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Ileus paralitik/obstruksi Apendisitis perforasi/akut Peritonitis primer/skunder Hernia
Invaginasi/intusepsi Volvulus/malrotasi Perforasi intestinal
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Hernia
A hernia is de ned as anabnormal protrusion of anorgan or tissue through adefect in its surroundingwalls
Although a hernia canoccur at various sites ofthe body, these defectsmost commonly involvethe abdominal wall,particularly the inguinalregion
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Hernia Inguinal !lassi ed as direct or indirect "he sac of an indirect inguinal hernia passes from the internal inguinal
ring obli#uely toward the e$ternal inguinal ring and ultimately into thescrotum
As indirect hernias enlarge, it sometimes can be di%cult to distinguishbetween indirect and direct inguinal hernias
In contrast, the sac of a direct inguinal hernia protrudes outward and
forward and is medial to the internal inguinal ring and inferior epigastricvessels &en are '( times more likely to have a groin hernia than women Indirect inguinal and femoral hernias occur more commonly on the right
side "he predominance of right)sided femoral hernias is thought to be caused
by the tamponading e*ect of the sigmoid colon on the left femoral canal
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+trangulation, the most common serious complicationof a hernia, occurs in only - to .- of groin hernias andis more common at the e$tremes of life
&ost strangulated hernias are indirect inguinal hernias
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Diagnosis "here may be associated pain or vague discomfort in the region, but groin
hernias are usually not e$tremely painful unless incarceration or strangulationhas occurred
patients may e$perience paresthesias related to compression or irritation of theinguinal nerves by the hernia
"he inguinal region is e$amined with the patient in the supine and standingpositions
Inspects and palpates the inguinal region, looking for asymmetry, bulges, or amass
Valsalva maneuver can facilitate identi cation of a hernia A bulge moving lateral to medial in the inguinal canal suggests an indirect
hernia If a bulge progresses from deep to super cial through the inguinal oor, a direct
hernia is suspected 0ltrasonography also can aid in the diagnosis 1!"2 of the abdomen and pelvis may be useful for the diagnosis of obscure and
unusual hernias as well as atypical groin masses
laparoscopy can be diagnostic and therapeutic for particularly challengingcases
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Acute Appendisitis
Appendicitis occurs more fre#uently in 3esterni4edsocieties Acute appendicitis remains the most common
emergency general surgical disease a*ecting theabdomen
Appendicitis occurs most commonly in 5) to 6)year)olds 7ne of the more common complications and most
important causes of e$cess morbidity and mortality isperforation
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Pathogenesis 8ecaliths, incompletely digested food residue, lymphoid
hyperplasia, intraluminal scarring, tumors, bacteria, viruses, andin ammatory bowel disease have all been associated with
in ammation of the appendi$ and appendicitis 7bstruction lumen appendicitis luminal distention, bacterial
overgrowth inhibit dlow of lymph and blood thrombosis,ischemic necrosis perforation distal appendi$
+ome cases of simple acute appendicitis may resolvespontaneously or with antibiotic therapy, and recurrent disease is
remotely possible 3hen perforation occurs, the resultant leak may be contained by
the omentum or other surrounding tissues to form an abscess 8ree perforation normally causes severe peritonitis infective
suppurative thrombosis portal vein intrahepatic abscesses "he prognosis of the develop this dreaded complication is very
poor
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Clinical Manifestation
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Laboratory Testing 9oes not identify patients with appendicitis but can help the clinician
work through the di*erential diagnosis 3hite blood cell count is only mildly to moderately elevated in
appro$imately :5- of patients with simple appendicitis 1with aleukocytosis of 5,555; 2
A ?left shift@ toward immature polymorphonuclear leukocytes ispresent in 6(- of cases
0rinalysis is indicated to help e$clude genitourinary conditions thatmay mimic acute appendicitis
In amed appendi$ that abuts the ureter or bladder may cause sterilepyuria or hematuria
!ervical cultures are indicated if pelvic in ammatory disease issuspected
Anemia and guaiac)positive stools should raise concern about thepresence of other diseases or complications such as cancer
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Imaging Plain lms of the abdomen not routinely obtained unless
the clinician is worried about other conditions such asintestinal obstruction, perforated viscus, or ureterolithiasis
Presence of a fecalith is not diagnostic of appendicitis "he e*ectiveness of ultrasonography as a tool to diagnosis
appen)dicitis is highly operator dependent 0ltrasonography may facilitate early diagnosis
0ltrasonographic ndings suggesting the presence ofappendicitis include wall thickening, an increasedappendiceal diameter, and the presence of free uid
!" imaging may be very helpful, although it is importantnot to be overly cautious and delay operative interventionfor those patients who are believed to have appendicitis
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Treatment In the absence of contraindications, a patient who has a strongly
suggestive medical history and physical e$amination with supportivelaboratory ndings should undergo appendectomy urgently
In patients in whom the evaluation is suggestive but not convincing,imaging and further study are appropriate
Pelvic ultrasonography is indicated in women of childbearing age !" may accurately indicate the presence of appendicitis or other
intraabdominal processes Barcotics can be given to patients with severe discomfort, especially if
the rst abdominal e$amination is completed before drugs areadministered
All patients should be fully prepared for surgery and have any uid andelectrolyte abnormalities corrected
Cither laparoscopic or open appendectomy is a satisfactory choice forpatients with uncomplicated appendicitis
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+uch patients are best served by treatment with broad)spectrum antibiotics, drainage if there is an abscess . cmin diameter, and parenteral uids and bowel rest if theyappear to respond to conservative management
"he appendi$ can then be more safely removed D; 'weeks later when in ammation has diminished >aparoscopic appendectomy is associated with less
postoperative pain and, possibly, a shorter length of stayand faster return to normal activity
have fewer wound infections, although the risk ofintraabdominal abscess formation may be higher Absent complications, most patients can be discharged
within 'E;E5h of operation most common postoperative complications are fever and
leukocytosis
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Acute Peritonitis Acute peritonitis, or in ammation of the visceral and parietal
peritoneum, is most often but not always infectious in origin,resulting from perforation of a hollow viscus
"his is called secondary peritonitis, as opposed to primary orspontaneous peritonitis, when a speci c intraabdominal sourcecannot be identi ed
In either instance, the in ammation can be locali4ed or di*use Infective organisms may contaminate the peritoneal cavity after
spillage from a hollow viscus, because of a penetrating wound ofthe abdominal wall, or because of the introduction of a foreignobFect like a peritoneal dialysis catheter or port that becomesinfected
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+econdary peritonitis mostcommonly results fromperforation of the appendi$,
colonic diverticuli, or thestomach and duodenum It mayalso occur as a complication ofbowel infarction or incarceration,cancer, in ammatory boweldisease, and intestinal
obstruction or volvulus 7ver 65- of the cases of
primary or spontaneousbacterial peritonitis occur inpatients with ascites orhypoproteinemia 1G g/>2
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Aseptic peritonitis is most commonly caused by theabnormal pres)ence of physiologic uids like gastric
Fuice, bile, pancreatic en4ymes, blood, or urine "he chemical irritation caused by stomach acid and
activated pancreatic en4ymes is e$treme and secondarybacterial infection may occur
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Clinical Features "he cardinal signs and symptoms of peritonitis are acute, typically severe,
abdominal pain with tenderness and fever Clderly and immunosuppressed patients may not respond as aggressively to
the irritation 9i*use, generali4ed peritonitis is most often recogni4ed as di*use
abdominal tenderness with local guarding, rigidity, and other evidence ofparietal peritoneal irritation
owel sounds are usually absent to hypoactive &ost patients present with tachycardia and signs of volume depletion with
hypotension
>aboratory testing typically reveals a signi cant leukocytosis, and patientsmay be severely acidotic adiographic studies may show dilatation of the bowel and associated
bowel wall edema 8ree air, or other evidence of leakage, re#uires attention and could
represent a surgical emergency
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Treatment &ortality rates can be less than 5- for reasonably
healthy patients with relatively uncomplicated, locali4edperitonitis
&ortality rates E5- have been reported for the elderlyor immunocompromised
+uccessful treatment depends on correcting anyelectrolyte abnormalities, restoration of uid volumeand stabili4ation of the cardiovascular system,appropriate antibiotic therapy, and surgical correction ofany underlying abnormalities
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Intussuception ac#uired invagination of the bowel into itself, usually involving
both small and large bowel "he more pro$imal bowel that invaginates into more distal bowel
is termed the intussusceptum, whereas the recipient bowel thatcontains the intussusceptum is termed the intussuscipiens
Invagination of the bowel leads to edema, and ischemic changeseventually superveneJ thus intussusception is an urgent condition,but prolonged delay in diagnosis is not uncommon, resulting inincreased risk for patients to present with obstruction, necrosis,and bowel perforation
!lassic pediatric intussusception involves invagination of the distalileum into the colon, as ileocolic or ileoileocolic intussusceptionJhowever, intestinal intussusception may occur along the entirelength of the bowel from the duodenum to the colon
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Etiology &ost cases of ileocolic intussusception occurring in
children are idiopathic
+ome reports suggest a viral etiology, most commonlyadenovirus, but enterovirus, echovirus, and humanherpes virus D also have been implicated
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Clinical Presentation Idiopathic intussusception occurs most commonly in infants
between ' months and . years of age, with a peak at age ( to 6months
"he classic clinical presentation of the child with intussusceptionis colicky abdominal pain, vomiting, bloody stools, and a palpableabdominal mass
!hildren with intussusception should be diagnosed as early aspossible to avoid bowel ischemia, necrosis, and surgery
"he clinical signs and symptoms of intussusception are often
nonspeci c and may overlap with those of gastroenteritis,malrotation with volvulus, and in older children, Henoch)+chKnleinpurpura
Venous hypertension leads to hematoche4ia, with a typicalmi$ture of stool, blood, and blood clots described as ?currant Fellystools,@ a nding highly suggestive of intussusception
Intussuscepted bowel may prolapse through the rectum
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Diagnosis & Imaging
Treatment
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Treatment Cnema reduction should be
undertaken in children withintussusception after surgical
consultation the only absolute
contraindications to enemareduction are signs ofperitonitis on clinical
e$amination or free air onabdominal radiographs
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Intestinal 7bstruction L &alrotation
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Clinical Presentation
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Clinical Presentation Patients with obstruction may e$hibit severe pain, abdominal
distension 1unless involvement is in the pro$imal MI tract2,diaphoresis, stigmata of dehydration, and vomiting with inability totolerate oral input
may be tachycardic 1both from pain and hypovolemia2 8ever raises concerns for intestinal ischemia, perforation, and
peritonitis +mall bowel obstruction leads to abdominal distension, cramping
discomfort in the middle or upper abdomen, and repeated
episodes of bilious vomiting If there is total obstruction, patients eventually become obstipated 7n rectal e$amination, if the obstruction is high in the colon, the
rectum will be devoid of stool, but hard stool in the rectum may bepresent if the patient has fecal impaction
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Evaluation & Management
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Evaluation & Management initial evaluation in the emergency department is to determine the acuity
and severity of the childNs illness "he rst pass on physical e$amination should #uickly ac#uire information
regarding the patientNs critical features, beginning with the A !s Vital signs should be evaluated for fever 1in the setting of obstruction,
concerning for ischemia2, tachycardia, hypotension 1worrisome fordecompensated shock2, and lownormal blood pressure with widened pulsepressure 1concerning for compensated shock2
Patients with vomiting should receive nothing by mouth 1BP72 and shouldhave an intravenous 1IV2 line started for maintenance uids
If there are signs of dehydration, isotonic uid boluses are appropriateuntil the patient is hemodynamically stable
If the patient is ill appearing or has fever in the conte$t of suspectedobstruction, the physician should strongly consider initiating IV antibiotictherapy with ade#uate coverage for common gut ora 1gram)negative andanaerobic organisms2 after obtaining a blood culture
Laboratory Finding
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Laboratory Finding If the patient is ill appearing or has fever in the conte$t
of suspected obstruction, the physician should stronglyconsider initiating IV antibiotic therapy with ade#uatecoverage for common gut ora 1gram)negative andanaerobic organisms2 after obtaining a blood culture
If the patient is ill appearing and has a fever, a bloodculture should be done before administration ofantibiotics
Radiologic Test
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Radiologic Test 8luoroscopic arium water)soluble contrast agent O perforation
In patients who are medically unstable, who have ahistory of trauma, or who have a suspected perforation,the study of choice is the !" scan
I endosco!y is a useful tool for diagnosing mucosaldisorders that may not be
obvious on radiologic imaging After enough clinical information is available to
determine whether the child should go to the operatingroom, laparotomy or, at some centers, laparoscopy
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eference >ongo 9>, asper 9>, Qameson Q>, 8auci A+, Hauser +>, >oscal4o Q, editors HarrisonNs Principle of Internal &edicine 6 th
&cMraw)HillJ '5 ( "anto !, >iwang 8, Hanifati +, Pradipta CA, editors apita
+elekta edokteran Cdisi E QakartaO &edia AesculapiusJ '5 E Intussusception !hapter imberly C Applegate !a*eyRs
Pediatric 9iagnostic Imaging, !hapter 5