CASE REPORT

Sunday, March 16 th, 2014

Team on duty :
dr. Razi
dr. Nizarli
dr. Guruh
dr. Pinim
dr. Andri
dr. Mohan
dr. Aswad.
I.

Patient identity
Name
Age
Sex
Address
CM
Phone
Body weigh
Patient came

: Rizqia Amalia
: 7 month old
: Girl
: Mns Teungoh meurah dua, Kec. Bandar Baru, Kab Pidie Jaya
: 97 07 86
: 085290445442
: 6000 gr
: at 13.22 PM

II.

Chief complain
Abdominal distention

III.

Patient illnes history

The patient referred from Bireuen district hospital with the chief complain
Abdominal distention for 2 day. The patient also with vomite whatever she eat and
drink. The last defecation was yesterday. There was history of devidece
colostomy due to anal imperforate high level with rectovaginal fistula and PSARP
before .

IV.

Physical examination
VS/ :
Consciousnes
Pulse
Respiratory Rate
Temp

: Alert
: 140 beats/mnt
: 38 breaths/mnt
: 36,7 C

L/S a.r. Abdomen

I
: Distension (+) ,colostomy (+) , bowel countour (-), redness at the
flank and umbilical region (-)
A : Bowel sound was increase
P : Pain(-), musculair rigidity (-)
P : Liver dullness (+)

Rectal toucher :
Spincter ani was tight
Recti ampulla feces (-)
Smooth mucose
Pain
: (-)
Gloove : Blood (-), feces (-)
V.

Assessments:
Total mechanical bowel obstruction due to susp. Adhesion and divided colostomy

VI.

Management
Stop oral intake
IVFD RL : Maintenance 600 cc/24 hours 25 cc/hours
Rehidration : 10% x 6000 = 600cc/6 hours 100 cc/hours

25 + 100 = 125 cc/hours for 6 hours

Inj. Ceftriaxone 300 mg
Inj. Metamizole sodium 80 mg/ 8 hours
OGT Greenwish
Catheter urine 8 cc/hours
Time
Volume (cc)
19.00
2 cc
20.00
5 cc
21.00
7 cc
22.00
7 cc
23.00
9 cc
00.00
8 cc
Routine Laboratory examination
Radiology Examination
VII.

Laboratory result
Hb
: 11,3 gr/dl
WBC
: 22.700 /ul
Trombocyte
: 737.000 /ul
HT
: 33 %
CT
: 6 minutes
BT
: 2 minutes
Potassium
: 4.2 Meq/l
Sodium
: 133 Meq/l
Cloride
: 95 Meq/l

VIII. Radiology
Baby Gram
There was Dilated of the small bowel
There was gas distribution throught to distal

IX.

Diagnose:
Total mechanical bowel obstruction due to susp. Adhesion + divided colostomy

X.

Consult to Pediatric surgery division :

Laparatomy exploration and colostomy clossure

XI.

Intra operative
Patient was supine position with general anesthesia.
A and anti septic procedure.
Clossure proximal colostomy
Performe incision parastoma until peritoneum;
Performe release of the stoma from abdominal wall.
There was found dilated small bowel adhesions and intestine can not be
excluded from the first incision.
Supra umbilical transverse incision, deeper until peritoneum
Entire colon removed, it appears the adhesions between the bowel with right
lower anterior abdominal wall which formed a band at a distance of 90 cm and
120
cm proximal from ileus caecal valve .There was found laceration
serosa
120 cm from ileus caecal valve and performe closed with primary suture
All of the ulserated bowel is viable
Performed anastomosis colon
The abdominal cavity irrigated with warm NaCl 0,9 % until clean
The incision wound was closed with primary suture.

XII.

Diagnose Post Operative

Total mechanical bowel obstruction due to band + colostomy (ICD 10 CM K66.0)

XIII. Patient follow up

Date
19-3-2014
2nd
day
post
operation

S
abdomin
al
distantio
n (-)

O
General Condition :
Pulse : 90 beats/mnt
RR : 20 breaths/mnt

A
Total
mechanical
bowel
obstruction due
L/S ar. Abdomen
to band +
I : distention (-),
colostomy
A : Bowel sound (+)
(ICD 10 CM
P : Musculaire rigidity K66.0)
(-)
P : Tymphani (+)
Post
laparotomy
exploration
release of band
and colostomy

P
IVFD RL 600
cc/day
Ceftriaxone
Inj 300 mg/12
hr
Metronidazol
50 mg/8hr
Metoclorpamid
e 1,5 mg /12hr
Antrain
inj
150 mg/8 hr
Aminofusin
120 cc/24hr
Observation

closur

urine out put

10 cc/hr