CURRICULUM VITAE

• Nama : Dr. Effendie Mansoor, SpRad(K)Abdomen

• Lahir : di Bandung 15 Maret 1954
• Status : Menikah dengan, 4 anak
• Email : effumma@yahoo.co.id

• Riwayat Pendidikan :
• 1978 : Dokter dari FK Universitas Padjadjaran Bandung.
• 1982 : Mengikuti pendidikan spesialis Radiologi.
• 1986 : Mengikuti pendidikan Ultrasonografi di Ultrasonic Institute University of Zagreb
dan Kursus reguler Ultrasonografi di Ian Donald Ultrasonic School Dubrovnic Croatia
• 1987 : Lulus sebagai Spesialis Radiologi.
• 2008 : Konsultan Radiologi bidang Radiologi Abdomen
• 2013 : Training Basic MRI, Jakarta, PDSRI, 17 – 20 Januari 2013
• 2014 : 12th ABDA (Asian Breast Disease Association) Teaching Course, Bali 17-18
Oktober 2014.
• 2014 : Training CT Thorax & Abdomen, Jakarta, 2-4 Maret 2014
• 2015 : Training CT Cardiac dan CTA, Jakarta, 28-30 Agustus 2015.
• 2016 : The 1st ASAR (Asian Society of Abdominal Radiology) Educational Lecture Course
of Abdominal Radiology, Jakarta, 8-9 October 2016
• 2017 : PDSRI : Workshop MSCT and MRI Abdomen, 12th Annual Scientific Meeting,
Hotel Royal Ambarukmo, Jogjakarta, 4 Mei 2017
• 2018 :PDSRI : Workshop Chest MSCT Imaging, Surabaya. 13th Annual Scientific Meeting.
Hotel Shangri La, 5th April 2018.
 CURRICULUM VITAE (lanjutan)
• Riwayat Pekerjaan :
• Institusi Pemerintah :
• 1978 : PKM Batumarta – Sumatera Selatan.
• 1982 : Pendidikan spesialis Radiologi di RS Hasan Sadikin / FK Universitas Padjadjaran
Bandung.
• 1986 : Staf Radiologi RS Hasan Sadikin Bandung.
• 1990 : SMF Radiologi RSU Sumedang.
• 1997 : Pensiun dari PNS

• Institusi swasta :
• 1987 - sekarang : Konsultan di Klinik Harapan Sehat Bandung.
• 1987 – 1997 : Konsultan di Lab. Klinik Biotest Bandung.
• 1990 – sekarang : Konsultan di RS Bungsu.
• 1993 - 1996 : Konsultan di Lb. Klinik Pramita Bandung.
• 1997 - 2005 : Konsultan di RSU – Bina Sehat Bandung.
• 2000 - 2007 : Konsultan di RS Muhammadiyah Bandung.
• 1997 - 2012 : Kosultan di SMF Radiologi RSI Al Ihsan Bandung.
• 2008 – 2012 : Konsultan di Lab. Prodia Bandung
• 2012 – sekarang : Eka Hospital Pekanbaru
 CURRICULUM VITAE (lanjutan)
• Aktifitas Profesi :
• Anggota IDI.
• Anggota PDSRI.
• Anggota PERABDIN
• Anggota PUSKI .
• 1989 – 1991 : Ketua PUSKI Jawa Barat.
• 1999 – 2002 : Ketua Komite Medik RSI Al Ihsan.

• Aktifitas Ilmiah :
• Pengajar berbagai kursus dan pelatihan yang diselenggarakan PUSKI.
• Pengajar berbagai kursus dan pelatihan yang diselenggarakan PDSRI.
• Invited Instructor USG OBGYN di Bag. OBGYN di UNHAS Makasar dan UNSRI
Palembang.
• Dosen di FK Unpad (1987-1990)
• Materi : Radiologi thorax dan traktus gastroenterologi
• Dosen Radiologi di Universitas Islam Bandung dan Universitas Jendral Ahmad Yani
Bandung, 2008
• Member of Sonoworld.com
• Member of Medscape.com
• Member of Obgynnet.com
• Member of Volusonclub.com.
ACUTE ABDOMEN
IN NEONATES
EFFENDIE MANSOOR
 INTRODUCTION

• A neonate with an acute abdomen usually

presents with vomiting, constipation and
distention of the belly.
• When the symptoms are present
immediately after birth, the most common
cause is a gastrointestinal obstruction.
 Acute Abdomen in the Neonates
High obstruction Low obstruction Aquired disease

Esophageal atresia Ileal atresia Necrotizing

enterocolitis (NEC)
Duodenal atresia Meconeum ileus Hypertrophyc
pyloric stenosis
Duodenal web Meconeum plug Incarcerated
inguinal hernia
Jejunal atresia Hirschprung
disease
Anal atresia
• High obstructions are defined as proximal
to the ileum.
Low obstructions are defined as occuring in
the ileum or colon.

• Although in high obstruction vomiting will

be the most striking symptom, whereas in
low obstruction this will be constipation,
both symptoms are often present
concurrently, and the clinical differentiation
between a high and a low obstruction is
difficult.
• Necrotizing enterocolitis (NEC) and hypertrophic
pyloric stenosis are the most common acquired
causes of an acute abdomen in the neonate.

• NEC is most common in prematures, especially

when there is an extreme low birthweight.
Hypertrophic pyloric stenosis typically presents
at the age of 4-8 weeks, but can sometimes
present in the early neonatal period.
 Normal progression of air
- Birth : Stomach
- 1 hour : Duodenum
- 3 hours : Proximal small bowel
- 12 hours : All of the small bowel
- 24 hours : Rectum
 Abdominal radiograph

• In suspected neonatal obstruction the

first step is an abdominal radiograph.

• On the radiograph an obstruction can

only be diagnosed if the bowel has had
sufficient time to become air-filled
after birth.
 Bowelgass pattern on the
radiograph
1 Dilatation
2 Number of dilated bowel loops
3 Small bowel or colon
4 Airfilled rectum
5 Pneumatosis intestinalis
6 Free air and ascites
• In addition to the front view, the dorsal
decubitus radiograph (cross-table view with
horizontal beams) should be performed,
which can depict free air and sometimes
can aid in differentiating the small intestine
from the colon.

• On the radiograph also check lines and

catheters and study the lungs, soft tissues
and skeletal structures.
Calcifications in the abdominal wall can be
seen in meconium peritonitis.
 1. Dilatation?
• When the bowel measures more than the
interpedicular width of L2, it is said to be
dilated.
• Massive dilatation is seen in complete
obstruction and is accompanied by fluid levels
on the dorsal decubitus radiograph.
• However, fluid levels alone do not necessarily
correspond to dilatation, but rather reflect
abnormal peristalsis.
• An unchanging bowel gas pattern over time
indicates absence of peristalsis.
Meconeum ileus – massive jejunal atresia
 2. Number of dilated loops?

• Up til three dilated small bowel loops on

an abdominal radiograph generally
indicate a high obstruction.

• More than three dilated loops indicate a

low obstruction.
Jejunal atreasia - ileal atresia
 3. Small bowel or colon?
• Since neonates do not have haustra in the colon
yet, it is often impossible to discriminate between
small bowel and colon on an AP radiograph.
A dorsal decubitus radiograph may help as colonic
obstruction may produce long fluid levels.
• Furthermore, the colon ascendens, descendens and
rectum are more dorsally located structures.
To discriminate small bowel from large bowel with
certainty is only possible with a colon enema.
 4. Airfilled rectum?

• If sufficient time has gone by after birth,

the rectum will be filled with air.
Absence of rectal air indicates an
obstruction.

• In Hirschsprung's disease there is usually no

air in the rectum or only a thin stripe of air.
 Pneumatosis intestinalis ?
• What at first sight looks like granular feces in
the bowel is actually caused by gas in the
bowel wall seen en face.
• Air in the bowel wall is most easily recognized
when seen in profile as linear black lines that
parallels the bowel lumen .
• Pneumatosis intestinalis is defined as gas in
the bowel wall.
• In neonates it is seen in bowel wall ischemia
in necrotizing enterocolitis.
• The air bubbles can be resorbed into
the venous system causing portal
venous gas.

• Pneumatosis intestinalis can lead to

perforation seen as
pneumoperitoneum.

• Late stage of Necrotizing enterocolitis.

 Free air and ascites ?
• Large amounts of free air can be seen on the front
radiograph under the diaphragms.
• Small amounts of free air can only be detected on the
dorsal decubitus radiograph (LLD).
• Ascites can only be suspected on a radiograph when
the amounts are large enough to cause the bowel to
float and cluster in the center of the abdomen
(floating bowel).
• The presence of both ascites, free air as well as
abdominal wall calcifications indicate that there has
been a perforation in utero with meconium peritonitis.
 Congenital high obstruction
• Clinical findings : vomiting is main symptom
• No distal bowel gas ---- complete obstruction
• Most high obstructions occur at the level of the
duodenum.
• Vomiting will be non-bilious if the obstruction is
localized proximal to the Vater ampulla, and bilious
(the color or which is green) if it is localized distal to
it.
• Bilious vomiting is an indication for urgent imaging
as a volvolus may be present.
 Esophageal atresia

• Hypersalivation with lateral

head position

• Feeding tube cannot be passed

• In 80% of cases a distal tracheo-
esophageal fistula is present.
• Less common is :
no fistula - no air in stomach
• proximal fistula - no air in stomach
• two fistulas - air in stomach
• Cases without a distal fistula can be
suspected antenatally when there is a
polyhydramnion and an empty stomach.
• Always screen the radiograph for other
anomalies as esophagus atresia can be
part of the VACTERL association
(vertebral anomalies, anal atresia,
cardiovascular malformations, tracheo-
oesophageal fistula, renal and limb
anomalies).
 Duodenal atresia
Finding in duodenal atresia
• Double bubble sign
• No distal bowel gas
• No further imaging is needed
• Web duodenal
• Polyhydramnion and double cystic sign
antenatally, diagnosis can be suspect
before birth
Atresia duodeni
Duodenal web
 Jejunal atresia
• Jejunal atresia is the 2nd most frequent
cause of upper intestinal obstruction.
• It is caused by an ischemic event in utero.
• Antenatally a polyhydramnion will be
present.
• More atretic foci can be present
simultaneously.
• 3 bubles on radiograph
 Congenital Low Obstruction

• Constipation main symptom.

• Abdominal radiograph > 3 dilated small

bowel loops.

• Microcolon = unuse colon

= obstruction proximal to the colon
• A low obstruction is an obstruction in the
ileum or in the colon.
• Passage of meconium should normally
occur within 48 hours from birth.
• In a low obstruction the neonate will
have difficulty passing meconium or will
not pass any meconium at all.
• Because of the constipation the child will
start to vomit.
 Ileal atresia
• As with jejunal atresia, ileal atresia
results from an in utero ischemic event.

More atretic foci can be present

simultaneously, but the distal ileum is the
most common site to be involved.
 Meconium ileus
• Meconium ileus occurs nearly exclusively
in patients with cystic fibrosis.
• In 10% of patients it is the first
presentation of the disease.
• Due to the exocrine dysfunction of the
pancreas and abnormal intestinal
secretions, the meconium is abnormally
thick and becomes impacted in the
ileum.
Hirschprung disease
 Hirschprung disease
75% short segment Rectum or
rectosigmoid
20% long segment Extended orally in
the colon
5% total aganglionosis Entire colon,
sometimes
involvement of small
bowel
• In Hirschsprung disease the ratio between
the denervated and the non-affected
bowel is <1.
• It is important to describe the length of the
affected segment.
• Most cases are short-segment and total
aganglionosis is rare.
• In case of total aganglionosis the diagnosis
is difficult, because the entire colon has a
small caliber and resembles a microcolon.
 Anal atresia
• The diagnosis of anal atresia is usually
clinically straightforward by inspection
and digital palpation.
• Anal atresia is part of the spectrum of
anorectal and cloacal malformations and
is a complex disorder.
• Knee-chest prone position is need.
• > 2 cm : high type ; < 2 cm : low type
 Acquired causes of acute
abdomen

• Necrotizing enterocolitis (NEC)

• Hypertrophic pyloric stenosis
• Incarcerated hernia
 Necrotizing enterocolitis

Different stage of
Necrotizing Enterocolitis
Bowel dilatatios +/- bowel Wall thickening

Pneumatosis intestinalis +/- portal venous air

Perforation with pneumoperitoneum

• Necrotizing enterocolitis is a severe bowel
inflammation.
• The etiology is not entirely clear and seems to be
a combination of immature bowel mucosa,
infection and ischemia.
• Initially radiographs are nonspecific and may only
show bowel dilatation.
• Pneumatosis intestinalis and portal venous air
(pneumoportogram) can both be seen on
radiographs and with ultrasound.
• The most feared complication is perforation.
 Hypertrophic pyloric stenosis
• Projectile vomiting is the key feature in
patients with hypertrophic pyloric
stenosis.
• There is a familial predisposition and it is
more common in boys.
• Hypertrophic pyloric stenosis typically
presents after the neonatal period, at
the age of 4-8 weeks.
• Ultrasound in a fasting child will show retained fluid
in the stomach. There is no passage along the
hypertrophic pyloric muscle.
• For optimal viewing the child must be positioned
right side down and if the stomach is empty it
should be filled by drinking Pedialyte or glucose
solution during the examination.
• A measurement of more than 3 mm on a transverse
image indicates hypertrophy.
A transverse total diameter more than 14 mm and a
total length of the pyloric canal more than 15 mm
support the diagnosis.
 Incarcerated hernia
• Neonates and especially prematures
have a relatively weak abdominal wall
and inguinal hernias are common,
especially in boys.
• In case of multiple dilated bowel loops
on the radiograph, always check the
groins for the presence of a hernia
containing a bowel loop.