LI LBM 3

Adita Ayu Aprilia

30101407112
1. What are the anatomy, histology and physiology of intesetine?
2. What causes bloating, decreasing urin output and stomached?

Blockage of the intestine or bowel obstruction can cause distension fluid

and electrolytes in the lumen of the intestine, it can stimulate the activity
of fluid secretion into the intestinal lumen and even a large amount of
protein is lost from the circulation, partly into the intestine and partially
into the wall of the intestine that can cause edema wall intestine and
plasma volume is reduced in excessive distension. Due not match the
increase in the rate of absorption pace with the increase in bowel
distension resulting reduction in the volume of fluid in the blood vessels
and lead to a decrease in renal activity so that the process of diuresis
decrease decreasing urine

Textbook of Medical Physiology, Guyton & Hall

3. Why he hasn’t passed stool and flatus since two days ago?

Because of an obstruction. Clogged intestinal lumen will progressively stretched by

liquid and gas. Gas and fluid accumulation in the intestinal lumen proximal of the
location of the obstruction resulted in severe distension of the intestinal wall that
will reduce the flow of water and sodium from the lumen of the gut into the blood
and cause rapid accumulation of intra-luminal quickly decreases absorption due to
stretching of the bowel so that disrupt the process of spending feces and gas.

Textbook of Internal Medicine, Vol IV

4. Why for the last one day he has vomit and greenish colour?
5. Why the doctor asked aboutthe stool that black, mucous, and blood?

Normal stool has brown color, it is associated with the presence of bilirubin
and its derivatives are stercobilin and urotilin and activities of normal
bacteria found in the intestinal. Bilirubin is a yellow pigment in bile. Stool
can be another color, especially when there are things that are abnormal.
For example; Stool black as pitch, this indicates bleeding from the stomach
or small intestine; color clay (acholic) showed a decrease in bladder
function; green or orange indicate an infection of the intestinal tract. Food
can also affect the color of feces, for example: sugar beet change the feces
to be red, sometimes green. Medications can also change the color of the
stool, such as iron, can make the stool black.
Under normal circumstances, the stool contains 60-90% of the remaining
approximately 25% water containing solids, diarrhea water can reach more
than 90% in patients with intestinal obstruction but this situation can be
turned around with the composition contains less water and more dense
substances. This happens because the contents and loss of fluids and
electrolytes in the body, especially the intestines.

Junadi P,Soemasto AS,Amels H.eds.Kapita selekta kedokteran. Edisi Ketiga

Jilid Pertama.Media Aesculapius FKUI.2000
6. What is the correlation between chronic cough with the symptoms?

Junadi P,Soemasto AS,Amels H.eds.Kapita selekta kedokteran. 3rd ed Media Aesculapius FKUI.2000
7. Why the mass appears in standing position, cough and straining, but disappears when the position lying
and pushed back with his finger?

Junadi P,Soemasto AS,Amels H.eds.Kapita selekta kedokteran. 3rd ed Media Aesculapius FKUI.2000
8. What are the correlation between his occupation with the symptomps?

One factor Hernia develops when intra-abdominal growing pressure as the

pressure when lifting something heavy (patient’s occupation is market
porter), when the bowel movement or coughing strong or sneezing and
displacement of part of the intestine to the abdominal muscles, excessive
pressure on the area abdominal it certainly will causing a weakness may
be due to abdominal walls are thin or not sufficiently strong in the area.
First of all damage is very small in the abdominal wall, then going hernia.
Because the organs are always doing a tough job and takes place in a long
time, so there was a protrusion and cause severe damage. thus eventually
causing the bag contained in the stomach into or experiencing weakness if
the blood supply is disrupted dangerous and can lead to gangrene (Oswari,
E. 2000).

Junadi P,Soemasto AS,Amels H.eds.Kapita selekta kedokteran. 3rd ed Media Aesculapius

FKUI.2000
9. Why the patient found the abdominal pain?
10. What are the interpretation of physical exam?

Pain indicates irritation of the peritoneum, the presence of free air or

free fluid can also be determined by percussion through examination
of heart and shifting dullness. In patients with peritonitis, hepatic
dullness would disappear, and percussion abdomen hiper-timpani
because of the free air earlier. Hipertimpani occur because of the
presence of air in the abdominal cavity  bloating

Campbell, Brendan., 2007. Abdominal exploration.

Due to obstruction in the distal lead accumulation of feces and the air
in the proximal thus will result in increased peristalsis to push the
stool proximally, and the percussion will happen hypertimpani causes
the accumulation of air in the proximal ileus in the abdominal cavity,
When there is intestinal obstruction, increased peristaltic accompanied
by pain (borborygmi). When the obstruction is more severe, abdomen
enlarged and tense, peristaltic higher as keeping clinking coins
(metallic-sound).
Matallic voice sound is a typical situation in patients with intestinal
obstruction ("tinkling", quiet = late). Sounds like this may occur due to
the collision of air and liquid because of blockage and mass
accumulation in the form of feces in the intestine.

http: //www.ncbi.nlm.nih.gov/pmc/PMC339403/
11. What are the DD?
a. A hernia is a protrusion or fill a cavity through a defect or weak parts of the wall
cavity concerned consisting of rings, bags, and the contents of the hernia
(Sjamsuhidajat R and Wim De Jong, 2005).
b. Obstruction mechanical ileus is an intestinal blockage that occurs because of the
mechanical work or power affects the intestinal wall, causing narrowing / blockage
of the intestinal lumen.

http://emedicine.medscape.com/article/2242141-differenti
Buku Ajar Ilmu Bedah, R. Sjamsuhidajat,
EGC
12. What kind of hernia?
a. By place:
- Inguinal Hernia
Is herniation of abdominal contents appear in the area between the
thighs (regio inguinal).
- Femoral Hernia
Abdominal hernia contents are visible in the area of the femoral fossa.
- Umbilical Hernia
Abdominal hernia contents are visible in the area of the stomach
contents.
- diaphragmatic hernia
Hernia is a hole that goes through the diaphragm into chest cavity.
- hernia nucleus pulposus (HNP).
b. By its nature
- Hernia reponibel
Namely the hernia contents can still be restored to the cavity Abdominal
again without surgery.
- Hernia ireponibel
Namely the hernia contents of the bag can not be returned to the cavity.
- Hernia accreta
Namely the contents of the bag on peritoneal adhesions hernia bag.
- incarcerated hernia
That is when the hernia contents squeezed by a hernia ring.
c. By contents
- Hernia adipose
Hernia contents are composed of fatty tissue.
- Hernia litter
Hernia is incarcerated or partially Strangulated the gut wall are wedged in
the ring of hernia.
- Slinding hernia
Hernia contents become part of the wall bag of hernia. (Sjamsuhidajat,
2004).

Buku Ajar Ilmu Bedah, R. Sjamsuhidajat, EGC

13. What are thelaboratory exam needed?
Laboratory and radiographic studies are used to help differentiate the two important
clinical aspects of this disorder: strangulation vs. Non-strangulation and partial vs.
complete obstruction.
Leukocytosis, with shift to the left, usually occurs when strangulation is present, but a
normal white blood cell count does not exclude strangulation.
Elevation of the serum amylase level is encountered occasionally in all forms of intestinal
obstruction.
Radiographic images demonstrating distention of fluid- and gas-filled loops of small
intestine usually arranged in a "stepladder" pattern with air-fluid levels and an absence or
paucity of colonic gas are pathognomonic for small-bowel obstruction. Complete
obstruction is suggested when passage of gas or stool per rectum has ceased and when
gas is absent in the distal intestine by x-ray. A general haze due to peritoneal fluid and
sometimes a "coffee bean"–shaped mass are seen in strangulating closed loop obstruction.
A thin barium upper gastrointestinal series may help to differentiate partial from complete
obstruction. However, thick barium given by mouth should be avoided when the
obstruction is considered to be high grade or complete since retained barium sulfate may
become inspissated and either make an incomplete obstruction complete or be aspirated
into the tracheobronchial tree.
CT is the most commonly used modality to evaluate patients for intestinal obstruction but
differentiating adynamic ileus, partial obstruction, and complete obstruction may be
difficult. The sensitivity and specificity of CT for strangulating obstruction are low (50 and
80%, respectively).

Harrison’s Principles of Internal Medicine, 18th Ed.

14. What are the management of patient?
15. What are the complication of intestinal obstruction?

In the colonic obstruction can occur in the progressive dilatation of the caecum which ended
with
the caecum perforated so that occurs due to contamination of the abdominal cavity with
generalized peritonitis.

Complications of obstructive ileus, among others, the occurrence of intestinal:

a. Bowel necrosis
b. Intestinal perforation due to the obstruction that has occurred is always long on intra-
abdominal organs.
c. Peritonitis due to absorption of the toxin in the peritoneal cavity, so it can make
inflammation or severe infections in intra-abdominal
d. Sepsis due to infection of peritonitis, which is not handled properly and quickly.
e. Shock dehydration caused by dehydration and loss of plasma volume
f. Abscesses short bowel syndrome with malabsorption and malnutrition
g. Pneumonia aspiration of vomit process
h. Electrolyte disturbances. Reflux vomiting may occur as a result of abdominal distension.
Vomiting resulting in loss of hydrogen ions and potassium from the stomach, and cause a
decrease in chloride and potassium in the blood.

Local: bowel necrosis, intestinal perforation, intestinal abscess, aspiration pneumonia

Systemic: sepsis, shock, dehydration, electrolyte disturbance

Buku Ajar Ilmu Bedah, R. Sjamsuhidajat, EGC