Selamat pagi senior, chief, dan rekan resident.
Good morning senior, chief and my fellow
Melaporkan laporan kasus IGD pada shift pagi
tanggal 17 Maret 2021, terdapat 1 kasus.
Mutmainah, P, 72 th, 1970979
Keluhan Utama : Nyeri seluruh lapang perut
RPS :
Pasien datang rujukan dari RS Aisyiyah muntilan
dengan curiga peritonitis
6 hari SMRS pasien mengeluh nyeri perut dan
perut sedikit membesar, lalu pasien
memeriksakan diri ke puskesmas dikatakan
pasien mengalami gejala sakit maag. Kemudian
pasien diberikan terapi obat.
3 hari SMRS keluhan tidak membaik, pasien
kembali datang ke puskesmas dan diberikan obat
tambahan
1 hari SMRS pasien memeriksakan diri ke praktek
dokter umum, dikatakan ada cairan didalam
perut, dan oleh keluarga pasien langsung di bawa
ke RS Aisyiyah, disana pasien dilakukan
penanganan awal dan pemeriksaan radiologi, dari
hasil radiologi abdomen 3 posisi didapatkan hasil
ileus obstruktif dengan tanda perforasi.
Lalu pasien di rujuk ke RSS untuk penanganan
lebih lanjut.
RPD: DM(-), hipertensi(-), asma(-), alergi(-),
penyakit jantung (-)
Pemeriksaan Fisik
KU lemah CM
TD 124/60 mmHg
N 118 x/mnt
RR 20 x/mnt
T 36°C
SpO2 96% dengan nasal kanul 3 lpm
Kepala: CA(+/+), SI (-/-), terpasang NGT dengan
produk hijau kehitaman
Leher: JVP tidak meningkat, lnn tidak teraba
residents reporting our activities in the
emergency room on morning shift of March 17th
2021, there was 1 case
Mutmainah, F, 72 y.o, 1970979
Chief complain:
Diffusse abdominal pain
Present illness:
Patient was referred from RS Aisyiyah Muntilan
Sleman with the chief complaint of abdominal
pain. 6 days before admitted to hospital, patient
complained of diffuse abdominal pain and.
Patient went to puskesmas and was said to have
gastritis and received some medications to
alleviate the pain. 3 days before admission, her
complaints were persistent, she went back to
puskesmas and was given some additional drugs.
1 day before admitted, her abdominal pain kept
persisting. She was not able to defecate and
flatus. She was then brought to a private doctor
and was told to be better to have treatment at
hospital. Her family then brought her to Aisyiyah
hospital at Muntilan. She had early treatment
there and abdominal x ray was performed. The
result showed hollow viscus perforation with
pneumoperitoneum. Patient was then referred to
emergency department of RSUP Dr. Sardjito for
further treatment.
Past illness:
There are no history of hypertension, DM ,allergy,
asthma, cardiac disease (-)
Physical examination
General status: weak, compos mentis
BP: 124/60 mmHg
HR: 117 x/mnt
RR: 20 x/mnt
T: 36°C
SpO2 96% with 3 lpm nasal cannule
Head: CA (+/+), SI (-/-) , NGT with black greenish
product
Thorax: Neck: JVP not distended, Lymph node unpalpable
I: simetris(+), KG(-)
P: VF kanan=kiri Thorax:
P: sonor (+/+) I: Symmetric (+)
A: ves(+/+), rh(-/-), wh(-/-) P: VF right=left
P: Sonor +/+
A: Vesicular (+ / +), crackles (-/-), wheezing (-/-)
Abdomen:
I: Distensi (+), darm contour (-), dum steifung (-) Abdomen:
A: BU(+) menurun I: Distention (+),darm contour (-), dum steifung (-)
P: timpani (+) A: Peristaltic (+) decreased
P: nyeri tekan(+) di seluruh lapang perut, defans P: Tympani (+)
muscular (+) P: Tenderness (+) in all abdominal regions,
muscular defense (+)
Ekstremitas:
Akral hangat, edema (-), CRT <2" Extremity:
Warm on palpation, CRT <2 '', edema (-)
RT : TMSA baik, mukosa licin, ampula tidak
kolaps, tidak teraba massa, NT (-), feses (+), STLD RT : TMSA within normal limit, mukosa clear,
(-) ampula not collpase, mass (-), tenderness (-),
feces (+)
Laboratorium 17/4/2021
AL 17.55 Laboratory result 17th March 2021
AE 3.88 WBC 17.55
Hb 10.4 Erythocyte 3.88
AT 242 Hb 10.4
Hmt 31.2 Platelet 242
PPT 17.7/13.7 Hmt 31.2
APTT 28.8/31.5 PPT 17.7/13.7
INR 1.41 APTT 28.8/31.5
Alb 2.17 INR 1.41
SGOT 90 Alb 2.17
SGPT 57 SGOT 90
GDS 53 SGPT 57
BUN 116.3 GDS 53
Cr 4.2 BUN 116.3
Na 135 Cr 4.2
K 3.57 Na 135
Cl 99 K 3.57
CRP Cl 99
LDH 232 CRP
HBsAg LDH 232
Anti SARs COV2 HBsAg
Swab antigen Neg Anti SARs COV2
Swab antigen Neg
Urinalisa: 17/4/2021
Glu Neg Urinalisa: 17/4/2021
Protein 1+ Glu Neg
pH 5 Protein 1+
BJ 1.015 pH 5
Nitrit 1+ BJ 1.015
Leukosit esterase 3+ Nitrit 1+
Eritrosit 568 Leukosit esterase 3+
Leu 563
Bacteria 2523.1 Eritrosit 568
Leu 563
AGD: Bacteria 2523.1
pH 7.309
PCO2 25.7 AGD:
PO2 79 pH 7.309
HCO3 12.9 PCO2 25.7
BE -13 PO2 79
sO2 95 HCO3 12.9
TCO2 14 BE -13
Lac 1.42 sO2 95
TCO2 14
Abdomen 3 posisi 17/4/2021 Lac 1.42
-Mengarah gambaran peritonitis disertai ascites
minimal Assessment:
-Terpasang gastric tube dengan ujung distal pada -General peritonitis ec susp hollow organ
proyeksi gaster perforation
-Acute Kidney Injury
-Hypoalbuminemia
Assessment
-Peritonitis umum ec susp perforasi organ Plan:
berongga Complete laboratory examination
-Acute Kidney Injury Abominal and chest x ray
-Hipoalbuminemia Fluid resuscitation 500cc RL
Inj. Ceftriaxone 1gr
Plan: Inj. Metronidazole 500mg
Cek lab lengkap Inj. Ranitidin 50mg
Ro abdomen 3 posisi Inj. Paracetamol 1gr
Ro Thorax PA Pr0 Laparotomi eksplorasi s/d stoma CITO
Resusitasi cairan 500cc RL
Inj. Ceftriaxone 1gr
Inj. Metronidazole 500mg
Inj. Ranitidin 50mg
Inj. Paracetamol 1gr
Pro Laparotomi eksplorasi s/d stoma CITO
ABDOMINAL X RAY
Cause of spontaneous colonic perforation

The cause of spontaneous colonic perforation is usually unclear. In general,

colonic perforation caused by feces is the most frequent occurrence. The disease
has often been seen in patients with chronic constipation. The solid feculent mass
compresses the colonic wall, diminishes the blood supply and leads to ischemia
and necrosis of colonic mucosa, which forms marked feculent ulcer changes. The
ulcer might lead to colonic rupture in some case. Maurer et al have proposed the
diagnostic criteria of feculent colonic perforation: (1) Rounded shape, more than
1 cm in diameter; (2) The colon is full of stool, which diffuses to the abdominal
cavity through the perforation; (3) Ischemia and necrosis of colonic mucosa
leading to feculent ulcer and acute inflammatory reaction surrounding the
perforation site can be seen at microscopical examination; (4) External injury or
other diseases such as obstruction, tumors and diverticulosis must be excluded.
Maurer et al also proposed that the feculent ulcer may present at multiple sites.
The proportion of cases with multiple ulcers in the same colonic segment is about
28%. Another cause is idiopathic colonic perforation. The pressure within the
colonic lumen increases and distributes asymmetrically, leading to an excess
pressure increase at the level of the angle. The colonic wall is hyperdilated,
becomes excessively thin and the perforation occurs. Compared to feculent
perforation, idiopathic colonic perforation has the following features: (1) The
perforation is linear; (2) Feculent ulcer cannot be seen at microscopic
examination. The mucosal edge is clear and does not extend to the serosa. The
broken ends of the muscular layer are regular. Although these two conditions are
different both macroscopically and microscopically, they are occasionally difficult
to distinguish at surgery. Surgical pathological examination is necessary to make a
definite diagnosis.

Most frequent sites of spontaneous colonic perforation

The most frequent location is opposite to the mesenteric edge of the sigmoid
colon and recto-sigmoid colon. Maurer et al reported that 52 out of 81 cases
(64%) of feculent perforation occurred at the above sites. In the study of Kasahara
et al, 68% (44/65) of idiopathic colonic perforation were located at those sites.
This phenomenon may be due to the special physiological and anatomical
features of sigmoid colon. There is no ramus anastomoticus between the lowest
branch of sigmoid arteries and the superior rectal artery, which causes a
physiological ischemia. When some stiff stool goes through sigmoid colon, the
colonic wall is compressed and leads to the hindrance of blood supply. The blood
supply to the opposite side of the mesentery is poor. The stool is more likely to
stay in the rectosigmoid colon because of the confined colonic cavity. The smooth
muscle contracts, which leads to the increase of the pressure of colonic cavity.
This disease is more frequent in the elderly and the mean age at onset is more
than 60. About 61% to 81% of patients had constipation history. It is often
misdiagnosed because doctors are unaware about this disease. Only 10% of
patients are definitely diagnosed prior to surgery. It is very important to increase
the awareness about this disease in order to improve the accuracy of diagnosis.
The possibility of this disease should be taken into consideration in elderly
patients who have chronic constipation, when they have a history of induction of
increased intra-abdominal pressure, present with sudden abdominal pain
spreading to the whole abdomen and have peritoneal irritation signs.
Surgical treatment of spontaneous colonic perforation

The mortality rate of this disease is as high as 35% to 47%. In case of perforation,
innumerable bacteria spread from the colon into the abdominal cavity and cause
acute diffuse peritonitis. Bacterial toxins are absorbed and lead to infectious
shock and then multiple organ failure. So, patients should undergo surgery as
soon as the disease is definitely diagnosed. The types of surgery are different
depending on the time of onset, degree of peritonitis, general physical condition
and lesion of the colon. The following types of surgery are common: neoplasty,
colostomy, neoplasty plus proximal colostomy, Hartmann surgery. Neoplasty plus
proximal colostomy is the most popular since it is safe and time-sparing. Serpell et
al found that the mortality and complication rates after Hartmann surgery were
lower than in case of other operations because Hartmann surgery dissects the
affected colon. Maurer et al proposed that feculent ulcer had multiple origins
and, therefore, other segments of the colon should be explored during the
operation. If the colonic wall is dilated or thinner, it should be resected. Subtotal
colectomy may be essential for some cases, which can spare time-consuming
coloclysis during the operation and avoid possible later re-perforation of the
affected colon. Spontaneous colonic perforation is noteworthy due to its high
mortality rate. The possibility of this disease should be taken into consideration in
elderly patients having chronic constipation and bed-ridden for long periods of
time.