dr hertanto
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Acute Cholecystitis
Pendahuluan
• Obstruction of cystic duct (80%) by gall stone impacted• Gall bladder become inflamed, distended, abdominal
pain n tenderness• Resolve spontaneously• Abcess formation, free perforation with generalized
peritonitis• 20% acalculus cholecystitis
– Cystic duct obstruction by a malignant tumor– Cystic arterial obstruction– Bacterial infection by E.coli,clostridiae,salmonella Typhii
Clinical Finding
• Symptoms n signs– Abdominal pain in RUQ, reffered pain in the
region of the right scapula– The pain persist associated with abdominal
tenderness– Nausea– Mild icterus (10%)– Temp 38-38,5 °C– Murphy sign (+)
Laboratorium
• Leucocyte 12.000-15.000 • Mild elevation of the serum bilirubin
Imaging
• Plain foto abdomen• USG
Essential of Diagnosis
• Acute right upper quadrant pain n tenderness• Fever n leucocytosis• Palpable gall bladder in one third of cases• Nonopacified gall bladder on radionuclide
excretion scan• Sonographic Murphy Sign (+) saat USG nyeri
Differential Diagnosis
• Acute Peptic Ulcer (with/without perforation)• Acute Pancreatitis• Acute Appendicitis
Complication
• Empyema (supurative cholecystitis)• Perforation (bila abses pecah)• Localized perforation may lead to abcess
formation• Free perforation may lead to generalized
peritonitis n sepsis• Treatment by emergency Laparotomy
Treatment
• IV fluid correct dehydration n electrolyte imbalance
• NG (Naso Gastric) Tube• Antibiotika (80% E.colli ,Klebsiella ,
Enterococcus n Enterobacter)• Cholecystectomy after recorvery ± 3 days (u/
basmi kuman)– Laparoscopy– Open cholecytectomy
Prognosis
• Death Rate 5%• Cholangitis from billiary obstruction• Suppurative forms of gall bladder (Empyema
or perforation)
Hemorrhoid
Internal Hemorrhoid• Painless bright red blood per rectum• Mucus discharge• Rectal fullness or discomfort• Anuscopy / Protoscopy, px posisi lithotomy dari
arah Right Anterolateral (jam 11),right posterolateral (7),left lateral (3)
• First degree : bleed• Second degree : bleed n prolaps, reduce
spontaneously• Third degree : bleed n prolaps, manual reduction• Fourth degree : bleed n cannot be reduce,
strangulate segera operasi (sangat sakit)
Clinical Finding
• Symptoms n signs– Bright red bleeding per rectum– Mucus discharge– Rectal fullness or discomfort– Become incarcerated, thrombosed n necrosis
• Anuscopy/ Protoscopy : first n second degree• Laboratory n Imaging– Anemia (chronic bleeding)– Barium enema , colonoscopy (malignancy n
inflamation)
External Hemorrhoid
• Sudden, severe perianal pain• Perianal mass• Stretching plexus hemorrhoidalis ext :
constipation or diarrhea (tidak khas)• Thrombosis pain
Differential Diagnosis
• Colorectal Malignancies• Inflamatory Bowel Disease• Diverticular Disease• Adenomatous Polyp
Complication
• Bleeding• Pain• Necrosis• Mucus discharge
Treatment
• Medical for 1st n 2nd degree– Diet– Elimination of constipation food– Fiber , stool softeners– intake of liquid– excercise
• If not succeed tx : elastic band ligation (15 minutes)
• Surgical– Elastic band ligation– Sclerotic agent (Injection)– Photocoagulation– Cryosurgery (pemotongan)– Exicional hemorrhoidectomy– Stappled hemorrhoidectomy
Prognosis
• Good
Prolaps Recti
Symptoms n Signs• Rectal fullness• Incomplete evacuation• Incontinence alvi• Rectal bleeding• Pain• Mucus discharge• Large external mass of prolapsed tissue with
concentric mucosal ring• DE decrease or abscent sphingter tone
Differential Diagnosis
• Hemorrhoid• carcinoma
Complication
• Nerve injury (daerah rectum)• Bleeding• Incontinence• Severe prolaps can no be reduced, Ischemia,
gangrene
Treatment• Medical : to stimulate bowel movement in the
morning• Surgical :– Abdominal Procedure• Sigmoid resection• rectopexy
– Perineal procedure• Anal encirclement• Delorme procedure• Altemeler procedure
Diverticulosis
symptoms n Signs
• 80% asymptomatic• Detected incidentally on barium enema or
endoscopy• Episodic pain, constipation, diarrhea• Mild tenderness in LLQ • Pain without inflamation
Imaging Studies
• Barium Enema : segmental spasm n muscular thickening
Differential Diagnosis
• Carcinoma
Complications
• Diverticulitis (infeksi = inflamasi)• Massive Hemorrhage
Treatment
• Medical (bila tidak hemorrhage massive)– High fiber diet (cereal,soup,salad n bread)– Anticholinergic, sedatives, tranquilizer, anti
depresant– Non opioid analgesia– education
• Surgical : for massive hemorrhage
Prognosis
• 10-20% pts diverticulosis develop diverticulitis or hemorrhage
• Baik asal tidak massive hemmorhage
Peritonitis
Signs n symptoms
• Ada penyakit primernya• Abdominal tenderness, febrile, nausea n
vomiting• Abdominal distended• Defans musculer• Tachycarida• Leukositosis (15.000)
Etiology
Chemical Bacterial
Perforasi gaster Perforasi Colon
Perforasi duodenum Perforasi Gallbladder
Perforasi Gallbladder Perforasi Thypoid
Pancreatitis Perforasi Appendicits
Therapy
• Laparotomy
Hernias
Introduction
• Abnormal protrusion of intra abdominal tissue through a fascial defect in the abdominal wall
• 75% indirect,direct inguinal, femoral hernia• 3% umbilical hernia• 3% others
Introduction, Continue
• Reducible hernia• Irreducible hernia• Incarcerated hernia,obstruction or
strangulation• Strangulated hernia,gangrene of the content
of the sac perforation• Definitive treatment is early operation repair
Anatomy• Fascia transversalis• Transversus abdominis• Internal oblique• Exteranl oblique• Rectus abdominis• Linea alba• Conjoined tendon• Inguinal (poupart) ligament• Hesselbach triangle
Causes
• Indirect Inguinal Hernia– Congenital : infants, children, young adult– Acquired : Increased intra abdominal pressure n
dilatation of the internal inguinal ring• Direct Inguinal hernia– Acquired as the result of a developed weakness of
the transversalis fascia in Hesselbach area• Femoral hernia– Usus masuk ke Femoral ring
Indirect n Direct Inguinal Hernias
Symptoms SignsLump or swelling in the groin Finger test
The patient must lie down to reduce the hernia
Compression over the internal Ring
Coughing n straining
Differential Diagnosis
• Herniation of the peritoneal fat (lipome of the cord)
• Hydrocele of spermatic cord• Lymphadenopathy or abcess of the groin• Varicocele (rare)
Treatment
• SURGERY• Adult Herniotomy n Hernioplasty (mesh)• Infant, child Herniotomy
Complication
• Bleeding / hematome• Pain• Infection• Fistel• reccurent
Femoral Hernia
• Descend through the femoral canal• Much more common in women• Incaceration n strangulation
Symptoms
• No symptoms• Discomfort in the abdomen than in the
femoral area (kemeng-kemeng)• Colicky abdominal pain n signs of intestinal
obstruction
Signs
• Small bulge (benjolan) in the upper medial thigh below the level of the inguinal ligament
Differential Diagnosis
• Inguinal Hernia• Saphenous Varix• Femoral Adenopathy
Treatment
• SURGERY
Pancreatitis
Etiology
• Gall stone disease (40%)• Alcholism• Trauma• Hyperlipidemia• Genetic• idiopathic
Acute Pancreatitis
Symptoms n Signs• Severe epigastric pain radiates through to the
back• Vomiting• Shock (pancreatitis hemorrhagis)• Dehydration, tachycardia n postural
hypotension• Myocardial function decrease• Abdomen– Bowel sound abscent– Tenderness localized to the epigastrium
• Temperature normal or slightly elevated• Grey Turner Sign (bluish discoloration in the
flank)• Cullen Sign (hemorrhagic pancreatitis)
Laboratory Finding
• Hematocrit naik• Leucocytosis (12.000)• Bilirubin (< 2 mg/dl)• Amylase concentration naik (2 ½ X)• Urine amylase excretion naik
Imaging Studies
• BOF• CT scan• USG
Differential Diagnosis
• Acute Cholecystitis• Penetrating or perforated duodenal ulcer• Acute appendicitis• Mesenteric infarction
Complications
• Abcess• pseudocyst
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