Muntah dan Kembung

Pada Bayi dan Anak

( Pendekatan Klinis )

Kustiyo Gunawan
FK Unair Surabaya

Bilious vomiting in the newborn: how often is further investigation undertaken?

Gregor M. Walker*, Peter A.M. Raine
Journal of Pediatric Surgery (2007) 42, 714 716

Results: A return rate of 81% was achieved. Most neonatologists (80%) would admit a neonate with a single bile vomit to the special care baby unit (SCBU), but more than 50% did not consider an upper gastrointestinal contrast study appropriate. One third felt that pediatric surgical referral is not appropriate for a single bile vomit. In a neonate with persistent bile vomiting, pediatric surgical referral was considered the highest priority.

Bilious Vomiting in the Newborn: How Often Is It Pathologic?

By Prasad Godbole and Mark D. Stringer Leeds, England
J Pediatr Surg 37:909-911. Copyright 2002, Elsevier Science (USA).

Conclusions: These data emphasize the maxim that bilious vomiting in the newborn should be attributed to intestinal obstruction until proved otherwise. However, in this prospective audit, bilious vomiting was not caused by intestinal obstruction in 62% of cases, and most of these infants suffered no further sequelae.

Intestinal malrotation must be excluded specifically.

Vomiting, Regurgitation, Rumination

Vomiting : Keluarnya isi lambung/usus dari mulut secara sadar disertai kontraksi dinding abdomen

Regurgitation: Keluarnya makanan tanpa tenaga, biasanya berasal dari esofagus (pseudovomiting)

Rumination : Secara sadar dan otomatis membawa makanan ke mulut dikunyah ditelan dibawa ulang ke mulut

Kausa Mutah
Iritasi ujung saraf di peritoneum atau mesenterium Obstruksi organ berrongga (intestine, ren, ureter, uterin canal, vermiform appendix)

Gangrenous appendix Acute Pancreatitis Strangulation Torsion of the pedicle of an ovarian cyst

Peristaltic contraction

Stretching of the muscular wall/spasm Pain (colic) Vomiting (occurs at the height of the spasm)

Relationship of Vomiting
Pain Frequency of The Vomiting Directly with acuteness (appendicitis, pancreatitis) Character of The Vomiting Duod. atr HPS Int. obstr Vomiting early, obstr.of the Sudden & violent colon no vomit (acute obst.ureter if vomit, /Bile duct) incomp. IC valve Vomiting after pain, depend on how high of intestinal obst. Acute loss of appetite & pain (appendicitis) same stimulus different grade Delayed passages of meconium Nausea & loss of Others Appetite symptoms (no vomit)

Vomiting Comming after pain (appendicitis)

Nausea

Vomiting

Vomiting (Prompt Dx and Tx)

Abdominal Emergencies Not Surgical Extra GI origin GI origin (inf.of the gut) indoubt indefinite symptoms

Discuss w a i t (discuss)CT,US

Bilious Persistent Acute loss of appetite Blood Pain Urgent need operation Delayed Transfer

Psychogenic Infectious pathology Neuromeningeal inf Metabolic pathology Intoxication

improve not improve observes

judge

correct diagnosis

Short gut survive syndrome

urgent need for operation

Importance of evaluating for cow's milk allergy in pediatric surgical patients with functional bowel symptoms
Kayo Ikedaa, Shinobu Idaa, Hisayoshi Kawaharab,., 1, Koji Kawamotoa, Yuri Etania, Akio Kubotab Journal of Pediatric Surgery (2011) 46, 23322335

Conclusions: A high index of suspicion regarding the possibility of concurrent CMA may be necessary to manage bowel symptoms in pediatric surgical patients.

ILEUS
Intestinal dilatation, Hypersecretion, bacterial overgrowth

Mechanical obstruction (extrinsic/intrinsic)

Non mechanical obstruction (GI paralysis, pseudo-obstruction)

Acute/Chronis

Partial/Complete

Simple / Closed loop (Traps the bowel mesentery) Blood supply compromise Ischemia Necrosis Perforation Strangulation Hernia, adhesion, volvulus

Intraabdominal adhesion Stricture Tumor Congenital

HISTORY AND CLINICAL SETTING

CC: Acute obstipation, Abdominal pain, Distention, Nausea, Vomiting Mechanical obstruction Middle of the abdomen Severe Increase severity and depth overtime Pseudoobstruction Diffuse of the abdomen Mild Increase severity and depth overtime

Pain location Pain severity Pain character

: : :

Pain decrease (fatique) Proximal Int. Obst. : Short periodically 3 4 Periodicity of Pain Distal small /large bowel: 15 - 20

Pain _____________________________ Nausea, vomiting, cramping

Abdominal distention

Sudden

Progressive partial

CAUSE AND TYPE OF BOWEL OBSTRUCTION In Hospital Medical History & Courses Medication: anticoagulants chemotherapy Metabolic Abdominal radiation Severe infection Fluid & elect imbalance Narcotic Intraabd. inflammation

Medical History Previous episodes of Bowel obst: etiology ? response of Tx ? Previous of abd/pelvic Operation: Operative report History of malignancy recurrence ? History of intraabdominal inflammation @Abdominal

Distention

Abdominal Pain

Abdominal Distention, Nausea, Vomiting

Gradual change in bowel Developing many Minimal crampy abd. In hospital Habit weeks Nausea Progressive abdominal Vomiting Distention Mild /crampy pain after Longstanding intermittent Meals mechanical obstruction Weight loss

Chronic Partial Mechanical Chronic process/ Chronic Intestinal Gastric atony Bowel Obstruction Progressive Partial Pseudo Obstruction Smallbowel Ileus Bowel Obstruction (CIPO) Acute Colonic Last flatus Pseudoobstr. Partial @ Complete

Cows milk protein allergy presenting with Hirschsprungs diseasemimicking symptoms

Akio Kubotaa,*, Hisayoshi Kawaharaa, Hiroomi Okuyamaa, Yoshiyuki Shimizua, Mariko Nakachob, Shinobu Idab, Masahiro Nakayamac, Akira Okadaa Journal of Pediatric Surgery (2006) 41, 2056 2058

Conclusion: The proportion of CMA in the cases presenting with HD-like symptoms in the neonatal period is much higher than what we expected, and most cases of BTNIN (benign transient nonorganic ileus of Neonates) are caused by CMA. If HD is ruled out, CMA should be considered.

Whole intestinal pattern on plain abdominal xray. Both the colon and small intestine are markedly dilated. A few air-fluid levels are observed.

Contrast enema. The size of the rectum and colon is normal, and no caliber change is observed, but the rectum and ascending colon demonstrate irregularity of the wall.

PHYSICAL EXAMINATION AND RESUSCITATION Sense of the Px illness & course INITIAL STEP Assessing the Px vital sign, hydration status, CP system Volume ? NG Tube Clear Bilious non feculent - Prox. SBO -Colonic obst+comp. IC valve Feculent -Distal SBO

Physical Examination
Urine

Character Volume Character

IV line: water & electrolyte replacement

Degree of distention: Prox little/no distention

Scar Observation Malignancy Asymetri Abscess Closed loop Peristaltic waves: acute SBO High pitch + rush + crumpy pain: Obstructive process Bowel sound Intestinal paralysis Intestinal fatique Longstanding obstruction Closed loop obstruction Guarding Rebound tenderness Strangulation Localized tenderness Dullness mass Tympani distended bowel Rectum : Mass ? Fecal impaction ? Occult blood ? Ileostomy : Exam stoma ( obstruction at the level of the stoma )

Auscultation

Palpation Percussion

Toucher

K e s i m p u l a n:
Tidak ada pemeriksaan tambahan sebelum pertimbangan klinis Anamnesis dan pemeriksaan fisik harus terstruktur Diagnosis dan penangana dini Keterlambatan : kematian / sequele