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PATIENTS IDENTITY Name Age Sex Religion Nationality Examination Date HISTORY TAKING Heteroanamnesis was taken on May

6th 2008 (the parents) Chief Complain: bloody-mucous stool Since three days before addmision , patients mother was complaining that bloody-mucous stool and vomited 3 times a day. Patients stomach looks bloated and he seemed to be more irritable, but he still has good apetite. Seven days before, the patient has had fever wich rises and falls gradually with the highest temperature at night. Patient also suffered from cold and cough. Patient taken to RS.Soreang no changes Urinate: normal Past Medical History Family medical history PRESENT STATUS General Appearance : Moderate Consciousness Illness Tension Heart Rate Respiration Temperature : Somnolen : Moderate : -: 130 x/minute, equal, reguler, strong : 34x/minute : 37,5 0 C 1 : Patient had never like this before : No congenital diseases happened in the family : C.W : 5 months : Male : Islam : Indonesian : May 6th, 2008

Weight Height Nutritional status

: 6,5 kg : 62cm : Fine

PHYSICAL EXAMINATION Head Eyes: anemic conjunctiva -/-, icteric sclera -/-, round pupil, isocor diameter 3mm, direct and indirect light reflex +/+ Neck No lymph node enlargement Chest Symetric in shape and movement, left = right Lung: VBS +/+, Rales -/-, Wheezing -/Heart: regular heart sound, souffle Abdomen Inspection Percussion Palpation Anus :+ Inguinal and genitalia Normal Extremities Normal Neurology 2 : distention : hypertympani : distended, saussage sign (+), dance sign (+) Auscultation : bowel sound increase Skin Pale (-), cyanotic (-), turgor: return quick

Physiological reflex +/+ Pathological reflex -/LABORATORY FINDINGS 6/5/2008 jam 7:40 Hb Leucocyt Tc Natrium Kalium : 11,1 g/dl : 14000/mm3 : 365000/mm3 : 137 meq/L : 3,8 meq/L

Random Serum Glucose : 89 mg/dl 6/5/2008 Pre-operation diagnosis: Intussusception ileocolo-colica Post-operation diagnosis: Intussusception ileocolo-colica Operation tehnique: Resection ileocolo-colica + Anastomosis end to end Non-surgical therapy : Metronidazole 2x25mg Cefotaxime 3x200mg Gastridin 3x0,2cc Kalmethasone 3x0,3cc Novalgin 3x0,2cc prn IV line : RL 500cc + D5% 200cc + Aminofusin paed 100cc/day Feeding test D5% 10cc/3 hour Prognosis Quo ad vitam: ad bonam Quo ad fungtionam: dubia ad malam

RESUME
Anamnesis A male baby, 5 months old, moderate ill, Somnolen, no anemic conjunctiva, no icteric sclera, no cyanotic, came to Immanuel Hospital on May 5th 2008, with chief complain bloody-mucous stool Since three days before addmision , patients mother was complaining that bloody-mucous stool and vomited 3 times a day. Patients stomach looks bloated and he seemed to be more irritable, but he still has good apetite. Seven days before, the patient has had fever wich rises and falls gradually with the highest temperature at night. Patient also suffered from cold and cough. Patient taken to RS.Soreang no changes Urinate: normal, no greenish stain on the diaper. Past Medical History Family medical history : Patient never experienced this circumstance before : No family history of congenital diseases

On Physical Examination The vital signs are normal Abdomen Inspection Percussion Palpation Anus :+ On Laboratory findings Hb 11,1g/dl : distention : hypertympani : distended, saussage sign (+), dance sign (+) Auscultation : bowel sound increase

Leucocyt DIAGNOSIS

14000/mm3

Preoperation Diagnosis Intussusception Ileocolo-colica Postoperation Diagnosis Intussusception Ileocolo-colica THERAPY Resection ileocolo-colica + Anastomosis end to end PROGNOSIS Quo ad vitam Quo ad functionam : ad bonam : dubia ad malam

INTUSSUSCEPTION
Introduction Intussusception is derived from the Latin words intus (within) and suscipere (to receive). Intussusception is the invagination of one part of the intestine (proximal portion of intestine Intussusceptum) into another (distal portion Intussuscipiens). Intussusception can be Ileoileal, Ileoileocolic, Ileocolic, Colocolic. Incidences The incidence of intussusception is 1.5-4 cases per 1000 live births, with a male-tofemale ratio of 3:2. The greatest incidence of idiopathic intussusception is in infants aged 9-24 months. A seasonal incidence has been described, with peaks in the spring, summer, and the middle of winter. These periods correspond to peaks in the occurrence of seasonal gastroenteritis and upper respiratory tract infections. Etiology and Pathogenesis Etiology of Intussusception is Pathological Lead Point (PLP), where at this point, there is disturbance of Intestinal motility, but in the most pediatric cases (95%), there is no any identifiable specific lead point that may cause intussusception, and may related to alteration of the feeding pattern. Intussusception is related with the marked swelling of the lymphoid tissue within the region of ileocaecal valve. The evidence show that reccurent viral Gastroenteritis and viral URTI, and Rota virus vaccine have significant role that cause swelling of the lymphoid tissue in Ileocecal valve region. The incidence of the pathologic lead point is up to 12% in most pediatric series and increases directly with age, more commonly found in children older than 3 years old. The most common PLP for Intussusception is the Meckels diverticulum, however other causes must be considered including polyps, appendix, intestinal neoplasm, submucosal hemorrhage due to Henoch-Schonlein Purpura, etc. Telescoping process can cause vascular compromise, edema with venous obstruction, and bowel ischemia due to arterial obstruction. Damage of the bowel wall and 6

vascularisation can cause diarrhae and bloody-mucous stool (currant jelly stool). Clinical Findings Symptoms : Crampy abdominal pain, occurring intermittently every 5-30 minutes. During these attacks, the infant screams and flexes at the waist, draws the legs up to the abdomen. Pale, diaphoretics Vomiting Lethargy, dehydration Currant jelly stool Signs : Distended abdomen Saussage sign in Abdominal palpation Dance sign Digital Rectal Examination: Currant jelly stool Diagnosis Complete Blood Count (CBC): Anemia, Leukocytosis, Dehydration. Plain radiography: dilated small intestine loop, with or without air fluid level. USG: Donut or Target sign, Pseudokidney sign Diagnostic and therapeutic enema (Barium & Pneumatic) Diagnosis is established by clinical findings and imaging findings. Complication Dehydration Sepsis 7

Bowel necrosis Peritonitis Therapy Initial : NPO, IV fluid, monitoring output urine, NGT Non Operative technique (initial sign less than 24 hours): Barium enema, Pneumatic enema Operative technique (Peritonitis, failed by contrast enema): a. Retrograde milking of the Intussusceptum, not pull apart b. Resection of the necrotic bowel segment and anastomosis

BIBLIOGRAPHY
1. Sigmund H. Ein and Alan Daneman. 2006. Intussusception. Pediatric surgery. 6th edition. Mosby. Page 1313-1337. 2. Warner BW. 2004. Pediatric Surgery in: Sabiston Textbook Of Surgery. 17th edition. Townsend CM (ed.). NewYork: Elseviere Saunders. p. 2112-2113. 3. Intussusception. www.emedicine.com/intussusception. 2 Mei 2008