Case 5 - GIT

Priscilla Sari

Defecation

Sherwood, Human Physiology

Mass motility in colon push colon contents into

the rectum rectum streched stimulate the
strech receptor on the wall of rectum defecation
reflex
Reflex by : relaxation of M. Sphincter Ani Internus
(smooth muscle) colon sigmoid & rectum
contraction stronger
And M. Sphincter Ani Externus (striated muscle)
relax defecation process
Defecation is helped by simultaneous contraction
by stomach muscle and force expiration increase
intra-abdominal pressure push out the stool

Defecation

Krauses food & nutrition Therapy

WEIGHT OF
STOOL

FREQUENCY

TRANSITE TIME

ADULTS

From one stool every

100-200 g daily three days to three
times per day

30-48 hours

CHILDRE
N

Lesser than
adult

8,5 hours

Two or three stools

daily

Individuals who consume a diet that contains the

recommended amounts of dietary fiber in the form of
fruits, vegetables, and whole grain breads and
cereals, legumes, seeds, and nuts tend to have larger,
softer stools that are relatively easy to pass
The recommended amounts of dietary fiber = 14 g/
1000 kcal
Children = 19-25 g daily
Adults = 25-38 g daily

Normal defecation frequents

for children
Age

Defecation per
week

Defecation per day

0-3months
-Breastfeeding
-Formula feeding

5-40
5-28

2,9
2,0

6-12moths

5-28

1,8

1-3years

4-21

1,4

>3years

3-14

1,0

Defecation Constipation
Sherwood, Human Physiology

Defecation is delayed too long time

constipation, why???
Colon contents detained H2O
absorp stool becomes hard and
dry constipation

Constipation

Krauses food & nutrition Therapy

Definition of constipation tend to be

highly subjective but usually include
hard stools,straining with defecation
and infrequent large bowel movements
Most common causes in adults :

Lack of response to the urge to defecate

Lack of fiber in diet
Insufficient fluid intake
Inactivity
Chronic use of laxatives

Constipation
Buku Ajar Gastroenterologi Hepatologi IDAI

Most common causes in children :

Functional
Anal fissure
Virus infection with ileus
Diet
Drugs

Epidemiology of
Constipation

Current Surgical : Diagnosis & Treatment

Buku Ajar Gastroenterologi-Hepatologi IDAI

Severe idiopathic constipation is

more common in women, often
begins in adolesence and worsens
during 20s or 30s
In children, most common etiology of
constipation is feces retention cause
of pain when defecation before,
usually with anal fissure

Diagnosis of constipation
STEP 1 : Constipation /
Pseudoconstipation ??
Consistency and frequent of feces
Palpation of abdomen
Digital rectal examination (if needed)
STEP 2 : Acute / Chronic Constipation ??
Acute constipation : 1-4 weeks or less
Chronic : more than 1 month

Chronic Constipation in
children
Anamnesis

Constipation
Anorexia
Weight loss
Encopresis
Physical Examination
Abdominal distention with disorder of peristaltic frequent
Abdominal mass on palpation in lower quadrant
abdomen
Feces mass in rectum, colon sigmoid, colon descenden,
all parts of colon
In severe case : anal fissure and distention of ampula
recti

Pemeriksaan penunjang

Foto polos abdomen

Barium enema test
Biopsi hisap rektum
Pemeriksaan manometri
Pemeriksaan lain untuk mencari
penyebab organik

Complication of constipation
in children

Anal pain and abdominal pain

Anal fissure
Encopresis
UTI / ureter obstruction
Prolaps rectum
Solitary ulcer
Stasis syndrome

Colitis : inflammation of
colon
INFECTIVE COLITIS
Shigellosis

Lower abdominal pain, dysentery, fever

Tuberculosis Colitis

Mass in RLQ, diarrhea with blood,

subfebris

Amebic Colitis

Dysentery and the other symptoms

(based on the clinical condition)

Pseudomembran Colitis

Diarrhea, cramp and pain abdominal,

fever, leucositosis, abdominal tenderness

NON-INFECTIVE COLITIS
IBD

Ulcerative Colitis
Chrons disease

Radiation Colitis
Ischemic Colitis
Simple Colitis

Diarrhea, fever, anemia, malnutrition

Nausea, vomit, diarrhea, tenesmus,
hematocezia, colic

Inflammatory Bowel Disease

Two major forms of IBD : Chrons disease
and ulcerative colitis
But, if we difficult to differentiate both :
indeterminate colitis
Cause of IBD is not completely understood,
but in involves the interaction of the GI
imun system, genetic, and environment
factors
General clinic characteristics of IBD :
diarrhea, fever, weight loss, anemia,
malnutrition, FTT

Specific clinic
characteristics
of
IBD
ULCERATIVE COLITIS vs. CHRONS
DISEASE
ULCERATIVE COLITIS

CHRONS DISEASE
Presentation
Perianal disease
Mass in abdomen
Abdominal pain (65%)

Bloody diarrhea

Gross Pathology
Rectum always involved
Thin wall
Stricture <<
Diffuse ulceration

Rectum may not be involved

Thick wall
Stricture >>
Cobblestone appearance

Histopathology
No granulomas
Inflammation <<
Deeper ulcers
Pseudopolyps

Granulomas
Inflammation >>
Shallow ulcers

Cancer of the
Large
Intestine
RIGHT COLON :
-Unexplained
weakness or anemia
-Occult bleeding in
feces
-Dyspeptic symptoms
-Persistent right
abdominal discomfort
-Palpable abdominal
mass
-X-ray findings
-Colonoscopic findings

LEFT COLON :
-Change in bowel habits
-Gross blood in stool
-Obstrutive symptoms
-X-ray findings
-Colonoscopic or
sigmoidoscopic findings
RECTUM :
-Rectal bleeding =
hematochezia
-Alteration in bowel
habits
-Sensation of
incomplete evacuation
-Intrarectal palpable
tumor
-Sigmoidoscopic

Laboratory findings

Urinalysis*
Leukocyte count*
Hemoglobin*
Serum proteins
Calcium
Bilirubin
Alkaline phosphatese
Creatinine

Chemical tumor marker = carcinoembryonic

antigen (CEA)

Special examination for colon

cancer
Proctosigmoidoscopy
Typical cancer : red, raised, centrally
ulcerated, bleeding slightly
Colonoscopy
Should be done before operative
treatment

Differential Diagnose of
colorectal cancer

Diverticular disease
Ulcerative colitis
Chrons disease
Ischaemic colitis
Amebiasis

Polyps of the colon and

rectum
TYPE
HISTOLOGICAL DIAGNOSIS
Neoplastic

Adenoma
Tubular adenoma (adenomatous polyp)
Tubulovillous adenoma (villoglandular
adenoma)
Villous adenoma (villus papilloma)
Carcinoma

Hamartomas

Juvenile polyp
Peutz Jeghers polyp

Inflammatory

Inflammatory polyp (pseudo-polyp)

Benign lymphoid polyp

Unclassified

Hyperplastic polyp

Miscellaneous

Lipoma
Leiomyoma
Carcinoid

Sign and symptoms

Most polyps = asymptomatic
Large lesion
Rectal bleeding = red or dark red
Large benign tumors
Tenesmus
Constipation
Increased frequency of bowel movements
Polypoid tumors
Peristaltic cramps
Obstuctive sydrome; like IBS and diverticular disease
If polyp very long prolapse anus, most frequent with
juvenile polyps