PEMICU 4_GI

Stevany M

ACUTE ABDOMINAL

DEFINITION
Refers to any acute intra & extra abdominal disease processes. Many cases require urgent surgical management, although some can be managed nonsurgically.

ETIOLOGIC
Parietal peritoneal inflammation Bacterial contamination : pelvic inflammatory disease, perforated appendix Chemical irritation : perforated ulcer, pancreatitis Mechanical obstruction of hollow viscera : Obstruction of the small or large intestine Obstruction of the biliary tree Obstruction of the ureter Volvulus Hernia

ETIOLOGIC
Vascular disturbances : Embolism or thrombosis Vascular rupture Pressure or torsional occlusion Abdominal wall : Distortion or traction of mesentery Trauma or infection of muscles Neoplasm intraabdominal Congenital disease

ETIOLOGY (ACCORDING TO AGE)

Neonatal causes of Abdominal Pain
Colic Milk Protein Allergy Gastroesophageal reflux Malrotation or Midgut volvulus Necrotizing Enterocolitis Hirschprung's Enterocolitis

Infant causes of Abdominal Pain

Intussusception Infantile colic Bowel Obstructionn
Pyloric stenosis Incarcerated Herniaa Internal hernia Omphalomesenteric band Hirschprung's Diseasee

Battered Infant
Jejunum perforation Duodenal hematoma

Gastroenteritis Constipation Urinary Tract Infection

ETIOLOGY (ACCORDING TO AGE)

Child causes of Abdominal Pain
Constipation Lactose Intolerance Lead Poisoning Helicobacte pylori Urinary Tract Infection Pneumonia Pancreatitis Appendicitis Mesenteric Lymphadenitis Gastroenteritis Intussusception or Volvulus (children under age 6) Abdominal trauma Pharyngitis (e.g. Strep Throat) Sickle Cell Crisis Henoch-Schonlein Purpura

Adolescent
Appendicitis Gastroenteritis Constipation Gynecologic cause
Pregnancy (or Ectopic Pregnancy) Mittelschmerz Dysmenorrhea Pelvic Inflammatory Disease Ovarian torsion

Testicular Torsion Drug and Alcohol use Sexual abuse Gallbladder disease Neoplasm Inflammatory Bowel Disease

ETIOLOGY/CAUSES/DIFFERENTIAL DIAGNOSIS OF ACUTE ABDOMEN

Gastrointestinal Appendisitis Perforated peptic ulcer Intestinal ischemia Diverticulitis Inflammatory bowel disease Meckels diverticulitis Pancreaticobiliary tract, liver, spleen Acute pancreatitis Calculous cholecystitis Acalculous cholecystitis Acute cholangitis Hepatic abscess Ruptured hepatic tumor Splenic rupture Urinary tract Renal/ureteral stone Gynecologic Ectopic pregnancy Tuboovarian abscess Ovarian torsion Uterine rupture Ruptured ovarian cyst or follicle Retroperitoneum Abdominal aortic aneurysm Supradiaphragmatic Pneumothorax Pulmonary embolus Acute pericarditis Empyema

PHYSICAL EXAMINATION
Patient overall appearance
Ability to communicate and habitus ? Lie quietly in bed or active move ? Lie on his or her side with knees and hips flexed? Appear dehydrated with dry mucous membranes?
Patient lying quietly in bed, avoiding motion, and complaining of abdominal pain -> serious intraabdominal disease

PHYSICAL EXAMINATION
Evaluation of the vital signs
Low fever (37.2 C 37.8 C) diverculitis, appendicitis, acute cholecystitis High fever (> 37.8 C) pneumonia, urinary tract infection, septic cholangitis, or gynecologic infection Rapid heart rate and hypotension complicated disease with peritonitis

PHYSICAL EXAMINATION
Inspection Scars Hernias Masses Abdominal wall defect Contour abdomen scaphoid, flat, distended Abdominal distention intestinal obstruction, ileus, or fluid including ascites, blood, or bile Peristaltic movement intestine obstruction Contraction abdomen perforation

PHYSICAL EXAMINATION
Auscultation Bowel sounds obstruction of small intestine, early acute pancreatitis Bowel sound chronic obstruction of intestine, difuse peritonitis, ileus

PHYSICAL EXAMINATION
Palpation Localized tenderness in :
McBurney poin appendicitis

RUQ inflamed gallbladder LLQ diverticulitis Throughout abdomen diffuse peritonitis Rebound tenderness peritonitis Deep palpation can detect abdominal masses (Acute cholecystitis, acute pancreatitis, abdominal aneurysm, diverticulitis)

PHYSICAL EXAMINATION
Percussion Hyperresonance or tympany gaseous distention of the intestine or stomach Resonance over the liver free intraabdominal gas Percussion pain which has the same located with rebound tenderness peritoneal irritation Shiffting dullness + fluid on peritoneal

CHARACTERISTIC OF THE PAIN

Visceral pain, comes from abdominal viscera, innervated by autonomic nerve fibers and respond mainly to the sensation of distention and muscular contraction. Typically vague, dull, and nauseating. Somatic pain, comes from parietal peritonium, innervated by somatic nerves, which respond to irritation from infectious, chemical, or other inflammatory processes. Sharp and well localized. Referred pain, perceived distant from its source and result from convergence of nerve fibers at the spinal cord. Ex: scapular pain due to biliary colic, groin pain due to renal colic, shoulder pain due to blood or infection irritating the diaphragm

LABORATORY TESTING
Intra-abdominal inflammation WBC Dehydration , vomitting, diarrhea, taking diuretic medicine -> measure the concentrations of serum sodium, potassium, blood urea nitrogen, creatinine, glucose, chloride, and carbon dioxide. Pancreatitis, perforated duodenal ulcer serum amilase Abdominal pain RUQ should have measurements of serum bilirubin, alkaline phosphatase, and serum transaminase

DIAGNOSIS ACUTE ABDOMEN

History: Acute appendicitis: periumbilical pain, low-grade fever, anorexia with/without vomiting followed by movement of the pain into the right lower quadrant McBurneys point. Constipation: obstructive conditions, inflammatory disorders produce ileus. Watery diarrhea: gastroenteritis, Bloody diarrhea: infectious colitis, inflammatory bowel disease, mesenterial ischemia. Jaundice: hepatic and pancreaticobiliary disease, sepsis. Urinary frequency, dysuria, hematuria, and suprapubic or flank pain : urologic disease.

DIAGNOSTIC IMAGING
USG -> Liver, gallbladder, bile ducts, spleen, pancreas, appendix, kidneys, ovaries, and uterus. Also detect and charaterizes the distribution of intra-abdominal fluid. Color doppler USG -> evaluation of intraabdominal adn retroperitoneal blood vessels. CT scan X-ray

RIGHT UPPER QUADRANT : Liver Gallbladder Duodenum Head of pancreas Right kidney and adrenal Hepatic flexure of colon Part of ascending and transverse colon

LEFT UPPER QUADRANT : Stomach Spleen Left lobe of liver Body of pancreas Left kidney and adrenal Splenic flexure of colon Part of transverse and descending colon

MIDLINE : Aorta Uterus (if enlarged) Bladder (if distended)

A B D O
M

RIGHT LOWER QUADRANT : Cecum Appendix Right ovary and tube Right ureter Right spermatic cord

LEFT UPPER QUADRANT : Part of descending colon Sigmoid colon Left ovary and tube Left ureter Left spermatic cord

E N

PERITONITIS

Peritonitis
An inflammation of the peritoneum Classification : Primary peritonitis :
No intra-abdominal source is identified

Secondary peritonitis (acute peritonitis) :

Most often infectious Usually related to a perforated viscus

Etiology

Signs and Symptoms

Swelling & tenderness in the abdomen with pain ranging from dull aches to severe, sharp pain Fever & chills Loss of appetite Thirst Nausea & vomiting Limited urine output

RISK FACTOR
Abdominal penetration or trauma Immune compromise Blood in the abdomen Ruptured appendix Peptic ulcer Colitis Diverticulitis Gangrene of the bowel Pancreatitis Pelvic inflammatory disease Inflamed gallbladder Recent surgery Tubes or shunts in the abdomen Cortisone drugs

Peritonitis (Type) Primary

Etiologic Organisms Class Gramnegative Type of Organism E coli (40%) K pneumoniae (7%) Pseudomonas species (5%) Proteus species (5%) Streptococcus species (15%) Staphylococcus species (3%) Anaerobic species ( <5%) E coli Enterobacter species Klebsiella species Proteus species Streptococcus species Enterococcus species Bacteroides fragilis Other Bacteroides species Eubacterium species Clostridium species Anaerobic Streptococcus species

Antibiotic Therapy Third-generation cephalosporin

Secondary

Gramnegative

Gram-positive Anaerobic

Second-generation cephalosporin Third-generation cephalosporin Penicillins with anaerobic activity Quinolones with anaerobic activity Quinolone and metronidazole Aminoglycoside and metronidazole

ETIOLOGY
Disseminated infection from the infected abdominal organ Hip Inflammation in women Infection from ovarium and uterus Heart and kidney failure After surgery Peritoneal dialysis irritation without infection

Tertiary

Gramnegative

Enterobacter species Pseudomonas species Enterococcus species

Gram-positive Fungal

Staphylococcus species Candida species

Second-generation cephalosporin Third-generation cephalosporin Penicillins with anaerobic activity Quinolones with anaerobic activity Quinolone and metronidazole Aminoglycoside and metronidazole Carbapenems Triazoles or amphotericin (considered in fungal etiology) (Alter therapy based on culture results.)

Laboratory findings and examination

Fluid examination for identification of germ Rontgen : supine and PA/AP Surgery

Terapi Antibiotik

ILEUS

ILEUS (Intestinal Obstruction)

Definition
Ileus obstructive intestinal lack of intestinal PERISTALSIS or intestinal MOTILITY 2 types :
Mechanical obstructive Ileus Non-mechanical obstructive Ileus (paralytic ileus)

Etiology
Mechanical obstructive ileus : Adhesi (usually congenital disorders) Hernia Tumors Intussusception Volvulus Foreign bodies Paralytic Ileus (no blockage) Post operative Neurologic disorders

Patophysiology
/ # of intestinal peristaltis (intestinal motility) food & water cannot pass through the intestine obstruction of the intestine dilatation & nonfunctioning of the intestine If the obstruction is not relieved intestinal gangrene and perforation

Symptom
Crampy abdominal pain that comes and goes (intermittent) Nausea Vomiting Inability to have a bowel movement or pass gas Swelling of the abdomen (distention) Abdominal tenderness Fever

INTUSSUSSCEPTION

rare but serious disorder in which part of the intestine either the small intestine or colon slides into another part of the intestine

INTUSSUSCEPTION
Intussusception is the most frequent cause of intestinal obstruction in the first 2 years of life. Male > females. The predisposing factors are: Polyps Meckel diverticulum Omphalomesenteric remnants Duplications Henoch Schnlein purpura Lymphoma Lipoma Parasites Foreign bodies Viral enteritis with hypertrophy of Peyer patches.

INTUSSUSCEPTION
Clinical Findings: Characteristically, a thriving infant between the ages of 3 and 12 months develops recurring paroxysms of abdominal pain with screaming and drawing up of the knees. Vomiting and diarrhea occur soon afterward (90% of cases), and bloody bowel movements with mucus appear within the next 12 hours (50%). Diagnosis: history, x-ray, barium enema Treatment: Barium enema, surgery

INTESTINAL OBSTRUCTION

DEFINITION
Intestinal obstructions are a partial or complete blockage of the small or large intestine, resulting in failure of the contents of the intestine to pass through the bowel normally.

ETIOLOGY
Mechanical obstructions The bowel is physically blocked and its contents can not pass the point of the obstruction. This happens when the bowel twists on itself (volvulus) or as the result of hernias, impacted feces, abnormal tissue growth, or the presence of foreign bodies in the intestines. Non-mechanical obstruction
Called ileus or paralytic ileus, occurs because peristalsis stops. Peristalsis is the rhythmic contraction that moves material through the bowel. Ileus is most often associated with an infection of the peritoneum (the membrane lining the abdomen). It is one of the major causes of bowel obstruction in infants and children.

CAUSES OF INTESTINAL OBSTRUCTION

Location Colon Causes Tumors (usually in left colon), diverticulitis (usually in sigmoid), volvulus of sigmoid or cecum, fecal impaction, Hirschsprung's disease Cancer of the duodenum or head of pancreas, ulcer disease Atresia, volvulus, bands, annular pancreas Hernias, adhesions (common), tumors, foreign body, Meckel's diverticulum, Crohn's disease (uncommon), Ascaris infestation, midgut volvulus, intussusception by tumor (rare) Meconium ileus, volvulus of a malrotated gut, atresia, intussusception

Duodenum (Adults) Duodenum (Neonates) Jejunum and ileum (Adults)

Jejunum and Ileum (Neonates)

EXAMPLES OF CAUSES OF INTESTINAL OBSTRUCTION

Obstruction due to adhesions

Obstruction due to mesenteric occlusion

Obstruction due to hernia

Obstruction due to intussusception

Obstruction due to tumor

Obstruction due to volvulus

SYMPTOMS
Small bowel
Abdominal cramps centered around the umbilicus or in the epigastrium, Vomiting Obstipation (in patients with complete obstruction) Diarrhea (partial obstruction) Severe, steady pain suggests that strangulation has occurred. In the absence of strangulation, the abdomen is not tender Hyperactive, high-pitched peristalsis with rushes coinciding with cramps is typical Dilated loops of bowel are palpable sometimes. With infarction, the abdomen becomes tender Auscultation reveals a silent abdomen or minimal peristalsis Shock and oliguria (serious signs that indicate either late simple obstruction or strangulation)

Large bowel
Increasing constipation leads to obstipation and abdominal distention. Vomiting may occur (usually several hours after onset of other symptoms) but is not common Lower abdominal cramps unproductive of feces occur No tenderness The rectum is usually empty. A mass corresponding to the site of an obstructing tumor may be palpable.

PHYSICAL EXAMINATION
Hyperactive bowel to overcome the obstruction (early) Hypoactive bowel sounds Proper genitourinary and pelvic examinations are essential Look for the following during rectal examination: Gross or occult blood, which suggests late strangulation or malignancy Masses, which suggest obturator hernia Check for symptoms commonly believed to be more diagnostic of intestinal ischemia, including the following: Fever (temperature >100F) Tachycardia (>100 beats/min) Peritoneal signs

LAB EXAMINATIONS
X-rays CT Scan MRI USG Sigmoidoscope CBC (Complete Blood Count) Electrolytes BUN (Blood Urea Nitrogen) Urinalysis Laboratory tests to exclude biliary or hepatic disease Phosphate level Creatine kinase level Liver panels

TREATMENTS
Non-Farmacologic :
Nasogastric tube Rectal tube Intravenous fluids Repair the hernia to correct the obstruction Surgery complete obstructions

Farmacologic :
Antibiotics : pre and post operation

PROGNOSIS
Most intestinal obstructions can be corrected with prompt treatment and the affected child will recover without complications. Untreated intestinal obstructions can be fatal, however. The mortality rate for unsuccessfully treated infants is 12 percent.

INFLAMMATORY BOWEL DISEASE

Inflammatory Bowel Disease

is the name of a group of disorders that cause the intestines to become inflamed (red and swollen). The inflammation lasts a long time and usually comes back over and over again.

CLASIFICATION
Two kinds of inflammatory bowel disease are:
Crohn's disease
usually causes ulcers (open sores) along the length of the small and large intestines. Crohn's disease either spares the rectum, or causes inflammation or infection with drainage around the rectum.

Ulcerative colitis.
usually causes ulcers in the lower part of the large intestine, often starting at the rectum.

Etiology of inflammatory bowel disease

The exact causes are unknown. The disease may be caused by a germ or by an immune system problem.

SYMPTOMS
abdominal cramps and pain, diarrhea, weight loss bleeding (intestines)

CROHNS DISEASE

Crohn Disease
Chronic granulomatous inflammatory disease of the GI tract. Can involve any part of GI tract from mouth to anus Ileum is involved in majority of cases Confined to colon in 20% Terms:regional enteritis, terminal ileitis, granulomatous ileocolitis

Crohn Disease
Etiology and pathogenesis are unknown. Infectious, genetic, environmental factors have been implicated. Autoimmune destruction of mucosal cells as a result of cross-reactivity to antigens from enteric bacteria.

Crohn Disease
Cytokines,including IL and TNF have been implicated in perpetuating the inflammatory response. Anti-TNF(remicade) drugs have shown efficacy in treating Crohn disease

Crohn Disease
Epidemiology: peak incidence is 15-22 years old with a second peak 55-66years 20-30% increase in women More common in European 4 times more common in Jews than non-Jews More common in whites vs blacks 10-15% have family hx

Crohn Disease
Pathology: most important is the involvement of all layers of the bowel and extension into mesenteric lymph nodes Disease has skip areas between involved areas Longitudinal deep ulcers and cobblestoning of mucosa are characteristic These result in fissures, fistulas, and abscesses

Crohn Disease
Clinical features: variable and unpredictable Abd pain, anorexia, diarrhea, and weight loss are present in most cases 1/3 of patients develop perianal fissures or fistulas, abscesses, or rectal prolapse

Complications
PERFORATION PERITONITIS ABSCESS ILEUS

Perforation of the Acute Appendicitis

DEFINISI & KLASIFIKASI

Penyakit inflamasi yang melibatkan saluran cerna, dengan penyebab pastinya belum diketahui jelas (IPD FKUI, 2006)

Secara garis besar dibagi 3 jenis:

Kolitis ulserativa Penyakit Crohn * Bila sulit dibedakan, maka dimasukkan dalam kategori Indeterminate Colitis.

KOLITIS ULSERATIVA
Kolitis Ulserativa merupakan suatu penyakit menahun, dimana usus besar mengalami peradangan dan luka, yang menyebabkan diare berdarah, kram perut dan demam. Penyakit ini biasanya dimulai di rektum atau kolon sigmoid (ujung bawah dari usus besar) dan akhirnya menyebar ke sebagian atau seluruh usus besar.

KOLITIS ULSERATIVA
Suatu serangan bisa mendadak dan berat, menyebabkan diare hebat, demam tinggi, sakit perut dan peritonitis (radang selaput perut). Selama serangan, penderita tampak sangat sakit. Yang lebih sering terjadi adalah serangannya dimulai bertahap, dimana penderita memiliki keinginan untuk buang air besar yang sangat, kram ringan pada perut bawah dan tinja yang berdarah dan berlendir. Jika penyakit ini terbatas pada rektum dan kolon sigmoid, tinja mungkin normal atau keras dan kering. Tetapi selama atau diantara waktu buang air besar, dari rektum keluar lendir yang mengandung banyak sel darah merah dan sel darah putih. Gejala umum berupa demam, bisa ringan atau malah tidak muncul.

KOLITIS ULSERATIVA
Jika penyakit menyebar ke usus besar, tinja lebih lunak dan penderita buang air besar sebanyak 10-20 kali/hari. Penderita sering mengalami kram perut yang berat, kejang pada rektum yang terasa nyeri, disertai keinginan untuk buang air besar yang sangat. Pada malam haripun gejala ini tidak berkurang. Tinja tampak encer dan mengandung nanah, darah dan lendir. Yang paling sering ditemukan adalah tinja yang hampir seluruhnya berisi darah dan nanah. Penderita bisa demam, nafsu makannya menurun dan berat badannya berkurang

CA KOLON
Kanker usus besar jarang menyebabkan demam atau keluarnya nanah dari rektum, namun harus difikirkan kanker sebagai kemungkinan penyebab diare berdarah.

CROHN DISEASE
Penyakit Crohn (Enteritis Regionalis, Ileitis Granulomatosa, Ileokolitis) adalah peradangan menahun pada dinding usus. Penyakit ini mengenai seluruh ketebalan dinding usus. Kebanyakan terjadi pada bagian terendah dari usus halus (ileum) dan usus besar, namun dapat terjadi pada bagian manapun dari saluran pencernaan, mulai dari mulut sampai anus, dan bahkan kulit sekitar anus.

ETIOLOGY
Penyebab penyakit Crohn tidak diketahui. Penelitian memusatkan perhatian pada tiga kemungkinan penyebabnya, yaitu: - Kelainan fungsi sistim pertahanan tubuh - Infeksi - Makanan

SIGN
Nafsu makan berkurang Penurunan berat badan. Pada pemeriksaan fisik ditemukan benjolan atau rasa penuh pada perut bagian bawah, lebih sering di sisi kanan. Sekitar sepertiga penderita penyakit Crohn memiliki masalah di sekitar anus, terutama fistula dan lecet (fissura) pada lapisan selaput lendir anus. Penyalit Crohn dihubungkan dengan kelainan tertentu pada bagian tubuh lainnya, seperti batu empedu, kelainan penyerapan zat gizi dan penumpukan amiloid (amiloidosis). Pada anak-anak, gejala-gejala saluran pencernaan seperti sakit perut dan diare sering bukan merupakan gejala utama dan bisa tidak muncul sama sekali. Gejala utamanya mungkin berupa peradangan sendi, demam, anemia atau pertumbuhan yang lambat.

 Beberapa penderita sembuh total setelah suatu serangan yang mengenai usus halus. Tetapi penyakit Crohn biasanya muncul lagi dengan selang waktu tidak teratur sepanjang hidup penderita. Kekambuhan ini bisa bersifat ringan atau berat, bisa sebentar atau lama. Peradangan cenderung berulang pada daerah usus yang sama, namun bisa menyebar pada daerah lain setelah daerah yang pernah terkena diangkat melalui pembedahan.

INTESTINAL OBSTRUCTION

Definition
Intestinal obstruction is a partial or complete blockage of the bowel that results in the failure of the intestinal contents to pass through.

Causes
a. Mechanical obstructions b. Non-mechanical obstruction (ileus or paralytic ileus)

Intestinal Obstruction
a. Mechanical obstructions Occur because the bowel is physically blocked and its contents can not pass the point of the obstruction. Mechanical causes of intestinal obstruction may include:
Abnormal tissue growth Adhesions or scar tissue that form after surgery Foreign bodies (ingested materials that obstruct the intestines) Gallstones Hernias Impacted feces (stool) Intussusception Tumors blocking the intestines Volvulus (twisted intestine)

Intestinal Obstruction
b. Non-mechanical obstruction (ileus or paralytic ileus) Occurs because peristalsis stops. Peristalsis is the rhythmic contraction that moves material through the bowel. Causes of paralytic ileus include:
Chemical, electrolyte, or mineral disturbances (such as decreased potassium levels) Complications of intra-abdominal surgery Decreased blood supply to the abdominal area (mesenteric artery ischemia) Injury to the abdominal blood supply Intra-abdominal infection Kidney or lung disease Use of certain medications, especially narcotics . Example : chemotherapy drugs such as vinblastine (Velban, Velsar) and vincristine (Oncovin, Vincasar PES, Vincrex)

Intestinal Obstruction

Intestinal Obstruction
Location
Colon

Causes
Tumors (usually in left colon), diverticulitis (usually in sigmoid), volvulus of sigmoid or cecum, fecal impaction, Hirschsprung's disease

Duodenum

a. Adult
b. Neonates Jejunum and Ileum a. Adult

Cancer of the duodenum or head of pancreas, ulcer disease

Atresia, volvulus, bands, annular pancreas Hernias, adhesions (common), tumors, foreign body, Meckel's diverticulum, Crohn's disease (uncommon), Ascaris infestation, midgut volvulus, intussusception by tumor (rare) Meconium ileus, volvulus of a malrotated gut, atresia, intussusception

b. Neonates

Pathophysiology
A. Mechanical obstruction Ingested fluid and food, digestive secretions, and gas accumulate above the obstruction The proximal bowel distends, and the distal segment collapses The normal secretory and absorptive functions of the mucosa are depressed The bowel wall becomes edematous and congested. Severe intestinal distention is self-perpetuating and progressive, intensifying the peristaltic and secretory derangements and increasing the risks of dehydration and progression to strangulating obstruction.

Pathophysiology
B. Non mechanical obstruction (Ileus) Ileus is mediated via activation of inhibitory spinal reflex arcs. Anatomically, 3 distinct reflexes are involved: 1.Ultrashort reflexes confined to the bowel wall 2.Short reflexes involving prevertebral ganglia 3.Long reflexes involving the spinal cord

Intestinal Obstruction
Ileus Pseudo-obstruction Mechanical Obstruction (Simple)

Symptoms

Mild abdominal pain, bloating, nausea, vomiting, obstipation, constipation,

Crampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia Borborygmi, tympanic, peristaltic waves, hypoactive or hyperactive bowel sounds, distension, localized tenderness
Isolated large bowel dilatation, diaphragm elevated

Crampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia Borborygmi, peristaltic waves, high-pitched bowel sounds, rushes, distension, localized tenderness
Bow-shaped loops in ladder pattern, paucity of colonic gas distal to lesion, diaphragm mildly elevated, air-fluid levels

Physical Examination Silent abdomen, Findings distension, tympanic

Plain Radiographs

Large and small bowel dilatation, diaphragm elevated

Exams and Tests

Listening bowel sound
If the obstruction has persisted for long time or the bowel has been significantly damaged bowel sounds decrease or silent Paralytic ileus decreased or absent bowel sound.

Tests that show obstruction include:

Abdominal CT scan Abdominal x-ray Barium enema
Barium enema is a special x-ray of the large intestine, which includes the colon and rectum. The liquid called barium sulfate is placed in the rectum that use for contrast .Contrast highlights specific areas in the body, creating a clearer image.

Upper GI and small bowel series

An upper GI and small bowel series is a set of x-rays taken to examine the esophagus, stomach, and small intestine.

Treatment
Initial assessment The first step in treatment is inserting a nasogastric tube to suction out the contents of the stomach and intestines. The patient is then given intravenous fluids to prevent dehydration and correct electrolyte imbalances.
Nonsurgical approaches In some cases of volvulus, guiding a rectal tube into the intestines will straighten the twisted bowels. In infants, a barium enema may reverse intussusception in 50-90%. An air enema is sometimes used instead of a barium enema. The treatment can relieves the obstruction in many infants. In patients with only partial obstruction, a barium enema may dissolve the blockage.

Treatment
Surgical treatment If these efforts fail, surgery is necessary. The obstructed area is removed and part of the bowel is cut away. If the obstruction is caused by tumors, polyps, or scar tissue, they are removed. Hernias, if present, are repaired. Antibiotics are given to reduce the possibility of infection.

Prevention
Most cases of intestinal obstruction are not preventable. Surgery to remove tumors, polyps, or gallstones helps prevent recurrences.

Prognosis
Mortality Delayed diagnosis of volvulus in infants has a mortality rate of 23-33% with prompt diagnosis and treatment the mortality rate is 3-9%. The bowel either strangulates or perforates, causing massive infection. With prompt treatment, most patients recover without complications. Recurrence As many as 80% of patients whose volvulus is treated without surgery have recurrences. Recurrences in infants with intussusception are most likely to happen during the first 36 hours after the blockage has been cleared. The mortality rate for unsuccessfully treated infants is 1-2%.