Dr. H.

Guntur Surya Alam, SpB, SpBA

Riwayat Pendidikan : Dokter Umum FKUGM(1993) Dokter Spesialis Bedah FKUGM (2002) Dokter Spesialis Bedah Anak FKUGM(2007)

ABDOMINAL DISTENTION in

Newborn baby and children

SURGERY CASES or NOT ? and TIMING of Operation ?

Guntur Surya Alam, Pediatric Surgeon Dr. Moewardi Teaching Hospital Surakarta

 Obstruksi usus dapat mengenai mulai gaster sampai anus Penyebab terbanyak kelainan gastrointestinal pada pasien pediatrik Penyebab gawat darurat bedah Tidak ditangani dengan benar menyebabkan morbiditas / mortalitas tinggi

Obstruksi usus pada neonatus Paling sering merupakan gawat darurat bedah Tantangan para Dokter Bedah Anak Neonatus sangat rentan terhadap perubahan hemostasis, temperatur Prognosis tergantung diagnosis cepat dan terapi segera

 Umumnya datang pertama kepada Dokter Anak/dokter umum/ Bidan Perlu mengenali cepat bahwa itu pasien bedah dan segera merujuk Segera mendapat penanganan bedah Terlambat berakhir dengan morbiditas atau mortalitas tinggi Akan dibahas diagnosis dan tatalaksana obstruksi usus pada pasien pediatrik

 Abdominal distension : is a enlargement of the abdomen .. a common complaint

Normally

- overeating - obesity

A prominent potbellycontour is normal in infants and young children.

- Im normal lho mom. - Im overeating .. Ha, ha,ha

 Physiologically : - pregnant woment Pathologically :

SURGICAL CASES NON SURGICAL CASES

Pathologic enlargement of the abdomen is a problem : - reduced breathing - reduced tone of the wall musculature - abdominal compartement syndrome

PROBLEM ABD DIST

1. 2. 3. 4. 5. 6. 7. 8. RESPIRATORY DISTRESS ABDOMINAL COMPARTEMENT INDICATION FOR OPERATION TIMING FOR OPERATION OPERATIVE OF CHOICE ANAESTHESIA OPERATIVE TECHNICS POST OPERATIVE CARE

ABDOMINAL DISTENSION

Must be evaluated carefully and systematically to rule out serious and lifethreatening conditions. A careful history and physical examination are necessary to develop an appropriate differential upon which to base a diagnostic plan.

Acute-onset abdominal distension is a sign that should be taken seriously especially when accompanied by bilious vomiting.

 History include :
IN CHILD
Age ? , Duration ? IN NEONATUS Fever ? , Pain ? Prenatal ? , Birth history / Vomitus ? , Flatus ? delivery process? Last Bowel movement ? Gestational age ? Diarrhea ? passage of meconium ? Trauma ?, Systemic Dis ? Weight loss ?

Adult ( women) : - last menstrual ?, - sexual history ?,

Abd Distent + -Acute Mass - Fever - Pain - Vomitus - Cant flatus - Cant defecation - Trauma

SURGICAL CASES

EMERGENCY

STRANGUTATION HEMORRHAGE SIMPLE OBSTRUCTION INFECTION NEOPLASMA OTHER

URGENT

ELECTIVE

Differential Diagnosis for failure to pass meconium: Disorders of the small intestine
Duodenal atresia Jejunoileal atresia Malrotation and volvulus Meconium ileus

Disorders of the large intestine

Meconium plug syndrome Anorectal malformation Hirschsprungs disease Small left colon syndrome

Other causes
Narcotics Electrolyte abnormalities; hypermagnesemia, hypokalemia, hypercalcemia Hypothyroidism Sepsis Congestive heart failure

Physical exam :

Plain KUB X-rays :

for hernias ?, masses ?, pelvic exam ( women ), signs of cirrhosis / portal hypertension, abdominal tenderness ?, and fluid wave or free air ?

Contrast study ?

bowel obstruction ? mass ?,fecal material ?, free luid Infection air swallowing, paralytic ileus ?, pneumo peritoneum ?

USG CT Scan MRI

NORMAL ABDOMINAL DISTENSION IN NEW BORN PATHOLOGIS ? Lower GI

- Acute, vomiting - Delayed passed mekonium - Polyhydramnion ? - Tendernes / erythema ? - Mass ?, Free fuid ?

SURGICAL CASES ?

GI Yeyuno ileal atresia obstruction Mekonium ileus ? Hirschsprung Dis Colonic stenosis / atresia Duplicatur Anorectal malformation Upper GI

NOT OBSTRUCTION

NOT ALWAYS NEC, hemorrhage Neonatal ascites Neoplasma

Esof Atresia Without Gastric outlet obstr Abd Disten Duodenal obstr

 Bowel Obstruction in the Newborn

is one of the most common newborn surgical emergencies. Successful management depends on timely diagnosis and prompt therapy. The diagnosis can usually be made based on history and physical examination and corroborated by simple radiographic studies. Kind of Disease
1 Esofageal atresia

UPPER / LOWER GI/ Abd Dist ?

MANAGEMENT
SYMPTOM

DIAGNOS TIC
- Insert NGT - Babygram

Transportatio n
Thermoregulati on

OPERATION

Technic
-Gastrostomy ? - Primary Anast ?

Timing

Upper GI / Not Distension

- Drolling, - hypersalivation,

Urgent
THORACOTOMY

Preoperative Care

Kind of Dis
Gastric outlet Obstr

Local ? / Abd Dist ?

UPPER GI / NOT Distens

MANAGEMENT
Symtom
Vomiting Projectile Non bilius Not dist Gastric wave

Diagnostic
Plain foto Abd UGI USG

Preoperative Care
Water & electrolit resus citation

Transport

OPERATION

Technic
Thermo regulation IHPS : pyloromyotomi Atresia : e/e anast. Bezoir : konserv

Timing

Urgent

Kind of Dis
Duoden al obstruct ion

Local ? / Abd Dist ?

MANAGEMENT
Symtom

Diagnostic
UPPER GI / NOT Distens Bilius vom abd flat Meko: delay Plain foto Abd DOUBLE BUBLE Colon inloop

Preoperative Care
Water & electrolit resus citation

Transport

OPERATION

Technic
Thermo regulation Laparotomi : -Ladds procedr -Duodeno - duo denostomi Duodenoplasty

Timing

Urgent

Kind of Disease

PROBLEM
DIAGNOSTIC

MANAGEMENT
Preoperative Care
Water & electrolit resuscitation Fasting, Decompresion, TPN, Antibiotika

TRANSPORTATI ON

OPERATION

Technic
Thermoregulation Conservative ( new ) Fail : operation ( perforation )

TIMING

NEC NOT OBSRUCTION

Unkwon Delayed Sepsis

Cinical sign Abd plain photo:pneumoint estinal Culture : blood & peritoneal fluid

Cito

Kind of Disease

PROBLEM
DIAGNOSTIC

MANAGEMENT
Preoperative Care
Water & electrolit , Respiration resuscitation Fasting, Decompresion, TPN, Antibiotika TRANSPORTATI ON Thermoregulation OPERATION OPERATION

Technic

TIMING

Gastric rupture NOT OBSRUCTION

Unkwon Delayed Sepsis

Cinical sign Abd plain photo:pneumoper itoneal

Cito

Kind of Dis
Jejunoileal obstr

Local ? / Abd Dist ?

MANAGEMENT
Symtoms
Fecal vom DIAGNOSTIC Plain foto Abd Colon inloop

Preoperative Care
Water & electrolit resus citation

Transport

OPERATION

Technic
Thermo regulation Laparotomi : -Direct anast. - delayed anast

Timing

Mid Gut/ DISTENS DISTENS

Meko : del

Urgent

Kind of Dis
Hirschs prung Dis

Local ? / Abd Dist ?

MANAGEMENT
Symtoms Preoperative DIAGNOSTIC Care Transport
OPERATION

Technic
Thermo regulation colostomi Pullthrough

Timing

Colon / DISTENS

Delayed meko Plain foto Bilious vom Colon inlp Abd distens Suction biop Manometri

Water & electrolit resus citation Decompr & washout

ACUTE Urgent

Manometri
CONTRACION

RELAXATION

Suction biopsy

PA

Kind of Dis
MAR

Local ? / Abd Dist ?

MANAGEMENT
Symtoms Preoperative DIAGNOSTIC Care Transport
OPERATION

Technic
Thermo regulation Depend of AMF types Low : anoplasty High : Colostomy

Timing

Anorectal/ DISTENS

Without meko Plain foto Water & Bilious vom ( invertogram ) electrolit resus citation. USG Abd Decomp distens +/-

ACUTE Urgent

- ANUS MEMBRAN - LOW AMF < 1 cm - HIGH AMF .. > 1 cm

AMF WITH FISTEL

MALE

LOW FISTEL : Recto cutan / perineal - Anterior anus - Bucket handle

High fistel

FEMALE

FEMALE : LOW FISTEL : - VESTBULAR fistel

CLOACA

NOT
ABDOMINAL DISTENSION
IN

NON SURG: - Ascites - DHF

CHILD
PATHOLOGIS

SURGICAL CASES ?

INFECTION Strangulated hernia Intussuception Volvulus Adhesion

OBSTRUCTION

Appendicitis Peritonitis Inflam Bowel Dis

- Fever - Pain - Acute - Vomiting - Cant flatus - Cant defecation - Abd discomfort - Diarrhe - Tendernes - Mass - Abnorm feses ( bloody/ mucus )

Kind of Disease

PROBLEM
DIAGNOSTIC

MANAGEMENT
Preoperative Care
Water & electrolit resuscitation Water & electrolit resuscitation Sedativum.

TRANSPORTATI ON

OPERATION

Technic
Thermoregulation Reposition : Non operative ( new ) Operative Conservative ( new ) Fail : operation

TIMING

6 Intussuception

Strangulation, Intestinal obstruction, Delayed Strangulation Recidif

Trias Colon inloop

Cito

7 Strangulated Hernia

Clinical sign

Thermoregulation Fowler position

Cito

MANAGEMENT

Kind of Disease

PROBLEM
DIAGNOSTICS

OPERATION

Preoperative Care
Water & electrolit resuscitation, Antibiotics

TRANSPORTA TION

Technic

TIMING

9 Peritonitis e/c Rupture Appendicitis Typhoid

Delayed Sepsis

Clinical sign Abd plain photo Blood examination

Thermoregula tion

Laparotomi Appendisektomi

Cito

Abdominal distension in children and other symptoms

Abdominal distension in children and Absence of bowel movement Abdominal distension in children and Absent bowel sounds Abdominal distension in children and Acanthosis nigricans in children Abdominal distension in children and Accumulation of adipose tissue Abdominal distension in children and Aches Abdominal distension in children and Aching pain Abdominal distension in children and Acidosis Abdominal distension in children and Acute abdominal pain Abdominal distension in children and Acute asthma-like breathing attacks Abdominal distension in children and Acute asthma-like breathing difficulty Abdominal distension in children and Acute asthma-like symptoms Abdominal distension in children and Acute asthma-like symptoms at night Abdominal distension in children and Acute colitis-like abdominal pain Abdominal distension in children and Acute COPD-like cough symptoms Abdominal distension in children and Acute COPD-like symptoms Abdominal distension in children and Acute Crohns-like diarrhea symptoms Abdominal distension in children and Acute Crohns-like symptoms Abdominal distension in children and Acute Crohns-like weight loss symptoms Abdominal distension in children and Acute croup-like breathing difficulty Abdominal distension in children and Acute croup-like wheezing symptoms Abdominal distension in children and Acute diarrhea in children Abdominal distension in children and Acute diarrhoea (1 cause) Abdominal distension in children and Acute emphysema-like cough symptoms Abdominal distension in children and Acute emphysema-like symptoms Abdominal distension in children and Acute episodic COPD-like symptoms Abdo distension in children and Acute episodic emphysema-like symptoms Abdominal distension in children and Acute expiratory wheeze in infants Abdominal distension in children and Acute fever in children (3 causes) Abdominal distension in children and Acute flank pain (1 cause) Abdominal distension in children and Acute ibd-like abdominal pain (2 causes) Abdominal distension in children and Acute ibd-like diarrhea (1 cause) Abdominal distension in children and Acute ibs-like abdominal pain (1 cause) Abdominal distension in children and Acute ibs-like symptoms (2 causes) Abdominal distension in children and Acute pain from intercourse (1 cause) Abdominal distension in children and Acute pelvic pain in children (1 cause) Abdominal distension in children and Acute prostate pain symptoms Abdominal distension in children and Acute prostate symptoms Abdominal distension in children and Acute prostatitis-like symptoms Abdominal distension in children and Acute recurring COPD-like symptoms Abd distension in children and Acute recurring emphysema-like symptoms Abdomdistension in children and Acute wheezing worse when lying down
Abd disten children and Abd discomfort Abd disten in children and Abd disten Abd disten in children and Abd guarding Abd distens children and Abd mass Abdo disten in children and Abd pain Abd disten in children and Inflammatory bowel disease Abdominal distension in children and Abdominal rigidity Abd distension in children and Abdominal swelling Abdominal distension in children and others symptoms Abdominal distension in children and Abd tenderness Abdominal distension in children and Abdominal tumor Abdominal distension in children and Abn pulse Abdominal distension in children and Abnormal sensations Abd disten children and Abnormal skin texture Abd disten children and Abnormal stool texture in children Abd disten children and uterine bleeding Abd disten children and vaginal bleeding Abd disten children and decreased urination Abd disten children and Abscessed teeth Abd distensi and Alternating constipation and diarrhea Abdominal distension in children and Alternating constipation and diarrhoea Abdominal distension in children and Amenorrhea (4 causes) Abdominal distension in children and Anal symptoms (4 causes) Abdominal distension in children and Anatomic obstruction (2 causes) Abdominal distension in children and Anemia (2 causes) Abdominal distension in children and Angina pectoris (1 cause) Abdominal distension in children and Angular cheilitis (1 cause) Abdominal distension in children and Anorectal pain (2 causes) Abdominal distension in children and Anorectal pain in children (1 cause) Abdominal distension in children and Aphthous Ulcer (1 cause) Abdominal distension in children and Apnea (2 causes) Abdominal distension in children and Apnea in children (1 cause) Abdominal distension in children and Apnea in infants (1 cause) Abdominal distension in children and Apnea in premature infants (1 cause) Abdominal distension in children and Appetite changes (6 causes) Abdominal distension in children and Areas of depigmentation (1 cause) Abdominal distension in children and Arm numbness (1 cause) Abdominal distension in children and Arm paresthesia (1 cause) Abdominal distension in children and Arm symptoms (2 causes) Abdominal distension in children and Arm weakness (1 cause) Abdominal distension in children and Arrhythmia (1 cause) Abdominal distension in children and Arrhythmias (1 cause)

Abdominal distension in children and Absence of bowel movement Abdominal distension in children and Absent bowel sounds Abdominal distension in children and Acanthosis nigricans in children Abdominal distension in children and Accumulation of adipose tissue Abdominal distension in children and Aches Abdominal distension in children and Aching pain Abdominal distension in children and Acidosis Abdominal distension in children and Acute abdominal pain Abdominal distension in children and Acute asthma-like breathing attacks Abdominal distension in children and Acute asthma-like breathing difficulty Abdominal distension in children and Acute asthma-like symptoms Abdominal distension in children and Acute asthma-like symptoms at night Abdominal distension in children and Acute colitis-like abdominal pain Abdominal distension in children and Acute COPD-like cough symptoms Abdominal distension in children and Acute COPD-like symptoms Abdominal distension in children and Acute Crohns-like diarrhea symptoms Abdominal distension in children and Acute Crohns-like symptoms Abdominal distension in children and Acute Crohns-like weight loss symptoms Abdominal distension in children and Acute croup-like breathing difficulty Abdominal distension in children and Acute croup-like wheezing symptoms Abdominal distension in children and Acute diarrhea in children Abdominal distension in children and Acute diarrhoea (1 cause) Abdominal distension in children and Acute emphysema-like cough symptoms Abdominal distension in children and Acute emphysema-like symptoms Abdominal distension in children and Acute episodic COPD-like symptoms Abdo distension in children and Acute episodic emphysema-like symptoms Abdominal distension in children and Acute expiratory wheeze in infants Abdominal distension in children and Acute fever in children (3 causes) Abdominal distension in children and Acute flank pain (1 cause) Abdominal distension in children and Acute ibd-like abdominal pain (2 causes) Abdominal distension in children and Acute ibd-like diarrhea (1 cause) Abdominal distension in children and Acute ibs-like abdominal pain (1 cause) Abdominal distension in children and Acute ibs-like symptoms (2 causes) Abdominal distension in children and Acute pain from intercourse (1 cause) Abdominal distension in children and Acute pelvic pain in children (1 cause) Abdominal distension in children and Acute prostate pain symptoms Abdominal distension in children and Acute prostate symptoms Abdominal distension in children and Acute prostatitis-like symptoms Abdominal distension in children and Acute recurring COPD-like symptoms Abd distension in children and Acute recurring emphysema-like symptoms Abdomdistension in children and Acute wheezing worse when lying down Abdominal distension in children and Additional Heart Sounds

Abd disten children and Abd discomfort Abd disten in children and Abd disten Abd disten in children and Abd guarding Abd distens children and Abd mass Abdo disten in children and Abd pain Abd disten in children and Inflammatory bowel disease Abdominal distension in children and Abdominal rigidity Abd distension in children and Abdominal swelling Abdominal distension in children and others symptoms Abdominal distension in children and Abd tenderness Abdominal distension in children and Abdominal tumor Abdominal distension in children and Abn pulse Abdominal distension in children and Abnormal sensations Abd disten children and Abnormal skin texture Abd disten children and Abnormal stool texture in children Abd disten children and uterine bleeding Abd disten children and vaginal bleeding Abd disten children and decreased urination Abd disten children and Abscessed teeth Abd distensi and Alternating constipation and diarrhea Abdominal distension in children and Alternating constipation and diarrhoea Abdominal distension in children and Amenorrhea (4 causes) Abdominal distension in children and Anal symptoms (4 causes) Abdominal distension in children and Anatomic obstruction (2 causes) Abdominal distension in children and Anemia (2 causes) Abdominal distension in children and Angina pectoris (1 cause) Abdominal distension in children and Angular cheilitis (1 cause) Abdominal distension in children and Anorectal pain (2 causes) Abdominal distension in children and Anorectal pain in children (1 cause) Abdominal distension in children and Aphthous Ulcer (1 cause) Abdominal distension in children and Apnea (2 causes) Abdominal distension in children and Apnea in children (1 cause) Abdominal distension in children and Apnea in infants (1 cause) Abdominal distension in children and Apnea in premature infants (1 cause) Abdominal distension in children and Appetite changes (6 causes) Abdominal distension in children and Areas of depigmentation (1 cause) Abdominal distension in children and Arm numbness (1 cause) Abdominal distension in children and Arm paresthesia (1 cause) Abdominal distension in children and Arm symptoms (2 causes) Abdominal distension in children and Arm weakness (1 cause) Abdominal distension in children and Arrhythmia (1 cause) Abdominal distension in children and Arrhythmias (1 cause) Abdominal distension in children and Arterial hypertension (1 cause) Abdominal distension in children and Arthralgia (1 cause)

SUMMARY
1. ANY KINDS AND CONDITIONS MAY CAUSED ABDOMINAL DISTENSION 2. ABD DISTENSION NOT ALWAYS CAUSED BY BOWEL OBSTRUCTION

3. BOWEL OBSTRUCTION NOT ALWAYS TO RESULT ABDOMINAL DISTENSION

4. HISTORY, SYSTEMATIC PHYSICAL EXAM .APPROPRIATE DIAGNOSTIC EXAM 5. LIFE THREATENING 6. ABD DISTENS : * ACUTE * * VOMITING *** TENDERNESS5. ABD DISTENSION ***** BOWEL PROBLEM

SURGICAL

THANKS WITH YOUR ATTENTIONS