in patients. Patient position: AP, AP with contrast, lateral photo
with contrast.
Kotras: BaSO4 as a contrast medium.
Observe the contrast position until where and note the mucosa, the
henration, Incisura, lumen of the colon (whether there is filling defect or
additional shadow)

Image 2 : Colon In Loop screening

3. Intravenous pielography
It is a photo after a contrast injection in the 3rd, 5th, 15th, 45, and when
necessary 60. On the 3rd minute photo check the kidney position, where
the left kidney is higher than the right with the upper limit as high as q12
or L1. Check the boundary of the kidney to see indentation or Mass.
Then look at the state of the pelviokalises system to see the calyx
cupping and see the dilation.
 Contrasts: Ioversol and Iopamidol.

Image 3: Intravenous pielography

4. BNO Examination – IVP
It is an examination of radiography and tractus urinarius (renal, ureter,
Vesica Urinaria, and urethra) with an intra-vein injection of positive
contrast.
Patient Position: AP
Contrast: Iodine

Image 4 : BNO examination - IVP

5. Colonoscopy, to check the condition of the intestine and rectum with a
colonoscope, such as blockages in the intestine.
6. Anorectal manometry, to determine the coordination of the muscles that
move the anus.
At present, this examination is rarely done. The principle of examination
with this technique is to determine the sensory and neuromuscular
function through pressure sensors on the catheter and the tip of the
balloon manometry. This test can also determine rectoanal inhibition
reflexes in diseases such as megacolon or megarectum. Sensory
dysfunction in the anorectal is determined based on the pressure
threshold at the time of the sensation of defecation and defecation
disinergy.
 Image 5 : Anorectal manometry
7. Rectographic defacography or photo with barium, to find out problems
in the function and coordination of muscles in the rectum.
8. Balloon booster test, to measure the length of the balloon filled with
water, which was previously inserted through the rectum, to be removed
from the rectum, so it can be estimated how long a person has defecated.
9. Endoscopy, the recommended endoscopic procedures are flexible
sigmoidoscopy and colonoscopy. Through this procedure the causes of
constipation, long-term use of laxatives, and lesions on the colonic
mucosa can be determined. Constipation arising from the use of drugs
cannot be ascertained through this examination.
This examination is useful in patients with danger signs or high risk
factors that require screening for colonic malignancy.

Image 6 : Endoscopy
 10. Defectography and Magnetic Resonance Defecography (MRD)
This check is not routinely carried out to establish a diagnosis of
constipation because of the high price and substandard. The principle of
this examination is a radiological visualization technique of X-ray and
MRI to determine structural abnormalities in the rectum and pelvic floor
organs.

Image 7 : Defectography and Magnetic Resonance Defecography (MRD)

 LABORATORY EXAMINATION
1. Blood Routine
A. Hemoglobin/HB
To detect the presence of anemia or kidney disease.
B. Hematocrit/HT
Measuring the concentration of red blood cells in the blood
2. Chemical Blood
A. SGPT (serum glumatik Piruvik in liver transaminases)
Used to detect the presence of hapatocellular damage.
B. Albumin
Performed to detect the recurrence of albumin synthesized by
hepar which aims to determine the presence of hapar disorders
or renal failure.
C. Bilirubin
A bilirubin test is performed to detect bilirubun levels. Bilirubin
Direct Dalakukan to detect the presence of obstructive
ikblistering by the stone/neoplasm hepatitis. Bilirubin indirect is
done to detect the presence of anemia or malaria.
 3. Endoscopy and biopsy
Endoscopy is recommended to evaluate the symptoms caused by
organ abnormalities. These disorders can be infections,
inflammation, or cancer. Through endoscopic procedures, doctors
are also assisted to take tissue samples (biopsy). Some of the
symptoms that may require endoscopy to support diagnosis include:
Gastrointestinal complaints, such as CHAPTERS or blood
vomiting, persistent diarrhea or vomiting, abdominal pain,
decreased weight, dysphagia, and a sense of heat in the liver. Cough
with blood or chronic cough. Urinary tract complaints, such as
BAK bleed or bedwetting.
Reference:
Bickley, Lynn S., Peter G. Szilagyi, and Barbara Bates. Bates ' Guide to Physical
examination and history taking. Lippincott Williams & Wilkins, 2009.
Mansjoer, Arif, and Kupusji Triyanti. "Capita Selecta Medical. " Jakarta: Media
Aesculapius (2000): 86-92.
7. Deferensial diagnose
1. Hemorrhoid
- Definition
Symptomatic hemorrhoidal disease (commonly referred to as
hemorrhoids) is a common anorectal condition characterized by enlargement
and downward displacement of the clusters of vascular tissue, smooth muscle,
and connective tissue that form the anal cushion.
- Etiology
 Hemorrhoids occur when the supporting connective tissues of the anal
cushions deteriorate and are displaced downward, causing venous dilatation.
 Cause is likely multifactorial and is thought to involve degeneration of
supporting connective tissue, dysregulation of vascular tone, vascular
hyperplasia, abnormal dilatation and distortion of vascular channels,
abnormal internal anal sphincter tone, and inflammation.
- Risk factor
 Age
 Although hemorrhoids can occur at any age, peak incidence is in
people aged 45 to 65 years
 Rare before age 20 years
 Sex
 No predilection for either sex
 Ethnicity/race
 More common in white than in African American populations
 Other risk factors/associations
 Situations or conditions that increase intra-abdominal pressure
 Prolonged straining while defecating
 Pregnancy
 Strenuous lifting
 Constipation
Recently this association has been questioned and some reports
suggest that diarrhea is a risk factor
 Prolonged sitting has been widely believed to be a risk factor for
hemorrhoids, although one study found a sedentary lifestyle to be
associated with decreased risk of hemorrhoids
 Obesity has been found to be associated with an increased risk of
hemorrhoids in some but not all populations studied
 Some reports have implicated dietary factors (eg, spicy foods, low-fiber
diet, excessive alcohol intake), but data are inconsistent
- Pathophysiology
The exact pathophysiology of hemorrhoidal development is poorly
understood. For years the theory of varicose veins, which postulated that
hemorrhoids were caused by varicose veins in the anal canal, had been popular
but now it is obsolete because hemorrhoids and anorectal varices are proven to
be distinct entities. Infact, patients with portal hypertension and varices do not
have an increased incidence of hemorrhoids.
Today, the theory of sliding anal canal lining is widely accepted. This
proposes that hemorrhoids develop when the supporting tissues of the anal
 cushions disintegrate or deteriorate. Hemorrhoids are therefore the pathological
term to describe the abnormal downward displacement of the anal cushions
causing venous dilatation. There are typically three major anal cushions, located
in the right anterior, right posterior and left lateral aspect of the anal canal, and
various numbers of minor cushions lying between them. The anal cushions of
patients with hemorrhoids show significant pathological changes.
These changes include abnormal venous dilatation, vascular thrombosis,
degenerative process in the collagen fibers and fibroelastic tissues, distortion
and rupture of the anal subepithelial muscle. In addition to the above findings,
a severe inflammatory reaction involving the vascular wall and surrounding
connective tissue has been demonstrated in hemorrhoidal specimens, with
associated mucosal ulceration, ischemia and thrombosis.
- Classification
Hemorrhoids are classified as internal or external:
 Internal hemorrhoids
Located proximal to dentate line
 Covered by columnar epithelium
 Viscerally innervated and usually do not cause pain>
 Further classified based on degree of prolapse from anal canal
 Grade I: prominent hemorrhoidal vessels without prolapse
 Grade II: prolapse with Valsalva maneuver and spontaneous
reduction
 Grade III: prolapse with Valsalva maneuver requiring manual
reduction
 Grade IV: chronic prolapse for which manual reduction is
ineffective
 External hemorrhoids
 Located distal to dentate line
 Covered by anoderm comprised of modified squamous epithelium
 Contain numerous somatic pain receptors and therefore can become
painful when thrombosed
- Diagnosis
 Anamnesis
Have any of the clinical presentation above.
 Physical Examination
 Perform physical examination with patient in prone, knee-chest, or
lateral decubitus position
 Inspect anus and perianal region to identify the following signs of
hemorrhoids:
 Anal skin tags or fissures
 External hemorrhoids
 Prolapsed internal hemorrhoids (appear as moist, dark pink mass
at anal margin)
 Thrombosed hemorrhoids (appear as firm purple-blue masses)
 Perform digital rectal examinations with patient at rest and while
patient strains to exclude distal rectal mass, anorectal abscess or
fistula, hemorrhoidal prolapse, and rectal prolapse
 Thrombosed hemorrhoids may be palpable as a firm, tender mass
 Also evaluate anal sphincter tone
 Perform an anoscopic examination to assess anal canal and distal
rectal anatomy; internal hemorrhoids appear as bulging purple-blue
veins
 Additional Diagnostic Tools
 Hemorrhoids are typically a clinical diagnosis based on history and
physical examination findings
 Consider proctoscopy or sigmoidoscopy to visualize
hemorrhoids if unable to do so on physical examination
 If there is any question that bleeding or mass could be anything
other than a hemorrhoid in a patient at low risk, visualize via
proctoscopy or sigmoidoscopy to confirm diagnosis
 Obtain CBC in patients with prolonged bleeding or severe
bleeding
 Review previous endoscopy records when available
  Colonoscopy (or another colorectal cancer screening modality) is
indicated to screen for colon cancer in select patients with
symptomatic hemorrhoids and rectal bleeding
 Patients aged 50 years or older who have not had a complete
endoscopic examination in the past 10 years
 Patients aged 40 years or older or 10 years younger than age of
relative at diagnosis and who have 1 first-degree relative with
colorectal cancer or advanced adenoma diagnosed before age 60
years
 Patients aged 40 years or older or 10 years younger than age of
relative at diagnosis and who have 2 first-degree relatives with
colorectal cancer or advanced adenoma
 Patients with positive result on fecal immunochemical test or
fecal immunochemical DNA test.
- Treatment
 Non Pharmacologic
 Symptom-based approaches to treatment
 Treat irritation and pruritus with topical preparations or sitz baths
 Treat bleeding hemorrhoids with dietary modification or topical
agents; if they persist, treat internal hemorrhoids with office-based
procedure and external hemorrhoids with hemorrhoidectomy
 Prolapsed hemorrhoids may be treated conservatively initially, but
more advanced grades may require office-based procedure or
surgery
 Thrombosed internal hemorrhoids generally resolve with
conservative therapy; however, severe pain associated with
thrombosed external hemorrhoid may necessitate surgical
treatment
 Conservative
 Increase fluid and fiber intake
 Avoiding straining and limiting time on tolet
 Sitz baths
 Rubber band ligation
  Sclerotherapy
 Surgical
 With Grade 3 and 4
 If patient has severe anemia
 Patient with thrombosed external hemorrhoids
 Pharmacology
 Topical treatment
 Phenylanine hydrochloride rectal cream 4 times daily on area that
affected
 Benzocaine rectal ointment 6 times daily
 Hydrocortisone rectal cream 2-4 times daily depending the
severity
- Complication
 Skin tags
 Perianal dermatitis
 Ulceration or necrosis of thrombosed hemorrhoid
 Strangulation or incarceration of hemorrhoid
- Prognosis
 Great with medical therapy and conservative therapy

2. Anal Fissure
- Definition
Anal fissure is a longitudinal tear or defect in the epithelium of the anal canal
typically extending from dentate line toward the anal verge.
- Etiology
 Primary anal fissure
Underlying causes of midline posterior and midline anterior fissures differ
 Posterior midline fissure
 Acute injury or trauma to the anoderm leads to a cycle of local
pain and spasm of the internal anal sphincter
 The resulting high resting anal sphincter tone leads to local
ischemia and poor wound healing
  Anterior midline fissure
 Associated with injury to or dysfunction of the external anal
sphincter
 Usually not associated with internal sphincter spasm or increased
resting tone
 Occurs more often in young women and postpartum women
Common causes of acute trauma
 Constipation and passage of hard bulky fecal mass
 Vaginal childbirth
 Anorectal intercourse
 Child abuse
 Saddle vibration in bicyclists
 Instrumentation associated with surgical procedures
 Prolonged or explosive bout of diarrhea
 Secondary anal fissure
 Nonhealing idiopathic primary anal fissure
 Previous anal surgery (eg, excision of perianal lesions, fissurectomy,
hemorrhoidectomy)
 Neoplastic disease (eg, colorectal carcinoma, anal carcinoma,
hematologic malignancy)
 Granulomatous disease (eg, tuberculosis, sarcoidosis)
 Dermatologic conditions (eg, psoriasis)
 Sexually transmitted infection (eg, HIV, syphilis)
 Inflammatory bowel disease (eg, ulcerative colitis, Crohn disease)
 Fissures affect up to 30% of patients with Crohn disease
- Risk Factor
 Age
Primary fussures are most common in young age but the secondary in elderly
people
 Sex
Woman have slightly higher incidence cause after vaginal childbirth
 Other
Low-fiber diet
- Pathophysiology
An anal fissure, which is a longitudinal tear or ulceration in the anoderm, occurs
just inside the anal margin. The underlying pathophysiology of anal fissures is
hypertonia of the internal anal sphincter. Typical anal fissures occur at the midline;
most commonly they occur posteriorly, but about 15% are found anteriorly or both
anteriorly and posteriorly. “Off-the-midline” fissures may represent a routine
fissure, but they generally require examination under anesthesia with culture,
biopsy, and pathological evaluation to exclude other causes such as anal cancer,
Crohn disease, syphilis, HIV, leukemia, or tuberculosis.
- Clinical Manifestation
 Rectal pain with hallmark feature and the feel of the pain it is like passing knives
or shards of glass which occurs during or after defecation. The pain is dominant
than the bleeding
 Rectal bleeding with blood is bright red and minimal in quantity and can
present on the surface of stool
 Perianal pruritus, discomfort, and irritation
 Constripation with hard stool
- Diagnosis
 Anamnesis
Had any of the clinical manifestation above.
 Physical Examination
 Anorectal visualization and digital palpation to examine the fissure
 By inspection we can find simple longitudinal or elliptical separation in
the epithelial lining of anal canal that characterized by sharply
demarcated, fresh mucosal edges for patient with acute fissure
 Hallmark triad of signs which is skin tag at the external apex,
hypertrophied anal papilla at internal apex, and exposed and
hypertrophied internal sphincter muscles within the base of the fissure
for patient with chronic fissure
  Additional Diagnostic Tool
 Examination under anesthesia with anoscopy to eases visualization in
patients with anal fissure who require rectal examination
 Biopsy that indicated on physical examination for cytology and
histopathology for signs of malignancy or infection.
- Differential Diagnosis
 Hemorrhoid
 Anorectal Fistula
 Anal Cancer
- Treatment
 Non Pharmacology
 Sitz Bath
 High fiber diet
 Increase fluid intake
 Encourage regular bowel movement
 Surgical management like fissurectomy or sphincterectomy
 Pharmacology
 Nitroglycerin 0.4% rectal ointment as Glyceryl trinitrate
 Diltiazem 2% topical gel or ointment as Calcium channel blockers
 OnabotulinumtoxinA Solution for injection as Botulinum toxin injection
- Complication
 Perianal infection
 Fissure Extention
 Chronic Abscess
- Prognosis
Good with full care medical attention

3. Colorectal Cancer
- Definition
Colorectal cancer is a malignant neoplasm of the colon or rectum, most commonly
adenocarcinoma; clinical presentation ranges from asymptomatic to imminently
life-threatening (eg, perforation, obstruction)
- Etiology
 Multifactorial; environment and inheritance play varying roles specific to
individual patients
 Most cases are sporadic, involving no apparent underlying genetic
predisposition
 In an estimated 12% to 35% of cases, inherited components (typically common
polymorphisms) contribute to pathogenesis 18
 Approximately 3% to 5% of cases arise from hereditary syndromes that mutate
several genes involved in cancer predisposition, causing early onset of disease
- Risk Factors
 Age, the higher the age the higher the risk
 Sex, Most common in men
 Genetics, Family history
 Specific Syndromes associated with susceptibility to colorectal cancer like
lynch syndrome
- Pathophysiology
Colorectal carcinomas exhibit a wide range of differentiation, which broadly
correlates with their clinical behaviour and prognosis. Most carcinomas are initially
exophytic (i.e., protruding into the lumen) and later ulcerate on the surface and
progressively invade the muscular bowel wall. Eventually, the tumour involves
serosa and surrounding structures. Stromal fibrosis may cause luminal narrowing,
responsible for the common acute presentation of large bowel obstruction.

Large bowel carcinomas metastase via lymphatics and the bloodstream, and by
the time of diagnosis, as many as 25% of patients already have distant metastases.
Lymphatic spread is sequential, first to mesenteric nodes and then onward to
paraaortic nodes. Occasionally, lymph node involvement is directly responsible for
the clinical presentation. For example, paraaortic nodes may present as a palpable
mass or cause duodenal obstruction. Other enlarged nodes may compress bile ducts
in the porta hepatis causing jaundice.
- Clinical Manifestation
 Asymptomatic on early stage
 Rectal bleeding
 Abdominal pain
 Change in bowel habits include narrowing of stool or diarrhea or constipation
 Hematochezia
 Recral pain
 Nausea and vomiting
 Weight loss
 Anorexia
 Fatigue
- Diagnosis
 Anamnesis
Have any of clinical manifestation above.
 Physical Examination
 Loss of weight
 Debilitated
 Pallor of skin and conjunctivae from blood loss
 Scleral icterus and jaundice can be find

 Additional Diagnostic Tools

 Colonoscopy to see where the tumor is
 CBC, Carcinoembryoic antigen level, serum chemistry level, and liver
function test to see how the functional of the organ
 Imaging of chest, abdomen, and pelvis usually with MRI or CT-Scan
 Biopsy
- Treatment
 Non Pharmacology
 Surgery is the keystone of treatment
 Chemotherapy
 Radiotherapy
  Pharmacology
 Fluorouracil as Pyrimidine analogues
 Oxiplatin as Platins
 Irinotecan as Camptotherin analogue
 Bevacizumab as Biologic response modifiers
- Differential Diagnose
 Hemorrhoids
 Diverticulitis
 Irritable Bowel Syndrome
 Crohn Disease
- Complication
 GI Bleeding
 Intestinal Obstruction
 Intestinal Perforation
 Metastasis
- Prognosis
Bad with 5- year survival of colon cancer
4. Polyp colorectal
- Definition
Benign tumors that commonly occur in the colon are polyps.A polyp is a tumor-
like mass protruding into the lumen of the intestine derived from epithelial mucosa
and submucosa and is the most benign neoplasms in the colon and rectum.
- Epidemiology
Most colon polyps arise sporadically, and increase in frequency with age. The
incidence of colon polyps increases with age, especially those over the age of 60
years, and is more common in men than women. "The mean age was around 40
years although it can also be found at a younger age between 20 to 40 years,
especially in patients with syndrome polyposis with familial adenomatous
polyposis (FAP) or hereditary non polyposis colorectal cancer (HNPCC). A
population study showed that approximately 30% of adults and elderly individuals
had colon polyps. in comparison, the incidence of colonic polyps in the United
States is one case among 6580- 8300 people. In Indonesia, data from endoscopy
center Cipto Mangunkusumo hospital in 2007, Julwan et al reported on 662 patients
 who underwent colonoscopy with any indication of which 23.2% were found polyps
and colorectal cancer
- Risk factor
 Aged 50 years and over
 Having family members who have had polyps or colon cancer
 Suffering from colitis, such as colitis ulcerative
 Type 2 diabetes uncontrolled
 Obesity and lack of exercise
 Smoking and frequent consumption of alcohol
- Classification of polyps
Histologically the colon and rectum polyps are classified into two main groups,
the polyps are non-neoplastic and neoplastic. Non-neoplastic polyps including
mucosal polyps, hyperplastic polyps, polyps juvenile, Peutz-Jeghers polyps and
inflammatory polyps. Neoplastic polyps includes adenomas, which can be
identified histologically as tubular adenomas, adenomas tubulovillous, or villous
adenomas.
A. Non-neoplastic polyps
1) Hamartoma
Hamartoma is characterized by the rapid growth of normal colon
component, such as the epithelium and connective tissue. Hamartoma
do not have the potential to experience deployment and less atipic or
invasive. Juvenile polyps and Peutz-Jegher's syndrome is characterized
as an Hamartoma.
2) Juvenile polyps
Juvenile polyps are found throughout the colon but is most often found
in the rectosigmoid area. These polyps are most often occurs in less than
5 years old, but is also found in adults of all ages; in the latter group, this
disorder can be referred to as a retention polyps. Whatever the
terminology, the lesion is usually greater in children (1 to 3 cm in
diameter) but smaller in adults; lesions are round, smooth or slightly
lobulated, and about 90% have stalks, where the length is up to 2 cm. In
general, these polyps are formed separately and are located in the
rectum. Polyps usually regress spontaneously and not be ganas.
 The main clinical symptoms are spontaneous bleeding from the rectum
are often not accompanied by pain, sometimes accompanied by mucus.
Because it is always stemmed, can protrude out of the anus during
defecation. In some cases the polyp can be twisted in the handle so
mangalami infark.
3) Peutz-Jeghers syndrome
Peutz-Jeghers polyps are non-neoplastic polyps which typically ranging
in size from 1 mm to 3 cm, usually multiple and have stalks. In
makrokopis, these polyps resemble lobular surface of adenomas.
Microscopic, muscularis mucosa which terarborsi covered by mucosa
contains glands, and propria layer. Symptoms include vomiting,
bleeding and pain in the lower abdomen.
4) Inflammatory polyp
Inflammatory polyps usually occur during the regenerative phase of
mucosal inflammation in the colon as it did in ulcerative colitis, Crohn's
disease, colitis amoeba and bacterial dysentery. The formation of
inflammatory polyps, however, occur as a result of ulceration without
an obvious cause, so that the presence of inflammatory polyps do not
always indicate a chronic inflammatory process in the colon. Polyps can
be small or large, and large-sized polyps can mimic neoplasms. In the
period of post inflammatory polyps may contain granulation tissue, but
the network will then be distorted again by normal mucosa.
5) Hyperplastic polyp
Hyperplastic polyp is a small polyps 1-3 mm in diameter are derived
from epithelial mucosa, hyperplastic and metaplastic. Polyps may be
only one, but usually multiple. Although it can be found anywhere
dikolon, in over half of all polyps found in the rectosigmoid.
These polyps are generally asymptomatic, but should be biopsied for
histological diagnosis. Histologically, the polyp contains many crypts
lined by absorptive epithelial cells or differentiated goblet cells,
separated by a little lamina propria. Although most polyps are
hyperplastic no potential to become malignant, it is now realized that
some of the so-called hyperplastic polyps on the right side of the colon
may be the precursors of colorectal carcinoma. These polyps exhibit
 microsatellite instability and can lead to cancers of the colon due to a
mismatch of regenerative pathways.
B. neoplastic polyps
1) adenomatous polyps
Adenomas are a premalignant lesions. Many an adenocarcinoma of the
colon is a progression of normal mucosa the development of adenomas
later develop into carcinoma. Adenomatous polyp is a polyp that
stemmed original and rarely found in the age under 21 years old. The
incidence increased with increasing age. Clinical features typically do
not exist, except for bleeding from the rectum and anal prolapse with
anemia. It is 70% in the sigmoid and rectum. These polyps are pra
malignant so it should be removed after it was discovered. Malignant
potential of adenomatous polyps depending on its size, its development
and the degree of epithelial atypical. Because of adenomatous polyps
may develop into abnormalities of premalignant and then to carcinoma,
preferably every adenomas were found removed. Based on this
possibility are encouraged to conduct periodic checks for life in patients
with multiple adenomatous polyps or those who have had adenomatous
polyps. Adenomatous polyps can be tubule, tubulovilous and vilous
typical tubular adenomas are small, spherical and stemmed with a
smooth surface. Villous adenomas are usually large and sessile with a
non-slip surface. Tubulovilous adenoma is a mixture of the two types of
adenoma. Villous adenomas occurred in the mucosa with changes
potentially malignant hyperplasia, especially in patients who are elderly.
These polyps sometimes produce a lot of slimy mucus, causing diarrhea
which may be accompanied by hypokalemia.
2) Hereditary neoplastic polyps
Polyposis colon or familial polyposis is a rare hereditary disease. Family
history is found accompanying a third of cases where a decline in
genetic. The first symptoms occurs at age 13-20 years. The same
frequency in men and women. Polyps that are scattered throughout the
colon and rectum is generally asymptomatic. Sometimes arise heartburn
or diarrhea accompanied by rectal bleeding. Cecum is usually not
affected. The risk of malignancy of 60% and often multiple.
 Wherever possible immediate colectomy with ileal pouch anastomosis
ileorektal with and reservoir. In these patients underwent endoscopy
should be a lifetime because there is still residual rectal mucosa. After a
total colectomy, do ileokutaneostomi (usually abbreviated ileostomy)
which is preternaturalist anus in the ileum. Because the anal canal are
not equipped polyposis, may also be done anoileostomi with reservoir
made from the terminal ileum.
For prevention, all family members should do genetic examination to
look for chromosomal alterations and checked regularly to reduce the
risk of colon carcinoma, by endoscopy or barium enema photo. The role
of endoscopy was instrumental in handling polyposis. Tissue biopsy and
polypectomy is usually done simultaneously.
Gardner syndrome is a hereditary disease that consists of colonic
polyposis with osteoma, multiple epidermoid tumors, cysts, sebaceous
and dermoid tumor. Treatment and prevention similar to that performed
on colonic polyposis.
- Pathophysiology
Normal rectal mucosa epitelnya cells regenerate every 6 days. In adenomas
occur genetic changes that interfere with the process of differentiation and
maturation of these cells, which starts with inactivation of adenomatous polyposis
coli gene (APC) that cause uncontrolled replication. With an increasing number of
these cells causes a mutation that activates the K-Ras oncogene, and p53 gene
mutations, it prevents apoptosis and prolong cell life.
- Polyps diagnosis
Clinical Symptoms and Signs

Most polyps are asymptomatic, but increasingly the extent of a polyp

the more it will give you symptoms. Perdaraham spontaneously through the
rectum are the most common complaints found in the rectum polyps. The blood
that comes out of fresh blood or blood-black depending on the location of the
polyps. Blood out intermittent, continuous bleeding is rarely found in a polyp.
Rectum polyps that have a long stalk, such as juvenile polyps, often have
prolapsed and exit to the anus.
 Physical examination provides little information about colon polyps.
Some may be palpated by digital rectal examination.

Supporting investigation

1. Kolon photos
Photos of the colon performed with contrast barium is inserted through
the rectum. By incorporating a barium swallow air after a bowel movement,
it would seem a thin layer of barium swallow in the colonic mucosa of the
colon so the disorder is more easily seen. This examination is called double-
contrast picture, which contrasts the air negative and positive contrast
barium swallow. Unfortunately, the photo of the colon abnormalities on
two-thirds of the distal rectum can not be assessed.
2. Barium enema
This examination is rarely used anymore as a primary diagnostic tool for
determining a polyp. The presence of filling defect showed a lesion due to
their mass.
3. Rektosigmoidoskopi
Rektosigmoidoskop is 25-30 cm long rigid pipe. With this tool, rectum
and sigmoid can be seen after the intestines are cleaned mechanically.
Examination with a rigid tool that is sometimes encountered difficulty in
rektosigmoid corner. At any abnormalities seen multiple biopsy should be
performed for pathological examination.
4. Colonoscopy
In a colonoscopy is used fiberskop bending to see the wall of the colon
than in the lumen until the terminal ileum. With this tool can be seen
throughout the colon, including those that are not visible on the colon. Small
polyps may be missed with a percentage of 5-10%. Fiberskop also be used
to biopsy any suspicious tissue, evaluation, and treatment measures for
example polypectomy.
 Image 8 : Colonoscopy

5. CT Kolonografi
CT examination kolonografi a potential technique for the diagnosis and
screening of a polyp. The advantage of this examination is a more
complete evaluation of the mucosal surface and extraluminal. However,
this examination requires preparation and need to be done several times
inspection to identify abnormalities in the colon. The use of computer-
aided detection (CAD) on CT kolonografi showed satisfactory results to be
used as a screening tool in the population at large.
- Management
Management polip in the colon and rectum is based on three things: because
polyps gives a disturbing phenomenon, because these polyps may be malignant
when it was first discovered, or because polyps can be a malignancy later.
1. Polypectomy
In the case of sessile polyps and berkonsistensi hard, removal of polyps
as colonoscopy done a curative action is often done. Polyps removed during
colonoscopy using a scalpel or a loop of wire that electrified. Colon polyp
recurrence after 1 year do polypectomy colonoscopy is rare but repeated at
3-12 months after polypectomy does sometimes recommended if there are
doubts whether colon polyp has been completely lost and / or risk of
malignancy.
 Image 9 : polypectomy

2. Endoscopic mucosal resection (EMR)

Endoscopic Mucosal Resectionhas now become a standard technique for

the resection of the colorectal polyps broad sessile. The use of EMR is
mainly considered in the sessile colorectal polyps measuring more than 1
cm. Complications that sometimes occur from the use of this technique is
the occurrence of hemorrhage EMR and mikroperforasi. Mikroperforasi
known late is an indication for the execution of laparotomy.

3. Laparoscopic colectomy

Laparoscopic colectomy procedure is mainly performed in cases of

colorectal polyps that can not be resected endoscopically example on polyps
that affect more than one-third of the colon or the broad sessile polyps. This
procedure is said to be a safe procedure performed for at least the
complications that occur.
 4. Colon resection

In the case of colon polyps associated with polyposis familia, resection

is often the only option management. Colon resection is also recommended
for patients with chronic ulcerative colitis who discovered the presence of
cells that had dysplasia. Surgical resection may be recommended on a large-
sized polyps, sessile polyps that are difficult to be removed or colonic polyps
that continue to relapse despite having been performed with endoscopic
polypectomy. Several surgical options have to do is a total colectomy,
subtotal colectomy or segmental resection. Histological examination of the
specimens that have been obtained are strongly encouraged to do. This is to
determine the likelihood of malignancy of a polyp and a role for further
management plan.

- Prognosis
Vilosum adenoma recurrence rate in the excision area about 15% of cases after
local treatment is done. Tubular adenomas rarely relapse, but new cases can be
resurfaced, as well as in patients who have any kind of adenoma are at greater risk
for the occurrence adenocarsinoma than the general population. Risk for
metachronous tumors after excision of colorectal adenomas would be greater if
there are multiple lesions index or if the sessile adenoma, villous, or more than 2
cm in diameter. the risk is greater in males than in females. In one study, the
cumulative risk of further progression of adenomas is linear over time, reaching
about 50% after the removal of one or more adenomas kolorectal, The cumulative
incidence of cancer in the same population increased to 7% in 15 years. When the
colon is cleaned with a total colonoscopy when excision of polyps, follow-up
colonoscopy at three years later just as effective as colonoscopy at 1 and 3 years
later to prevent the development of dangerous neoplasm.

Reference
1. Leslie R. D. 2019. Clinical Overview of Hemorrhoid. Elsevier. Accessed from
Clinicalkey.com
2. Varut L. 2017. World Journal of Gastroenterology Chapter: Hemorrhoids.
Accessed from ncbi.nlm.nih.gov
 3. Leslie R. D. 2019. Clinical Overview of Anal Fissure. Elsevier. Accessed from
Clinicalkey.com
4. Robert D. M., Genevieve. B. M. 2019. Goldman-Cecil Medicine 26th Edition
Chapter: Diseases of the Rectum and Anus. Elsevier. Accessed from
Clinicalkey.com
5. Leslie. R. D. 2019. Clinical Overview of Colorectal Cancer. Elsevier. Accessed
from Clinicalkey.com
6. Clive R. G., Suzanne M. B. 2019. Essential Surgery: Problems, Diagnosis and
Management 6th Edition Chapter: Colorectal Polyps and Carcinoma. Elsevier.
Accessed from Clinicalkey.com

7. Hafid A, Gratitude A, Achmad IA, Ridad AM, Ahmadsyah I, Airiza AS, et al. Smooth
intestines, appendix, colon and Anorektum. In: Sjamsuhidajat R, de Jong W (ed).
Textbook of Surgery Second Edition. Jakarta, EGC Book Medical Publishers, 2005:
p.654-657,

8. Sudoyo AW, Setiyohadi B, Alwi I, Simadibrata KM, Setiati S, editors. Internal

medicine textbook. 4th ed. Jakarta: PAPDI; 2014

9. Poddar U, BR Thapa, Vaipei K et al. Juvenile polyposis in a Tropical Country.

Archives of Disease in Childhood, British Medical Journal 1998 Volume 78: 264-
266.

10. Sanchez, et al (2012). Physical Activity Reduces Risk for Colon Polyps in a
Multiethnic Population Colorectal Cancer Screening. BMC Res Notes, doi:
10.1186 / 1756-0500-5-312

11. Yamaji Y, Mitsushima T, Yoshida H et al. The Potential of Freshly Developed

Malignant Colorectal Polyps According to Age. American Association for Cancer
Research Journals, 2006. Volume 15: 2418-2421.

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8. Perspektif islam
 ‫علَ ْي ِه‬
َ ‫ض ِبي ۖ َو َم ْن يَ ْح ِل ْل‬ َ ‫علَ ْي ُك ْم‬
َ ‫غ‬ ْ َ ‫ت َما َرزَ ْقنَا ُك ْم َو ََل ت‬
َ ‫طغ َْوا فِي ِه فَيَ ِح َّل‬ َ ‫ُكلُوا ِم ْن‬
ِ ‫ط ِيبَا‬
‫ض ِبي فَقَ ْد ه ََوى‬ َ
َ ‫غ‬
Kulụ min ṭayyibāti mā razaqnākum wa lā taṭgau fīhi fa yaḥilla 'alaikum gaḍabī, wa may
yaḥlil 'alaihi gaḍabī fa qad hawā .
Arti :
Makanlah di antara rezeki yang baik yang telah Kami berikan kepadamu, dan
janganlah melampaui batas padanya, yang menyebabkan kemurkaan-Ku menimpamu.
Dan barangsiapa ditimpa oleh kemurkaan-Ku, maka sesungguhnya binasalah ia.
Kandungan :
Makanlah dari rizki Kami yang baik-baik, dan janganlah kalian melampaui
batas padanya dengan cara sebagian kalian menzhalimi sebagian yang lain, akibatnya
kemurkaanKu akan menimpa kalian. Dan siapa saja yang ditimpa kemurkaanKu,
sungguh dia akan binasa dan merugi.