Pemicu 4 B

Gastrointestinal

Septriawan Aenul Rizky

405090177
Kelompok 16

Fakultas Kedokteran
Universitas Tarumanagara
 DEFINITION
Refers to any acute intra & extra
abdominal disease processes. Many
cases require urgent surgical
management, although some can be
managed nonsurgically.
 ETIOLOGIC
Parietal peritoneal inflammation
Bacterial contamination : pelvic inflammatory
disease, perforated appendix
Chemical irritation : perforated ulcer,
pancreatitis
Mechanical obstruction of hollow viscera :
Obstruction of the small or large intestine
Obstruction of the biliary tree
Obstruction of the ureter
Volvulus
Hernia
 ETIOLOGIC
Vascular disturbances :
Embolism or thrombosis
Vascular rupture
Pressure or torsional occlusion
Abdominal wall :
Distortion or traction of mesentery
Trauma or infection of muscles
Neoplasm intraabdominal
Congenital disease
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
Gynecologic cause
Urinary Tract Infection
Pregnancy (or Ectopic Pregnancy)
Pneumonia
Mittelschmerz
Pancreatitis
Dysmenorrhea
Appendicitis
Pelvic Inflammatory Disease
Mesenteric Lymphadenitis
Ovarian torsion
Gastroenteritis
Testicular Torsion
Intussusception or Volvulus (children
under age 6) Drug and Alcohol use
Abdominal trauma Sexual abuse
Pharyngitis (e.g. Strep Throat) Gallbladder disease
Sickle Cell Crisis Neoplasm
Henoch-Schonlein Purpura Inflammatory Bowel Disease
ETIOLOGY/CAUSES/DIFFERENTIAL
DIAGNOSIS OF ACUTE ABDOMEN
Gastrointestinal
Appendisitis
Perforated peptic ulcer
Intestinal ischemia
Diverticulitis
Inflammatory bowel disease
Meckels 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
 cullen's sign
kehr's sign

iliopsoas sign
murphy's sign grey-turner's sign
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 C 37.8 C)
diverculitis, appendicitis, acute
cholecystitis
High fever (> 37.8 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
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
CHARACTERISTIC OF THE
PAIN
Visceral pain, comes from abdominal viscera,
innervated by autonomic nerve fibers and respond
mainly to the sensation of distention and muscular
contraction. Typically vague, dull, and nauseating.
Somatic pain, comes from parietal peritonium,
innervated by somatic nerves, which respond to
irritation from infectious, chemical, or other
inflammatory processes. Sharp and well localized.
Referred pain, perceived distant from its source and
result from convergence of nerve fibers at the spinal
cord. Ex: scapular pain due to biliary colic, groin pain
due to renal colic, shoulder pain due to blood or
infection irritating the diaphragm
LABORATORY TESTING
Intra-abdominal inflammation WBC
Dehydration , vomitting, diarrhea, taking
diuretic medicine -> measure the
concentrations of serum sodium,
potassium, blood urea nitrogen, creatinine,
glucose, chloride, and carbon dioxide.
Pancreatitis, perforated duodenal ulcer
serum amilase
Abdominal pain RUQ should have
measurements of serum bilirubin, alkaline
phosphatase, and serum transaminase
DIAGNOSIS ACUTE
ABDOMEN
History:
Acute appendicitis: periumbilical pain, low-grade fever,
anorexia with/without vomiting followed by movement of
the pain into the right lower quadrant McBurneys point.
Constipation: obstructive conditions, inflammatory
disorders produce ileus.
Watery diarrhea: gastroenteritis,
Bloody diarrhea: infectious colitis, inflammatory bowel
disease, mesenterial ischemia.
Jaundice: hepatic and pancreaticobiliary disease, sepsis.
Urinary frequency, dysuria, hematuria, and suprapubic
or flank pain : urologic disease.
DIAGNOSTIC IMAGING
USG -> Liver, gallbladder, bile ducts,
spleen, pancreas, appendix, kidneys,
ovaries, and uterus. Also detect and
charaterizes the distribution of intra-
abdominal fluid.
Color doppler USG -> evaluation of
intra-abdominal adn retroperitoneal
blood vessels.
CT scan
X-ray
Evaluation of Abdominal Pain in
Special Populations
Evaluation of Right Upper
Quadrant Abdominal Pain
Evaluation of Right Lower
Quadrant Abdominal Pain
Evaluation of Left Lower
Quadrant Abdominal Pain
 EXAM
Physical Exam Labs Radiology
Perform in comfortable, Screening Flat and Upright
non-threatening 1) Complete Blood abdominal XRay (KUB)
environment Count Consider
Growth 2) Erythrocyte 1) Barium Enema
Development Sedimentation 2) RUQ Ultrasound
Appearance Rate 3) Pelvic Ultrasound
Vital signs 3) Urinalysis 4) Abdominal CT
Comprehensive exam 4) Urine Pregnancy Skeletal Survey (assess
Abdominal exam Test (Urine HCG) physical abuse)
a) Test rebound as when appropriate Upper GI with small bowel
"Jump on and off 5) Liver Function follow through
table" Tests Upper endoscopy (EGD)
b) Avoid removing 6) Amylase Colonoscopy
hand rapidly (loses 7) Lipase
patient trust) Consider additional testing
Rectal Exam necessary 1) Helicobacter Pylori
titer
2) Ova and Parasites
(e.g. Giardia)
3) Hepatitis
Serologies (A,B,C)
4) Lead Ingestion
 DD Acute Abdominal Pain
GENERALIZED/ UPPER LOWER
PERIUMBILICA
L
RIGHT LEFT RIGHT LEFT

Gastroenteritis Hepatitis Pancreatitis Appendicitis Inflammatory

Obstipation Biliary colic Splenic Inflammatory bowel disease
Small bowel Peptic ulcer infarction bowel disease Diverticulitis
obstruction disease Pyelonephritis Salpingitis Salpingitis
Large bowel Pyelonephritis Myocardial Rectus Rectus
obstruction Acute infarction abdominus abdominus
Mesenteric cholecystitis muscle strain muscle strain
ischemia Ureteral Ureteral
Peritonitis calculus calculus
Abdominal Ruptured Ovarian
aortic dissection corpus luteum torsion
Sickle cell cyst Ruptured
crisis Ruptured corpus luteum
ectopic cyst
pregnancy Ruptured
Ovarian torsion ectopic
pregnancy
Sigmoid
volvulus
Treatment
Based on the cause :
Operatif
Medicamentosa
Rehydration and nutrition
Complication
Bowel necrosis
Bowel perforation
Sepsis
Shock hipovolemic
Abscess
Short bowel syndrome with malabsorption and
malnutrition
Decreased absorption
Dehydration
Kidney failure.
Death
INTESTINAL
OBSTRUCTION
DEFINITION
Intestinal obstructions are a partial or
complete blockage of the small or
large intestine, resulting in failure of
the contents of the intestine to pass
through the bowel normally.
ETIOLOGY
Mechanical
obstructions
The bowel is physically
blocked and its contents
can not pass the point of
the obstruction.
This happens when the
bowel twists on itself
(volvulus) or as the result
of hernias, impacted
feces, abnormal tissue
growth, or the presence of
foreign bodies in the
intestines.
Non-mechanical
obstruction
Called ileus or paralytic ileus,
occurs because peristalsis
stops.
Peristalsis is the rhythmic
contraction that moves
material through the bowel.
Ileus is most often associated
with an infection of the
peritoneum (the membrane
lining the abdomen). It is one
of the major causes of bowel
obstruction in infants and
children.
 INTESTINAL OBSTRUCTION
Causes of 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
Adults Cancer of the duodenum or head of pancreas, ulcer
disease
Neonates Atresia, volvulus, bands, annular pancreas

Jejunum and ileum

Adults Hernias, adhesions (common), tumors, foreign body,
Meckel's diverticulum, Crohn's disease (uncommon),
Ascaris infestation, midgut volvulus, intussusception
by tumor (rare)

Neonates Meconium ileus, volvulus of a malrotated gut, atresia,

intussusception
EXAMPLES OF CAUSES OF
INTESTINAL OBSTRUCTION

Obstruction due to
Obstruction due to Obstruction due to
hernia
adhesions mesenteric occlusion

Obstruction due to
intussusception Obstruction due to
Obstruction due to
volvulus
tumor
 SYMPTOMS
AbdominalSmall
cramps bowel
centered around Large bowel
the umbilicus or in the epigastrium,
Vomiting Increasing constipation
Obstipation (in patients with complete leads to obstipation and
obstruction) abdominal distention.
Diarrhea (partial obstruction)
Severe, steady pain suggests that
Vomiting may occur (usually
strangulation has occurred. In the several hours after onset of
absence of strangulation, the other symptoms) but is not
abdomen is not tender
common
Hyperactive, high-pitched peristalsis
with rushes coinciding with cramps is Lower abdominal cramps
typical unproductive of feces occur
Dilated loops of bowel are palpable
sometimes.
No tenderness
With infarction, the abdomen The rectum is usually empty.
becomes tender
A mass corresponding to the
Auscultation reveals a silent abdomen
or minimal peristalsis site of an obstructing tumor
Shock and oliguria (serious signs that may be palpable.
indicate either late simple obstruction
PHYSICAL EXAMINATION
Hyperactive bowel to overcome the obstruction (early)
Hypoactive bowel sounds
Proper genitourinary and pelvic examinations are essential
Look for the following during rectal examination:
Gross or occult blood, which suggests late strangulation
or malignancy
Masses, which suggest obturator hernia
Check for symptoms commonly believed to be more
diagnostic of intestinal ischemia, including the following:
Fever (temperature >100F)
Tachycardia (>100 beats/min)
Peritoneal signs
LAB EXAMINATIONS
X-rays
CT Scan
MRI
USG
Sigmoidoscope
CBC (Complete Blood Count)
Electrolytes
BUN (Blood Urea Nitrogen)
Urinalysis
Laboratory tests to exclude biliary or hepatic disease
Phosphate level
Creatine kinase level
Liver panels
TREATMENTS
Non-Farmacologic :
Nasogastric tube
Rectal tube
Intravenous fluids
Repair the hernia to correct the
obstruction
Surgery complete obstructions
Farmacologic :
Antibiotics : pre and post operation
PROGNOSIS
Most intestinal obstructions can be
corrected with prompt treatment and the
affected child will recover without
complications.
Untreated intestinal obstructions can be
fatal, however.
The mortality rate for unsuccessfully
treated infants is 12 percent.
COMPLICATIONS
Dehydration Kidney failure (severe
dehydration)
Irregular heartbeat
Shock
Systemic infection from perforation
of the bowel
 Intussusception

Intussusception is the most common cause

of intestinal obstruction in children between
3 months and 6 years of age. It occurs when
a portion of the bowel "telescopes" into
itself, causing intestinal obstruction.
 Cause
Idiopathic (unknown but
following a viral infection)
lead point (change in the
mucosa from another condition
such as cystic fibrosis, or
hematoma)
Post operative
 Assessment
1-Paroxysmal abdominal pain; legs drawn up
2-Blood in stool, or later currant jelly stools
containing sloughed mucosa, blood, and mucus
3- vomiting
4-Increasing absence of stools.
5-Abdominal distention, bowel sound diminished,
absent or high pitch.
6-Sausage like mass palpable in abdomen
(Dances sign).
7-Unusual looking anus; may look like rectal
prolapse.
8-Dehydration and fever
9-Shock like state with rapid pulse, pallor, and
 Diagnostic
X-ray of abdomen may show absence of
gas or mass in right upper quadrant.
Barium enema is done if there is no
appearance of peritonitis; shows a
concave filling defect (will help reduce
the invagination).
Ultrasonogram may be done to locate
area of telescoped bowel.
 Treatment

Two approaches are used in treating

intussusception -- nonoperative
reduction and surgery
Nonoperative reduction
Gentle pressure exerted within the
intestine, using barium or air enemas.
If there are abdominal infection or
has other complications, reduce the
intussusception with the enema.

Both barium and air enemas have a

low risk (less than 2%) of
complications, which could include
tearing the intestine.
Surgery

For children who are too ill to have this

diagnostic procedure, who may have
significant infection in the abdomen, or in
whom intussusception does not resolve
with the enema, surgery is necessary. If
the child has several episodes of
intussusception, a surgical procedure may
be performed in an attempt to determine
the cause of the recurrent intussusception.

With the child under general anesthesia,

the surgeon makes an incision in the
abdomen, locates the intussusception, and
pushes and manipulates the bowel in
order to return it to its normal position. If
the bowel is severely damaged as a result
Appendicitis
Typical Symptoms of Appendicitis

1. A sense of being ill

2. Generalized abdominal discomfort
3. Loss of appetite
4. Nausea
5. Pain in the right lower quadrant of
the abdomen
6. Fever
7. Vomiting
Prevalence of Common Signs
and Symptoms of Appendicitis

Sign or symptom Frequency (%)

Abdominal pain 99 to 100
Right lower quadrant pain or tenderness 96
Anorexia 24 to 99
Nausea 62 to 90
Low-grade fever 67 to 69
Vomiting 32 to 75
Pain migration from periumbilical area to the right 50
lower quadrant
Rebound tenderness 26
Right lower quadrant guarding 21
Common Signs of Acute
Appendicitis
Sign Description
McBurney sign Localized right lower quadrant pain or guarding on palpation of the
abdomen (the single most important sign)

Psoas sign Pain on hyperextension of right thigh (often indicates retroperitoneal

retrocecal appendix)

Obturator sign Pain on internal rotation of right thigh (pelvic appendix)

Rovsing sign Pain in the right lower quadrant with palpation of the left lower quadrant

Dunphys sign Increased pain in the right lower quadrant with coughing

Hip flexion Patient maintains hip flexion with knees drawn up for comfort

Other peritoneal signs Rebound tenderness, hyperesthesia of the skin in the right lower quadrant
 STRENGTH OF
RECOMMENDATIONS
Key clinical recommendation Label
If the diagnosis of acute appendicitis is clear from the history and physical examination, no C
further testing is needed.

When the diagnosis of appendicitis is uncertain, computed tomography (CT) and ultrasonography C
may reduce the rate of perforation.

The diagnostic accuracy of ultrasonography for acute appendicitis has been reported to range C
from 71 to 97 percent
The most useful sign of acute appendicitis on ultrasonography is an outer appendiceal diameter
of 6 mm or greater on cross-section.

Depending on the technique used, the diagnostic accuracy of CT in acute appendicitis ranges C
from 93 to 98 percent
On CT, an inflamed appendix is greater than 6 mm in diameter, has appendiceal wall thickening,
and wall enhancement after contrast media infusion, and reveals inflammatory changes in the
surrounding tissues.
Algorithm for the evaluation and management of
patients with possible acute appendicitis based on
surgical assessment of clinical probability of the
diagnosis
Diagnosis
and
Manageme
nt of
Appendiciti
s
Clinical Algorithm for Suspected
Cases of Acute Appendicitis
Ruptured Ectopic Pregnancy
Ectopic Pregnancy
Alternative Names: Tubal pregnancy; Cervical
pregnancy; Abdominal pregnancy
An ectopic pregnancy is an abnormal pregnancy
that occurs outside the womb (uterus)
The baby (fetus) cannot
survive, and often does not
develop at all in
this type of pregnancy
Ectopic pregnancies occur
in 1 in every 40 to 1 in
every 100 pregnancies
Symptoms
Abnormal vaginal bleeding
Amenorrhea
Breast tenderness
Low back pain
Mild cramping on one side of the
pelvis
Nausea
Pain in the lower abdomen or pelvic
area
Symptoms
If the area of the abnormal pregnancy
ruptures and bleeds, symptoms may get
worse. They may include:
Feeling faint or actually fainting
Intense pressure in the rectum
Pain that is felt in the shoulder area
Severe, sharp, and sudden pain in the lower
abdomen

Internal bleeding due to a rupture may

lead tolow blood pressureand fainting in
Risk Factor
Age over 35
Having had many sexual partners
In vitro fertilization
Risk Factor

Risk factor Number of studies Odds ratio*

Previous tubal surgery 3 21.0

Previous ectopic pregnancy 10 8.3

In utero diethylstilbestrol exposure 5 5.6

Previous genital infections 24 2.4 to 3.7

Infertility 9 2 to 2.5

Current smoking 6 2.3

Previous intrauterine device use 16 1.6

Initial
Diagnosi
s of
Suspecte
d Ectopic
Pregnan
cy
Differential Diagnosis
Acute appendicitis
Miscarriage
Ovarian torsion
Pelvic inflammatory disease
Ruptured corpus luteum cyst or
follicle
Tubo-ovarian abscess
Urinary calculi
Diagnosing Suspected Ectopic Pregnancy Following Transvaginal
Ultrasonography
Exams & Tests
Culdocentesis
Hematocrit
Pregnancy test
Quantitative HCG blood test
Serum progesterone level
Transvaginal ultrasoundorpregnancy ultrasound
White blood count

A rise in quantitative HCG levels may help tell a normal (intrauterine)

pregnancy from an ectopic pregnancy. Women with high levels should
have a vaginal ultrasound to identify a normal pregnancy.
Other tests may be used to confirm the diagnosis, such as:
D and C
Laparoscopy
Laparotomy
 Treatment
You will need emergency medical help if the area of the ectopic pregnancy
breaks open (ruptures). Rupture can lead to shock, an emergency condition.
Treatment for shock may include:
Blood transfusion
Fluids given through a vein
Keeping warm
Oxygen
Raising the legs

If there is a rupture, surgery (laparotomy) is done to stop blood loss. This

surgery is also done to:
Confirm an ectopic pregnancy
Remove the abnormal pregnancy
Repair any tissue damage

In some cases, the doctor may have to remove the fallopian tube.
A minilaparotomy and laparoscopy are the most common surgical treatments
for an ectopic pregnancy that has not ruptured. If the doctor does not think a
rupture will occur, you may be given a medicine called methotrexate and
monitored. You may have blood tests and liver function tests.
Prognosis
One-third of women who have had one ectopic
pregnancy are later able to have a baby. A repeated
ectopic pregnancy may occur in one-third of women.
Some women do not become pregnant again

The likelihood of a successful pregnancy depends on:

The woman's age
Whether she has already had children
Why the first ectopic pregnancy occurred

The rate of death due to an ectopic pregnancy in the

United States has dropped in the last 30 years to less
than 0.1%.
Prevention
The following may reduce your risk:
Avoiding risk factors for pelvic
inflammatory disease (PID) such as
having many sexual partners, having
sex without a condom, and getting
sexually transmitted diseases (STDs)
Early diagnosis and treatment of STDs
Early diagnosis and treatment of
salpingitis and PID
Stopping smoking