PLENARY 4 GASTROINTESTINAL

BLOCK
GROUP 16
 Group 16 Tutor : dr. Chrismerry Song, M.Biomed

Leader : Vamelda Agustin / 405140014

Writer : Michael Chen / 405140150
Secretary : Deti Tiffani / 405140156
Members :
• Winsen H. / 405120122
• Tommy Widjaja / 405140029
• Priesca Pricilia Nathasya / 405140073
• Metta Andriliana Tantra / 405140093
• Stefanus Evan / 405140104
• Siti Nur Rokhmah Firda F. / 405140134
• Nadya Arini Puspasari / 405140225
• Josephine Angelia S. / 405140233
• Feras Zaki Azzubaidi / 405140248
 Problem 4
A 45-year-old man presented with a three-day history of right sided non-colicky
abdominal pain radiating to the back, fever, rigor, vomiting and feeling bloated.
He had previous history of kidney stone. His past surgical history includes
abdominal surgery at the age of six months due to rectal bleeding. He drinks
alcohol in moderate amounts regularly and denies taking any medications.

Physical examinations: pulse 120 bpm, temperature 38,5°C, respiratory rate

38x/minute. Palpation of the abdomen revealed a tender 15x10 cm swelling in
the right lumbar region extending to the right lower abdomen.

Laboratory results: leucocytes 21.000/μL (normal: 5.000-10.000/μL), potassium

level 2,3 mEq/dL (normal: 3,5-5,5 mEq/dL), C-reactive protein (CRP) of 200 mg/L.

What can you learn from the problem?

 Unfamiliar Terms
• Non-colicky : continous abdominal pain
• Rigor : a sudden feeling of cold with shivering accompanied by a
rise in temperature, often with copious sweating, especially at the
onset or height of a fever
 Define the Problems
1. Bagaimana interpretasi hasil pemeriksaan fisik dan lab?
2. Adakah hubungan operasi abdominal usia 6 bulan dengan keluhan
sekarang?
3. Adakah hubungan minum alkohol dan tidak dalam pengobatan
dengan keluhan sekarang?
4. Adakah hubungan batu ginjal dengan keluhan sekarang?
5. Apa yang menyebabkan pasien non kolik di perut sebelah kanan
dan meluas ke punggung?
6. Pemeriksaan penunjang apa yang tepat untuk dilakukan
berdasarkan keluhan pasien?
 Brainstorm Possible Hypothesis of
Explanation
1. Interpretasi hasil: takikardi, demam febris, takipneu, leukositosis,
hipokalemia, crp tinggi. Kalau bengkak bisa dikarenakan divertikulitis,
obstruksi ileus, hernia inguinal
2. Alkohol diserap lambung -> dibawa ke hati oleh vena porta -> sirosis
hati -> terasa nyeri di perut sebelah kanan
3. Intususepsi -> menyingkirkan DD
4. batu ukurannya besar -> nyangkut di ureter -> nyeri
5. Yang menyebabkan sakit non kolik di perut kanan meluas ke punggung
-> sakit abdomen kanan atas : Kolesistitis, pankreatitis, pneumonia,
hepatitis; sakit abdomen kanan bawah : Apendisitis, Salpingitis, Hernia
Inguinalis, Kehamilan Ektopik, Inflammatory bowel disease.
6. Ct-scan, foto abdomen
45-year-old man
Symptoms : Review
• three-day history of right sided non-colicky abdominal pain radiating to the back
• fever
• rigor
• Vomiting
• feeling bloated

Examination :
takikardi, demam febris,
takipneu, leukositosis,
hipokalemia, crp tinggi.

past surgical history

includes abdominal
surgery at age 6 months Appendicitis
due to rectal bleeding ileus obstruction
Colitis
Ascariasis
inguinal hernia
intussusception
 Learning Objectives :
1. Mm appendicitis
2. Mm ileus obstruction Definition, classicification,
epidemiology, etiology,
3. Mm colitis pathophysiology, sign and
symptoms.investigations,
4. Mm ascariasis diagnosis, therapeutic
management, complication
5. Mm intussusception and prognosis, prevention and
health education
6. Mm inguinal hernia
Learning Objective 1

MM APPENDICITIS
(DEFINITION, CLASSICIFICATION, EPIDEMIOLOGY, ETIOLOGY,
PATHOPHYSIOLOGY, SIGN AND SYMPTOMS.INVESTIGATIONS,
DIAGNOSIS, THERAPEUTIC MANAGEMENT, COMPLICATION AND
PROGNOSIS, PREVENTION AND HEALTH EDUCATION)
 APPENDICITIS
• an inflammation of the inner lining of the vermiform appendix that
spreads to its other parts.
• one of the most common causes of acute abdominal pain.

Epidemiology
• occurs more frequently in Westernized societies
• Acute appendicitis remains the most common emergency general
surgical disease affecting the abdomen
• occurs most commonly in 10-19 years old, male to female ratio is 1:1
• Overall ,70% of patients are < 30 years old and most are men
• One of the more common complications and most important causes of
excess morbidity and mortality is perforation
 Etiology
• Appendicitis is a very common cause of emergency surgery.
• The problem most often occurs when the appendix becomes
blocked by feces, a foreign object, or rarely, a tumor.

Risk Factors
• Most cases occur between the ages of 10 and 30 years.
• family history of appendicitis may increase a child's risk
• Having cystic fibrosis also seems to put a child at higher risk.
 Pathophysiology

http://medchrome.com/major/surgery/acute-appendicitis-easy/
 General Clinical Manifestation
• Abdominal discomfort
 • Nausea and vomiting
• Fever
• in infants
– < 2 years old have 70-80% incidence with perforation and
generalized peritonitis, Vomiting, abdominal pain, fever
• In elderly individuals
– pain and tenderness often blunted
– delay diagnosis, 30% incidence of perforation
• In pregnancy
– the most common during the third trimester

Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, et al. Harrison’s Principles of Internal
Medicine. 18th Edition.
 Physical Examination
• Bowel sound ↓
• Blumberg sign and McBurney +
• Rovsing sign +
• Obturator sign +
• Psoas sign +
• Dunphy sign +
Lab Diagnosis
• Complete Blood Count
- WBC > 10.500 sel / uL
- Ht >>
• Urinalysis
 Diagnostic Scoring
MANTRELS score

• score of 3 had a 3.6%

incidence of appendicitis
• patients with scores of 4-
6 had a 32% incidence of
appendicitis
• patients with scores of 7-
10 had a 78% incidence
of appendicitis
 Radiograph
• Radiographs are rarely of value except when an opaque fecalith (5%
of patients) is observed in the right lower quadrant (especially in
children)  abdominal films are not routinely obtained unless
other conditions such as intestinal obstruction or ureteral calculus
may be present
• Ultrasonic demonstration of an enlarged and thick-walled appendix
– Ultrasound is most useful to exclude ovarian cysts, ectopic pregnancy,
or tuboovarian abscess
• Several studies have recently demonstrated the benefit of contrast-
enhanced or nonenhanced CT over ultrasound and plain
radiographs in the diagnosis of acute appendicitis.
– The findings on CT will include a thickened appendix with
periappendiceal stranding & often the presence of a fecalith
Differential Diagnosis
 Treatment
• open or laparoscopic appendectomy; treatment delay increases mortality.
• A contraindication to appendectomy : IBD involving the cecum. caecum
is normal, the appendix should be removed.
• IV antibiotics during appendectomy (Gen 3 Cephalosporins)
– nonperforated appendicitis : no further antibiotics are required.
– perforated appendicitis : antibiotics should be continued until the
patient's temperature and WBC count have normalized or continued
for a fixed course.
3 treatment categories:
• Phlegmon or a small abscess
• Larger well-defined abscess
• Multicompartmental abscess
 Complication

Prognosis
• Without surgery or antibiotics, mortality is > 50%.
• With early surgery, the mortality rate is < 1%, and recovery time is
normally rapid and complete.
• With complications (rupture and development of an abscess or
peritonitis), the prognosis is worse.
Learning Objective 2

MM ILEUS OBSTRUCTION
(DEFINITION, CLASSICIFICATION, EPIDEMIOLOGY, ETIOLOGY,
PATHOPHYSIOLOGY, SIGN AND SYMPTOMS.INVESTIGATIONS,
DIAGNOSIS, THERAPEUTIC MANAGEMENT, COMPLICATION AND
PROGNOSIS, PREVENTION AND HEALTH EDUCATION)
 INTESTINAL OBSTRUCTION (ILEUS)
• In 75% of patients, acute intestinal obstruction results from
previous abdominal surgery secondary to adhesive bands or
internal or external hernias.
• Other causes include lesions intrinsic to the wall of the intestine,
e.g., diverticulitis, carcinoma, regional enteritis; and luminal
obstruction, e.g., gallstone obstruction, intussusception.
 Etiology

Harrison’s Principle of Internal Medicine p.1982

 Pathophysiology
• Distention of the intestine is caused by the accumulation of gas and fluid
proximal to and within the obstructed segment.
• Between 70 and 80% of intestinal gas consists of swallowed air, and because
this is composed mainly of nitrogen, poorly absorbed from the intestinal
lumen
• The accumulation of fluid proximal to the obstructing mechanism results
from, ingested fluid, swallowed saliva, gastric juice biliary and pancreatic
secretions and from interference with normal sodium and water transport.
• During the first 12–24 h of obstruction, a marked depression of flux from
lumen to blood occurs of sodium and consequently water in the distended
proximal intestine.
• After 24 h, sodium and water move into the lumen, contributing further to
the distention and fluid losses.  Intraluminal pressure rises from a normal
of 2–4 cmH2O to 8–10 cmH2O.
 Classification
• There are 2 types of obstruction :
• 1. Paralytic ileus
• 2. Mechanical ileus :
• -Low mechanical ileus
• -High mechanical ileus:
• - Obstruction above the pylorus
• - Obstruction under the pylorus
 Symptoms
• cramping midabdominal pain  occurs in paroxysms, relatively comfortable in
the intervals between the pains  less severe as distention progresses
• Audible borborygmi
• Strangulation: localized, steady and severe non-colicky.
• Vomiting :
– contains bile and mucus and remains obstruction is high in the intestine.
– low ileal obstruction  becomes feculent, i.e., orange-brown in color with a
foul odor, which results from the overgrowth of bacteria proximal to the
obstruction.
• Hiccups (singultus) are common.
• Obstipation and failure to pass gas by rectum complete obstruction
• Diarrhea  partial obstruction.
• Blood in the stool  rare, intussusception.
 Physical Findings
• Abdominal distention
• early obstruction : tenderness and rigidity are usually minimal; the
temperature is rarely >37.8°C (100°F).
• shock, tenderness, rigidity, and fever  contamination of the
peritoneum with infected intestinal
• Hernial orifices should always be carefully examined for the
presence of a mass.
• Auscultation: loud, highpitched borborygmi coincident with colicky
pain or a quiet abdomen
• The presence of a palpable abdominal mass  closed-loop
strangulating small-bowel obstruction; the tense fluidfilled loop is
the palpable lesion.
 Laboratory and Radiographic

• Blood test : leukocytosis

• Serum amylase level
• X-ray :
– distention of fluid and gas-filled loops of small intestine  a
“stepladder” pattern with air-fluid levels and an absence or
paucity of colonic gas  small-bowel obstruction.
– passage of gas or stool per rectum has ceased and gas is absent
in the distal intestine  complete obstruction
– “coffee bean”–shaped mass  strangulating closed loop
obstruction.
– A thin barium upper gastrointestinal series may help to
differentiate partial from complete obstruction
 Treatment
• Surgical  laparoscopic techniques
• fluid and electrolyte balance restored and decompression 
nasogastric tube.
• Replacement of potassium is especially important because intake is
nil and losses in vomitus are large.

Prognosis
• The overall mortality rate for obstruction of the small intestine is
about 10%.
• While the mortality rate for nonstrangulating obstruction is 5–8%,
the mortality rate for a strangulating obstruction ranges from 20 to
75%.
Learning Objective 3

MM COLITIS
(DEFINITION, CLASSICIFICATION, EPIDEMIOLOGY, ETIOLOGY,
PATHOPHYSIOLOGY, SIGN AND SYMPTOMS.INVESTIGATIONS,
DIAGNOSIS, THERAPEUTIC MANAGEMENT, COMPLICATION AND
PROGNOSIS, PREVENTION AND HEALTH EDUCATION)
 COLITIS
• The term colitis refers to inflammation of the colon.
• It may be associated with enteritis (inflammation of the small
intestine), proctitis (inflammation of the rectum) or both.
• Inflammatory bowel disease (IBD) is a generic term used to describe
3 idiopathic disorders that are associated with gastrointestinal
inflammation :
– Crohn disease (CD).
– Ulcerative colitis (UC).
– Indeterminate colitis.

http://emedicine.medscape.com/article/927845-overview
 Etiology
• Necrotizing enterocolitis (NEC).
• Allergic colitis.
• Pseudomembranous colitis.
• Infectious colitis (bacterial, parasitic, or viral).
• Ischemic colitis.
• Colitis secondary to immune deficiency disorders.

http://emedicine.medscape.com/article/927845-overview
 Pathophysiology
• NEC :
– Common cause of colitis in newborn.
– Appears to involve an inappropriate inflammatory response in an
immature intestine.
– Final common pathway : the endogenous production of
inflammatory mediators such as endotoxin lipopolysaccharide,
platelet-activating factor, tumor necrosis factor and other cytokines,
decreased epidermal growth factor and progressive mucosal
damage by free radical production.
– NEC presents with the gas accumulation in the submucosa of the
bowel wall and progresses to necrosis leading to perforation of the
bowel, peritonitis, and sepsis.
– Histological changes in NEC include mucosal edema, hemorrhage,
coagulation necrosis, and mucosal ulceration.
http://emedicine.medscape.com/article/927845-overview#a3
• Allergic Colitis :
– In children aged 2 weeks to 1 year  most common, results from
hypersensitivity commonly to cow’s milk and soy milk.
• Pseudomembranous colitis :
– Is a form of inflammatory colitis characterized by the pathologic
presence of pseudomembranes consisting of mucin, fibrin, necrotic
cells and polymorphonuclear leukocytes (PMNs).
• Parasitic colitis :
– Entamoeba histolytica is the most common cause of parasitic colitis in
the world.
– Transmission takes place through ingestion of trophozoites (usually
from water contamination) and person to person transmission
(typically because of poor sanitation).

http://emedicine.medscape.com/article/927845-overview#a3
• Viral colitis
– caused by cytomegalovirus (CMV) infection is a rare form that
typically is found in immunocompromised patients (eg, organ
recipients who are receiving immunosuppressive treatment).
• It results in deep round ulcerations that have a tendency to bleed
easily and profusely.
– Adenovirus infection can also cause a severe colitis in
immunocompromised patients, especially those with AIDS, although
patients with solid organ and bone marrow transplants are also at risk
• Ischemic Colitis
– Ischemic colitis is a form of vasculitis that results from inflammation
and ischemia of colonic mucosa, which causes rectal bleeding and
abdominal pain.
 Physical Examination
• NEC: abdominal distention, tenderness, and guarding. Hypotension,
tachycardia, tachypnea, hypoxia, shock, disseminated intravascular
coagulation (DIC), and cardiopulmonary arrest may be noted. The
stool may have frank blood or may be heme-guaiac positive.
• Allergic colitis : blood and mucus in the stool. Children are usually
well-appearing; however, in rare cases, in patients with allergic
enterocolitis, the colitis is severe, and the children may become
anemic and present with failure to thrive
• Pseudomembranous colitis : diarrhea with frank blood or a guaiac-
positive stool. An abdominal examination may elicit tenderness.
Signs of perforation, peritonitis, and toxic megacolon may be
present and may require an emergent colectomy.
• IBD : pallor, tachycardia, abdominal tenderness, and blood in the
stool. An elevated temperature, weight loss, and dehydration may
be noted. The presence of abdominal distention with decreased or
absent bowel sounds is indicative of actual or impending
obstruction or perforation. Rarely, CD causes intestinal obstruction.
• Amebiasis : temperature elevation, hematochezia, abdominal
tenderness, or complications such as liver abscess, colonic
perforation, and peritonitis.
• HSP : a purpuric symmetric rash, commonly over the legs, buttocks,
and arms. Asymptomatic microhematuria occurs in 80% of affected
patients. The child may have hypertension, proteinuria, and
hematochezia. Joint swelling may be present.
 Treatment
• NEC :
– cessation of feedings, nasogastric decompression, and intravenous (IV)
fluid resuscitation with attention to electrolytes and acid-base balance.
– Antibiotics, Close monitoring with cardiorespiratory support
– Surgical therapy
• pseudomembranous colitis :
– Mild cases: antibiotics and supportive therapy with fluids and
electrolytes.
– severe or persistent antibiotic-associated colitis for C difficile toxin in
the stool.
– with oral metronidazole (30 mg/kg/day in 4 divided doses) or oral
vancomycin (40 mg/kg/day in 4 divided doses).
• Bacterial colitis : Antimicrobial therapy  Trimethoprim-
sulfamethoxazole (TMP-SMZ) is the initial drug of choice;
fluoroquinolones and ceftriaxone are the alternatives.
• amebic colitis : metronidazole and iodoquinol or paromomycin.
• IBD  6 categories, as follows:
– Aminosalicylates (eg, sulfasalazine and mesalamine)
– Corticosteroids (eg, prednisone and budesonide)
– Immunomodulators (eg, azathioprine, 6-mercaptopurine [6-MP])
– Antibiotics (eg, metronidazole and ciprofloxacin)
– Probiotics (eg, Lactobacillus GG and Saccharomyces boulardii)
– Biologic agents (eg, infliximab)
 Differential Diagnosis
• Amebiasis
• Appendicitis
• Chronic Anemia
• Growth Failure
• Pediatric Malabsorption Syndromes
• Protein-Losing Enteropathy
• Ulcerative Colitis Imaging
• Yersinia Enterocolitica Infection
 Complications
• toxic megacolon
• colon cancer
• bowel strictures, fistulas, abscess, and intestinal obstruction.
• short bowel syndrome and malabsorption.
• Hemolytic uremic syndrome (HUS)
Learning Objective 4

MM ASCARIASIS
(DEFINITION, CLASSICIFICATION, EPIDEMIOLOGY, ETIOLOGY,
PATHOPHYSIOLOGY, SIGN AND SYMPTOMS.INVESTIGATIONS,
DIAGNOSIS, THERAPEUTIC MANAGEMENT, COMPLICATION AND
PROGNOSIS, PREVENTION AND HEALTH EDUCATION)
 ASCARIASIS
• Ascariasis, also known as roundworm, is an intestinal infection
caused by the parasitic worm Ascaris lumbricoides, and is part of a
family of parasites known as the soil- transmitted helminths.
• Ascaris lumbricoides is a nematode (roundworm) which inhabits
the intestines of humans. It measures 13-35 cm in length and may
live in the gut for 6-24 months
• HD : human
• Humidity
• Temperature
 Epidemiology
• Ascariasis -> most commonly found in warm tropical and sub-
tropical climates (Sub-Saharan Africa and Southeast Asia)
• Often found in developing areas of the world where poor or
substandard sanitation, crowded living conditions and poverty
persist
• More than 807 million people are infected with ascariasis
worldwide, and more than 60,000 die from the disease annually.
• Ascariasis is the most common human worm infection.
 Risk Factors
• Warm tropical or sub-tropical climates
• Rural or overcrowded living areas with poor
• sanitation
• Farming practices utilizing improperly treated
• wastewater or human feces as fertilizer
• Young children ages 3 – 8 years

Harrison’s Principle of Internal Medicine p.1414

 Clinical Features
• During the lung phase of larval migration (9 – 12 days after egg
ingestion), patients may develop a irritating nonproductive cough
and burning substernal discomfort that is aggravated by coughing
or deep inspiration, dyspnea and blood-tinged sputum (less
common), fever, eosinophilia (subsides slowly over weeks).
• In established infections, adult worms in the small intestine usually
cause no symptoms.
• In heavy infections, particularly in children, a large bolus of
entangled worms can cause pain and small-bowel obstruction,
sometimes complicated by perforation, intussusception or volvulus.
• Migration of an adult worm up the esophagus can provoke
coughing and oral expulsion of the worm.
Larva stage
• cause mild symptoms in the liver and the lungs will cause Loeffler's
syndrome. Loeffler's syndrome is a collection of signs such as fever,
shortness of breath, eosinofilia, and the thoracic X-ray images to be
visible infiltrates disappeared for 3 weeks.
• serious effects -> worm clot -> bowel obstruction (ileus)
• In certain circumstances wander into adult worms:
– bile duct
– Appendix
– bronchus
• In the adult stage
• the intestinal worm will cause the typical gastrointestinal symptoms
such as no appetite, vomiting, diarrhea, constipation, and nausea.
• When the worm into the biliary tract can cause colicky eat or
jaundice.
• When the worms mature and go through the peritoneum or
abdominal body it can cause acute abdomen
 Laboratory Findings
• Can be diagnosed by microscopic detection of characteristic Ascaris
eggs in fecal samples.
• Occasionally, patients present after passing an adult worm
identifiable by its large size and smooth cream-colored surface in
the stool.
• During the early transpulmonary migratory phase, when
eosinophilic pneumonitis occurs, larvae can be found in sputum or
gastric aspirates before diagnostic eggs appear in the stool.
• A plain abdominal film may reveal masses of worms in gas filled
loops of bowel in patients with intestinal obstruction.
 Treatment
• Ascariasis should always be treated to prevent potentially serious
complications.
• Effective :
– Albendazole (400 mg once).
– Mebendazole (100 g twice daily for 3 days or 500 mg once).
– Ivermectin (150 – 200 μg/kg once).
• Contraindicated in pregnancy.
• Partial intestinal obstruction should be managed with nasogastric
suction, IV fluid administration and instillation of piperazine through
the nasogastric tube.
• Complete obstruction and its severe complications require
immediate surgical intervention.
• Piperazine citrate
– 150 mg/kg PO initially, followed by 6 doses of 65 mg/kg at 12 hr
intervals PO  causes neuromuscular paralysis of the parasite
(the treatment of choice for intestinal or biliary obstruction)
• Pyrantel pamoate
– 11 mg/kg PO once, maximum 1 g
• Nitazoxanide
– 100 mg bid PO for 3 days for children 1-3 yrs of age,
– 200 mg bid PO for 3 days for children 4-11 yr
– 500 mg bid PO for 3 days for adolescents and adults produces cure
rates comparable with single-dose albendazole.
• Surgery may be required for cases with severe obstruction
 Complications

Prognosis
• good prognosis, it can heal itself within 1.5 years.
• With treatment, the cure rate is 70-99%
 Prevention
• Avoid eating foods prepared without adequate sanitation
or hygiene.
• Avoid water and other beverages obtained from
contaminated source.
• Avoid contact with soil that may be contaminated with
human feces.
• Wash vegetables cleanly before eating.
• Wash hands after using the restroom .
 Ascariasis Ball
Definition • Ascariasis can cause serious intra-abdominal complications such as
intestinal obstruction at the terminal ileum although large numbers
of worms may exist in the jejunum
Etiology Ascaris lumbricoides

http://www.journalagent.com/travma/pdfs/UTD_15_3_301_305.pdf
http://www.nejm.org/doi/full/10.1056/NEJMicm1205279#t=article
 Pathogenesis Intestinal obstruction may be attributed to:
1)Multiple worms  mechanical obstruction of the lumen of the small bowel
2)Ascaris secretion neurotoxin  inhabit the ileocecal valve  prompts small-
bowel contraction
Sign and • Colicky abdominal pain
symptoms • Distended abdomen
• loss of appetite
• Constipation
Physical • Present early: low grade or no fever, slight abdominal distension, and mild
examination diffuse tenderness
• Present late: look seriously ill and dehydrated, and high fever

http://www.medscape.com/viewarticle/451597_3
http://www.antimicrobe.org/new/b17.asp
http://www.journalagent.com/travma/pdfs/UTD_15_3_301_305.pdf
 Diagnosis • Identifying Ascaris eggs in a stool sample
• X-ray  multiple fluid air levels
• Ultrasound
Treatment • Enterotomy
• No more obstruction  antihelminthic drug  eradicate any worms that
might have been in the larva phase

http://www.journalagent.com/travma/pdfs/UTD_15_3_301_305.pdf
http://ijri.org/temp/IndianJRadiolImaging151107-4228046_114440.pdf
Learning Objective 5

MM INTUSSUSCEPTION
(DEFINITION, CLASSICIFICATION, EPIDEMIOLOGY, ETIOLOGY,
PATHOPHYSIOLOGY, SIGN AND SYMPTOMS.INVESTIGATIONS,
DIAGNOSIS, THERAPEUTIC MANAGEMENT, COMPLICATION AND
PROGNOSIS, PREVENTION AND HEALTH EDUCATION)
 INTUSSUSCEPTION
• Intussusception is a serious condition in which part of the intestine
slides into an adjacent part of the intestine. This "telescoping" often
blocks food or fluid from passing through. Intussusception also cuts
off the blood supply to the part of the intestine that's affected,
which can lead to a tear in the bowel (perforation), infection and
death of bowel tissue.
• Intussusception is the most common cause of intestinal obstruction
in children younger than 3. The cause of most cases of
intussusception in children is unknown.
• If left untreated, however, this condition is uniformly fatal in 2-5
days.
 Risk Factors
• Age. Children especially young children are much more likely to
develop intussusception than adults are. It's the most common
cause of bowel obstruction in children between the ages of 6
months and 3 years.
• Sex. Intussusception more often affects boys.
• Abnormal intestinal formation at birth. Intestinal malrotation is a
condition in which the intestine doesn't develop or rotate correctly,
and it increases the risk for intussusception.
• A prior history of intussusception. Once you've had
intussusception, you're at increased risk of developing it again.
• A family history. Siblings of someone who's had an intussusception
are at a much higher risk of the disorder.
 Epidemiology
• Overall, the male-to-female ratio is approximately 3:1. With
advancing age, gender difference becomes marked; in patients
older than 4 years, the male-to-female ratio is 8:1.

• Two thirds of children with intussusception are younger than 1

year; most commonly, intussusception occurs in infants aged 5-10
months. Intussusception is the most common cause of intestinal
obstruction in patients aged 5 months to 3 years.
 Etiology
• Idopathic ( most common in children)
• Neoplasm
• Postoperative ( more common in small bowel)
• Meckel diverticulum
• Colitis

Classification
• Intussusception presents in 2 variants:
– idiopathic intussusception, which usually starts at the ileocolic
junction and affects infants and toddlers
– enteroenteral intussusception (jejunojejunal, jejunoileal, ileoileal),
which occurs in older children.
 Pathophysiology
• The pathogenesis of idiopathic intussusception is not well
established. It is believed to be secondary to an imbalance in the
longitudinal forces along the intestinal wall.
• In enteroenteral intussusception, this imbalance can be caused by a
mass acting as a lead point or by a disorganized pattern of peristalsis
(eg, an ileus in the postoperative period).
• As a result of imbalance in the forces of the intestinal wall, an area of
the intestine invaginates into the lumen of adjacent bowel. The
invaginating portion of the intestine (ie, the intussusceptum)
completely “telescopes” into the receiving portion of the intestine
(ie, the intussuscipiens). This process continues and more proximal
areas follow, allowing the intussusceptum to proceed along the
lumen of the intussuscipiens.

http://emedicine.medscape.com/article/930708-overview#showall
 Sign and Symptoms
• Stool mixed with blood and mucus (sometimes referred to as
"currant jelly" stool because of its appearance)
• Vomiting
• A lump in the abdomen
• Lethargy
• Diarrhea
• Fever
 Diagnosis
• USG, X-ray or (CT) scan
– Imaging will typically show a "bull's-eye,"
representing the intestine coiled within the
intestine. Abdominal imaging also can show
if the intestine has been torn (perforated).
• Air or barium enema.
– basically enhanced imaging of the colon.
– In addition, an air or barium enema can
actually fix intussusception 90% of the time
in children, and no further treatment is
needed.
– A barium enema can't be used if the
intestine is torn.
 Treatment
• A barium or air enema. This is both a diagnostic procedure and a
treatment. If an enema works, further treatment is usually not necessary.
This treatment is highly effective in children, but rarely used in adults.
• Intussusception recurs as often as 10 percent of the time and the
treatment will have to be repeated.
• Surgery. If the intestine is torn, if an enema is unsuccessful in correcting
the

• or if a lead point is the cause, surgery is necessary. The surgeon will free
the portion of the intestine that is trapped, clear the obstruction and, if
necessary, remove any of the intestinal tissue that has died. Surgery is the
main treatment for adults and for people who are acutely ill.
 Complications
• Complications associated with intussusception, which rarely occur when
the diagnosis is prompt, include the following:
– Perforation during nonoperative reduction
– Wound infection
– Internal hernias and adhesions causing intestinal obstruction
– Sepsis from undetected peritonitis (major complication from a missed
diagnosis)
– Intestinal hemorrhage
– Necrosis and bowel perforation
– Recurrence
• With early diagnosis, appropriate fluid resuscitation, and therapy, the
mortality rate from intussusception in children is less than 1%. If left
untreated, this condition is uniformly fatal in 2-5 days.

http://emedicine.medscape.com/article/930708-overview#showall
 Differential Diagnosis
• Abdominal hernia.
• Appendicitis.
• Colic.
• Gastric volvulus.

Prognosis
• prognosis in patients with intussusception is excellent if the
condition is diagnosed and treated early, otherwise, severe
complications and death may occur.
• The recurrence rate of intussusception after nonoperative reduction
is usually less than 10%.

http://emedicine.medscape.com/article/930708-differential
Learning Objective 6

MM INGUINAL HERNIA
(DEFINITION, CLASSICIFICATION, EPIDEMIOLOGY, ETIOLOGY,
PATHOPHYSIOLOGY, SIGN AND SYMPTOMS.INVESTIGATIONS,
DIAGNOSIS, THERAPEUTIC MANAGEMENT, COMPLICATION AND
PROGNOSIS, PREVENTION AND HEALTH EDUCATION)
 INGUINAL HERNIA
• An inguinal hernia happens when contents of the abdomen—usually fat
or part of the small intestine—bulge through a weak area in the lower
abdominal wall. The bulge can be painful, especially when you cough,
bend over or lift a heavy object.
• The abdomen is the area between the chest and the hips. The area of the
lower abdominal wall is also called the inguinal or groin region.

• Two types of inguinal hernias:

– indirect inguinal hernias : caused by a defect in the abdominal wall
that is congenital, or present at birth
– direct inguinal hernias : usually occur only in male adults and are
caused by a weakness in the muscles of the abdominal wall that
develops over time

https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/inguinal-hernia/Pages/facts.aspx
 Epidemiology
• Males > females. (25%:2%)
• one side will have or will develop a hernia on the other side.
• any age
• Indirect hernias age 1 - <30; however, they may appear later in life.
• Indirect hernias  the most common type of inguinal hernia, 2-3%of
male children; less common in female children, occurring in <1%.
• Premature infants = higher chance  indirect inguinal hernia.
• Direct hernias  only occur in male adults, > age 40  muscles of
the abdominal wall weaken with age.
• People with a family history of inguinal hernias
• Smoke  increased risk

https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/inguinal-hernia/
Pages/facts.aspx
 Etiology
• Some inguinal hernias have no apparent cause. Others might occur
as a result of:
• Increased pressure within the abdomen
• A pre-existing weak spot in the abdominal wall
• A combination of increased pressure within the abdomen and a
pre-existing weak spot in the abdominal wall
• Straining during bowel movements or urination
• Strenuous activity
• Pregnancy
• Chronic coughing or sneezing
 Risk Factors
• Being male. Men are 8x more likely to develop an inguinal hernia
• Being older. Muscles weaken as you age.
• Being white.
• Family history. You have a close relative, such as a parent or sibling, who
has the condition.
• Chronic cough, such as from smoking.
• Chronic constipation : causes straining during bowel movements.
• Pregnancy. can weaken the abdominal muscles and cause increased
pressure inside your abdomen.
• Premature birth and low birth weight.
• Previous inguinal hernia or hernia repair. Even if your previous hernia
occurred in childhood, you're at higher risk of developing another inguinal
hernia.
 Pathophysiology
• Indirect inguinal hernias :
– A defect in the abdominal wall that is present at birth causes an indirect
inguinal hernia.
– During the development of the fetus in the womb, the lining of the
abdominal cavity forms and extends into the inguinal canal.
• In males, the spermatic cord and testicles descend out from inside the abdomen and
through the abdominal lining to the scrotum through the inguinal canal. Next, the
abdominal lining usually closes off the entrance to the inguinal canal a few weeks before
or after birth.
• In females, the ovaries do not descend out from inside the abdomen, and the abdominal
lining usually closes a couple of months before birth.
– Sometimes the lining of the abdomen does not close as it should, leaving
an opening in the abdominal wall at the upper part of the inguinal canal.
Fat or part of the small intestine may slide into the inguinal canal through
this opening, causing a hernia. In females, the ovaries may also slide into
the inguinal canal and cause a hernia.

https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/inguinal-hernia/
Pages/facts.aspx
https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/inguinal-hernia/
Pages/facts.aspx
 • Direct inguinal hernias.
– usually occur only in male adults as aging and stress or strain
weaken the abdominal muscles around the inguinal canal.
– Previous surgery in the lower abdomen can also weaken the
abdominal muscles.
– Females rarely form this type of inguinal hernia. In females, the
broad ligament of the uterus acts as an additional barrier
behind the muscle layer of the lower abdominal wall. The broad
ligament of the uterus is a sheet of tissue that supports the
uterus and other reproductive organs.

https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/inguinal-hernia/
Pages/facts.aspx
 Sign and Symptoms
• A bulge in the area on either side of your pubic bone, which
becomes more obvious when you're upright, especially if you cough
or strain
• A burning or aching sensation at the bulge
• Pain or discomfort in your groin, especially when bending over,
coughing or lifting
• A heavy or dragging sensation in your groin
• Weakness or pressure in your groin
• Occasionally, pain and swelling around the testicles when the
protruding intestine descends into the scrotum
Incarcerated hernia
• Signs and symptoms of a strangulated hernia include:
– Nausea, vomiting or both
– Fever
– Sudden pain that quickly intensifies
– A hernia bulge that turns red, purple or dark
– Inability to move your bowels or pass gas
 Diagnosis
Laboratory studies include the following:
• Stain or culture of nodal tissue
• Complete blood count (CBC)
• Electrolytes, blood urea nitrogen (BUN), and creatinine
• Urinalysis
• Lactate
 Treatment
• Herniorrhaphy (Open hernia repair)  local anesthesia + sedation
– an incision in the groin  moves the hernia back into the
abdomenreinforces the abdominal wall with stitches 
reinforces the weak area with a synthetic mesh (hernioplasty) to
provide additional support.

http://www.mayoclinic.org/diseases-conditions/inguinal-hernia/symptoms-causes/dxc-20206367
 • Laparoscopic hernia repair  small incisions in your abdomen  a
small tube equipped with a laparoscope is inserted into one incision
 inserts tiny instruments through another incision to repair the
hernia using synthetic mesh.

http://www.mayoclinic.org/diseases-conditions/inguinal-hernia/symptoms-causes/dxc-20206367
 Prognosis
• In a study investigating complications during and after 780
laparoscopic inguinal herniorrhaphies in 569 patient
• Coelho et al found that hernias recurred in 14 patients (2.5%) and
that intraoperative complications occurred in 28 (4.9%), with
extensive subcutaneous emphysema being the most common
complication.
 Complications
• Pressure on surrounding tissues. Most inguinal hernias enlarge
over time if not repaired surgically. In men, large hernias can
extend into the scrotum, causing pain and swelling.
• Incarcerated hernia. If the contents of the hernia become trapped
in the weak point in the abdominal wall, it can obstruct the bowel,
leading to severe pain, nausea, vomiting, and the inability to have a
bowel movement or pass gas.
• Strangulation. An incarcerated hernia can cut off blood flow to part
of your intestine. Strangulation can lead to the death of the
affected bowel tissue. A strangulated hernia is life-threatening and
requires immediate surgery.
 References
• Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J,
editors. Harrison’s gastroenterology and hepatology. 2nd ed. San
Fransisco: McGraw-Hill Education; 2013
• http://emedicine.medscape.com/article/773895-overview
• http://www.mayoclinic.org/diseases-conditions/inguinal-hernia/
symptoms-causes/dxc-20206367
• https://www.niddk.nih.gov/health-information/health-topics/
digestive-diseases/inguinal-hernia/Pages/facts.aspx
• http://emedicine.medscape.com/article/927845-overview
• http://emedicine.medscape.com/article/189563-overview
• http://emedicine.medscape.com/article/149608-overview
• http://emedicine.medscape.com/article/930708-overview#a7