Tutorial Klinik

Laboratorium Ilmu Bedah

Divisi Bedah Anak

Pembimbing : dr. Sp.BA

Dinni Astriani
1910017049

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Kasus
Bayi usia 15 hari, muntah hijau, BB 3300
gr

▰ Anamnesis?
▰ Pemeriksaan Fisik?
▰ DD?
▰ Diagnosis Kerja?
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 Anamnesis
▰ Muntah sejak kapan? Proyektil? Bercampur darah? Warna? Terus menerus?
▰ Keluhan penyerta? Kembung? Sulit BAB? Demam?
▰ Mekonium terlambat keluar?
▰ Usia lahir? Berat badan lahir? Langsung menangis?
▰ Penyulit saat kehamilan? USG?
▰ Sindrom down?
▰ Kelainan kongenital lain?
▰ Sistem? Riwayat penyakit dahulu?
▰ Riwayat penyakit keluarga. Keluhan yang sama? Kelainan kongenital pada keluarga?

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 Pemeriksaan Fisik
Jantung
▰ Vital sign Thorax: I: ikts kordis?
I: simetris? retraksi P:iktus kordis teraba
▰ Inspeksi Umum: organ tubuh lengkap? pucat? menangis? dinding dada? dimana?
P: benjolan? P:batas jantung
▰ Kepala: normocephali? P:sonor? A: BJ I? BJ II?
▰ A:wheezing? rhonki? bising?
Mata: konjngtiva anemis? sklera ikterik?
▰ Telinga: normotia?
Abdomen Anogenital:
▰ Hidung: napas cuping hidung? I:distensi? benjolan? Laki-laki/perempuan?
A:bising usus? Inspeksi perineal?
▰ Mulut: bibir sianosis? kering? hipersaliva? palatum bercelah? Lubang anus? anal
P: soepel?
P: timpani? dimple? mekonium?
▰ Ekstremitas: deformitas? spastik?

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Pemeriksaan Penunjang

▰ Foto polos abdomen

▰ Barium enema

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 Diagnosis Banding

▰ Duodenal obstruction
▰ Small bowel atresia
▰ Malrotation
▰ Meconium ileus
▰ Hirschsprung’s disease
▰ Anorectal abnormality
▰ Necrotising enterocolitis(NEC)

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 Diagnosis Kerja
Obstruksi usus

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“Bilious vomiting should be assumed to be due to
intestinal obstruction until proved otherwise”

bile-stained
vomiting

Triad
neonatal
abdomina
bowel
l
obstruction
distension

failure
to pass
meconium 8
TINJAUAN
PUSTAKA 9
 Duodenal Obstruction
• Anatomically, duodenal obstructions are classified as either atresias or stenoses
Stenosis-> incomplete obstruction. Atresia-> complete obstruction
• 1 per 5000 to 10,000 live births, associated with Down syndrome
• 4th week: the duodenum begins to develop from the distal foregut and the proximal midgut
• 5th-6th week: duodenal lumen temporarily obliterates due to proliferation of its epithelial cells
• 11th week : duodenal recanalization. An embryologic insult during this period can lead to an
atresia or stenosis

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 Duodenal Obstruction
Diagnosis
• X-rays of the abdomen ‘double bubble’
pattern: two large air bubbles (one in
stomach and the other in the dilated
proximal duodenum)

Treatment
• Resuscitation, gastric decompression,
surgical treatment: duodeno-duodenostomy

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 Duodenal Obstruction
Duodeno-duodenostomy

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 Small Bowel Atresia

• Atresia can occur at any point most frequently in the

distal ileum
• The form of the atresia may be a very tight stenosis
with no functional orifice, or a thick septum with the
bowel in continuity, or a missing segment with a gap
of centimetre or more between the closed ends
• The cause may be interruption of the mesenteric
arcades by a vascular accident in utero

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 Small Bowel Atresia
Diagnosis
Plain X-Ray:
upper jejunal atresia-> three or four fluid levels
ileal atresia-> many fluid levels

Treatment
• Gastric decompression, fluid resuscitation,
antibiotics should be initiated if there is
suspicion for perforation or infection,
laparoscopic and anastomosis performed in
an extra-corporeal fashion
Ileal atresia Jejunal atresia
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 Malrotation
A. During the fifth week of gestation, the
developing intestine herniates out of the
coelomic cavity and begins to undergo a
counterclockwise rotation about the axis of the
superior mesenteric artery.
B and C. Intestinal rotation continues, as the
developing transverse colon passes anterior to
the developing duodenum.
D. Final positions of the small intestine and
colon resulting from a 270° counterclockwise
rotation of the developing intestine and its
return into the abdominal cavity.

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Malrotation
Malrotasi usus adalah kelainan bawaan berupa kegagalan perputaran atau rotasi usus, terutama usus
bagian tengah, selama perkembangan embriologik

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Malrotation

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 Meconium Ileus

• Occurs when meconium become extremely viscid, sticky, protein-rich causing

an intraluminal obstruction in the distal ileum, usually at the ileocecal valve
• Always associated with cystic fibrosis (CF)
• The baby presents with bile-stained vomiting, abdominal distension and failure
to pass meconium.
• ‘doughy’ character that indent on palpation
• Rectal examination : no normal meconium but pale mucus pellets.

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 Meconium Ileus
Imaging
• Plain x-rays : distended loops of gut filled with a bubbly
appearance. Erect: no air-fluid levels
• Contrast enema: microcolon with pellets in the terminal
ileum

Treatment:
Antibiotics, rehydration, sometimes the obstructing
meconium can be removed by a water soluble contrast enema
under x-ray screening. If this non-invasive method fails,
laparotomy is performed and a temporary enterostomy is
performed

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 Hirschsprung Disease
• Hirschsprung disease is characterized by the absence of ganglion cells in the myenteric and
submucosal plexuses of the intestine.
• occurs in approximately 1 : 5,000 live births
• Ganglion cells are derived from the neural crest. By 13 weeks post-conception, the neural
crest cells have migrated from proximal to distal through the gastrointestinal tract, after
which they differentiate into mature ganglion cells.
• There are two main theories why this process is disturbed in children with HD. The first
possibility is that the neural crest cells never reach the distal intestine due to early
maturation or differentiation into ganglion cells
• The neural crest cells reach their destination, but fail to survive or differentiate into
ganglion cells due to an inhospitable microenvironment. 20
 Hirschsprung Disease
• Diagnosis is confirmed by rectal biopsy
• Many surgeons advocate continued rectal decompression
with washouts followed by early neonatal surgical
correction without the need for stoma formation
• Colostomy or ileostomy

Absence of ganglion cells

in the myenteric plexus
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Hirschsprung Disease

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 NEC
• Necrotising enterocolitis is a disease with combined ischaemia and
infection of the bowel wall.
• Presents with abdominal distension and bile-stained vomiting,
resembling obstruction.
• The passage of blood per rectum and a characteristic appearance on
abdominal x-ray help to distinguish necrotising enterocolitis from
neonatal bowel obstruction

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 Anorectal Abnormality
• While the etiology remains unknown, it is likely multifactorial, with
genetic factors suspected as anorectal malformation is associated with
many syndromes and in members of the same family. 1anorectal
malformation occur in 1–4 out of 5,000 newborn babies
• Approximately 80% of anorectal malformation have associated
genitourinary anomalies. Other associated congenital anomalies
include spinal, cardiac, other gastrointestinal as well as limb
abnormalities, with the most common association being VACTERL.

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Algoritma

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 Metabolic Complications

1. Berkurangnya volume cairan & perfusi jaringan yang buruk karena kurangnya asupan cairan, muntah,
kurangnya penyerapan cairan diusus. -> hipotermi & asidosis

2. Penyimpanan glukosa jaringan pada neonates rendah. Simpanan glukosa cepat habis-> metabolism
anaerob-> asidosis hipoglikemik-> efek buruk KV & kerusakan otak

3. Hipotermia

4. Gangguan pernapasan karena distensi abdomen

5. Sepsis

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References

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Terima Kasih

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