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