Saturday, Lenny

November 23rd , 2019

Interesting Case
Risk Factors and Cause of Abdominal Bloating in Toddler

Cici, Ester, Manu, Aya, Alfa, Wening, Yehez, Lenny

 Lenny
E – 1 year 1 month old – Girl - Yogyakarta

Bloating Abdomen
 3 days before admission Lenny

- No history of constipation/
diarrhea
Fever throughout the day - Smoker Father
(not measured) - No history of dyspneu
Vomitted 3x/day - Diaper was used since 7 m.o.
used only in the evening and
contained food & water,
throughout the night, was not
volume @±10-20cc, not projectile changed until morning
Cough with phlegm
Loss of appetite - Midwife: Tx Paracetamol,
(Al Hydroxide + Mg Hydroxide
+Simeticone) syrup
2 Days before admission 1 Days before admission Lenny

Symptoms persisted Symptoms improved

+ Vomitted ↑ 5x/day Fever and vomit stop
volume ±10-20cc/vomit Cough
+ Straining while urinating but
Low intake + Diarrhea 2x/day, yellow, loose
watery stool, no mucous/blood,
volume @±50cc
Pediatrician + Bloating
Dx: UTI & acute faringitis - Flatulance (+)
- Irritable (+)
Tx: Cefixim, vitamin
 Day of admission Lenny
Abdominal USG
+ Sudden distended abdomen +
+ Decrease urinating 3 position BNO
- No vomit
Nasogastric Tube
Private Hospital
+ Diarrhea 3x in ER Referred To Sardjito Hospital
volume @±50cc - Decreased bloating abdomen
+ Bursting defecation - Diarrhea
- Cough with phlegm
- No Vomit
Distended abdomen decrease
Private Hospital 22 November 2019
Abdominal USG
- High grade Ileus Obstruction susp
- Liver, Vesica fellea, Spleen,
Kidney within normal limit
 BNO in Private Hospital 22 Nov 19

UPRIGHT LLD
SUPINE

Susp Low Grade Obstructive Ileus mix Paralytic, susp Ascites

Routine Blood Count in Private Hospital, November 22nd 2019 Lenny
Parameter Result Reference Parameter Result Reference
WBC 13,400 4.000 – 11.000/µL Diff Segment 43.22% 40 – 70 %
RBC 4.46 3.5 – 5.5 106/µL Diff 20 - 40 %
45.6%
Haemoglobin 13.13 11 -17 g/dl Limphocyte
Hematocrite 37.5 32 – 52 % Diff 10.52% 2-8%
Monocyte
Platelet 390,700 150.000 – 450.000/µL
Diff Eosinophil 0.24% 0-3%
Blood 80-120 mg/dl
Glucose
60 Diff Basophil 0.42% 0.0 – 1.0%

Hypoglicemia, Increased in Diff Limphocyte and Monocyte

History of prenatal, natal, and postnatal care Lenny
Mother aged 37 y.o, G2P1A0, 36 weeks of GA
• History of preterm pregnancy of the first child
• Vaginal delivery birth on preterm pregnancy because of Premature Rupture of
Membrane
• History of bleeding mother after delivery
• Birth weight 2.000 gram
• Jaundice at 3 days y.o.
• Phototherapy
• No history of late pasage of meconium
• Went home with parents after 7 days of hospitalization
• Mother's flat nipple
Born Premature, Low Birth Weight, Received Phototheraphy
for two days because developed jaundice at 3 days old
IMMUNIZATION Lenny

Good immunization status

 Patient's History
• No history of Allergy
• No history of constipation
• Living in crowded environment
 History of Feeding
• 0 - 6 months : breastfeeding + formula milk
• 6 - 7 months: instant fortificated cereal
• 7 months - 13 months: porridge 3x/day
• The patients with low appetite during the last two months
because of teeth eruption
 Growth and development
• Gross Motoric : Sit, Unable to stand alone
• Fine motoric : put block in a cup
• Language : 1-2 words
• Personal social : Able to indicate wants

Caution in Gross Motoric Development

 Lenny
Nutritional Status
FEMALE
Chronological Age 1 YEARS AND 1 MONTHS
Corrected Age 1 YEARS
WEIGHT 7 kg
LENGTH 69 cm
Head Circumference 44 cm
WAZ -3 ≤ x ≤ -2
LAZ -3 ≤ x ≤ -2
WHZ -3 ≤ x ≤ -2
Head cirfumference -1 ≤ x ≤ 0

MODERATE MALNUTRITION; NORMOCEPHAL

 PHYSICAL EXAMINATION Lenny

November 23rd 2019

Appearance : Irritable
Consciousness : compos mentis, E4V5M6
Vital Signs
HR : 132 x/minute
RR : 30 x/minute
Temperature : 36.8 oC Irritable, with
SpO2 : 98 % room air
normal vital sign
Head : no anemic conjungtival, no ichteric sclera, normal
light reflexs on both eyes, no sunken eyes,
connected NGT, pharynx difficult to evaluate
Neck : no lymph nodes enlargement
 PHYSICAL EXAMINATION Lenny

Thorax : Symmetric, no retraction

 Lung : Vesicular sounds, no crakles, no wheezing on both lungs
 Heart : Single sound S1, Non fixed split S2, no murmur, no gallops
Abdomen : no distention, normal peristaltic sounds, tymphani on
percussion, liver and spleen not enlarged, skin turgor <2 seconds
Umbilical abdominal circumference 36.5 cm
Largest abdominal circumeference 37 cm
Extremities: warm extremities, normal Capillary Refill Time, no edema

Irritable with normal limit physical examination

BNO In Sardjito Hospital 23/11/19
Leads to Meteorism
No sign of Ascites, Pneumoperitoneum, Peritonitis neither Ileus
November 23rd 2019 Lenny
Parameter Result Reference Parameter Result Reference
WBC 29.240 5.500 – 17.500/µL Neutrophil 81.9% 50 – 70 %
RBC 4.07 4,1 – 5,5 106/µL Limphocyte 11% 25 - 40 %
Haemoglobin 11.1 9,6 -15,6 g/dl Monocyte 7.0% 2-8%
Hematocrite 32.1 32 – 42 % Eosinophil 0.0% 1-4%
MCV 78.9 76 - 92 fL
Basophil 0.1% 0.0 – 2.0%
MCH 27.3 23 - 31.0 pg
MCHC 34.6 32 – 36 g/dl
Platelet 360,000 150.000 – 450.000/µL
RDW 40.3 35 – 45 fL

Leucocytosis with predominant of neutrophils

November 23rd 2019 Lenny

Parameter Result Reference

Albumin 3.9 3.4 - 5.0 g/dL
Natrium 137 132-141
Kalium 4.38 3.5-5.1
Chloride 100 97-107
Procalcitonin 0.32 <0.5

Normal
 DATA LIST AND DIAGNOSIS Lenny
No Data list Diagnosis Plan
1.  Girl, 1year and 1month old Meteorism dd Decompression with NGT
 Bloating abdomen after Functional Ileus ec Zink 20mg/24hours PO
history of diarrhea acute diarrhea Prebiotic 1 sachet/
 Decreased after bursting without sign of 12hours
defecation dehydration ORS
 No history of constipation Observation of abdominal
 Ø Abdomen : 37cm circumference
 Irritable
 No sunken eyes, no dry
lips,
turgor abdomen <2seconds
 Leucocytosis 29.240
 Procalcitonin, Electrolyte
within normal limit
 DATA LIST AND DIAGNOSIS Lenny
No Data list Diagnosis Plan
2.  Girl, 1 years and 1 month Acute Bronchitis Mucolytic
old susp Nebulation NaCl 0.9%
 Cough with phlegm for 3 Chest Physiotheraphy
days
 Smoker Father
 RR 30x/minute
 SpO2 97% room air
 No chest retraction
 No crackles nor wheezing
 No history of allergy
3.  WAZ -3 ≤ x ≤ -2 Moderate Based on Recommended
 LAZ -3 ≤ x ≤ -2 Malnutrition Dietary Allowance
 WHZ -3 ≤ x ≤ -2
 Gladys

Interesting points

• Learn more about risk factors and cause of abdominal bloating

in Toddler
 Causes Obstruction of the bowel may due to:
A mechanical cause -> means something is in the way
• Ileus, a condition in which the bowel does not work correctly,
but there is no structural problem causing it
• Paralytic ileus, also called pseudo-obstruction, is one of the
major causes of intestinal obstruction in infants and children.
 Causes of paralytic ileus may include:
• Bacteria or viruses that cause intestinal infections
(gastroenteritis)
• Chemical, electrolyte, or mineral imbalances (such as
decreased potassium levels)
• Complications of abdominal surgery
• Decreased blood supply to the intestines (mesenteric ischemia)
• Infections inside the abdomen, such as appendicitis
• Kidney or lung disease
• Use of certain medicines, especially narcotics
 Causes of paralytic ileus may include:
• Adhesions or scar tissue that forms after surgery
• Foreign bodies (objects that are swallowed and block the
intestines)
• Gallstones (rare)
• Hernias
• Impacted stool
• Intussusception (telescoping of one segment of bowel into
another)
• Tumors blocking the intestines
• Volvulus (twisted intestine)
 Lenny

THANK YOU
• Intussusception is the most common cause of intestinal
obstruction in infants and children aged 3 months to 6 years
and is the second most common cause of acute abdomen in
this age group. Approximately 60% of children are younger
than 1 year, and 80-90% are younger than 2 years.
• It occurs when a proximal segment of the intestine (called the
intussusceptum) telescopes or invaginates into the lumen of
another, immediately adjacent distal segment (called the
intussuscipiens)
• Kembung sering pula terjadi pada anak yang kurang gizi,
biasanya akibat kombinasi gangguan pencernaan,
pertumbuhan bakteri usus yang berlebihan, dan gangguan
peristaltik usus akibat kekurangan elektrolit.

• Kembung dapat pula terjadi bila kita sampai ke daerah yang

tinggi. Pada kondisi ini sebagian gas yang terlarut dalam darah,
terutama gas nitrogen, akan berdifusi ke saluran usus. Oleh
karena itu di daerah yang tinggi, seperti puncak gunung kita
akan sering kentut dan bisa kembung.
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