INVAGINASI

Dr. AHMADWIRAWAN Sp.B. SpBA

Sub Bagian Bedah Anak

Bagian Bedah
Fakultas Kedokteran
Universitas Hasanuddin
Makassar
 DEFINISI
Keadaan dimana suatu segmen prox.
usus masuk kedlm lumen usus yg lebih
distal, yg menyebabkan penyumbatan
lumen usus sebagian/seluruhnya

strangulasi & nekrosis usus

 SEJARAH
Zaman Hippocrates dikenal tx enema
(memompa udara ke dlm anus)
Thn 1950 Hirschprung, laporan ttg
penggunaan tek.hidrostatik sbg pengobatan
invaginasi
Pengobatan pembedahan dilaporkan berhasil
Thomson,1835,Tennessee
Ravitch,1959 menjelaskan aspek penyakit
invaginasi
 ETIOLOGI
Penyebab pasti blm diketahui
Faktor pencetus :
divertikulum meckeli, polip usus,
duplikasi usus, limfoma.
Beberapa kasus terdpt spasme
lokal, rotavirus pada feses bayi
diare hiperperistaltik & hipertrofi
folikel kel.lemfe atau Peyers patch
pd ileum terminalis
 PATOFISIOLOGI
Terjadi pada usus halus bag.proksimal
ileosekal, Ileum + mesenterium masuk
ke sekum kolon ascendens
kadang mencapai anus

Ujung usus yg masuk intususeptum

Ujung usus yg menerima
intususepiens
 PATOFISIOLOGI
Bag.leher intususeptum terjepit mesenterium
tertarik bendungan aliran vena & limfe
edema

Bendungan kontinyu bendungan arteri. Pd

Intususeptum gangren & nekrosis darah &
lendir

Aliran sal.cerna bag.prox.invaginasi terhenti

obstruksi
 INSIDENS

Umur 312 bln, bayi yg

mengalami perubahan jenis
makanan, cair semi
padat padat ,jarang pada
neonatus
 DIAGNOSA
Ditegakkan berdasarkan:
1. Anamnesis yg lengkap
2. Px Fisis yg teliti
3. Px penunjang :

Laboratorium
Radiologi :
Foto Polos abd
USG
Barium Enema (Dx & Tx)
 GAMBARAN KLINIS
Klasik & atipik
Bayi awalnya sehat & etropis 3 - 12 bln, neonatus jarang
Bayi tiba2 menjerit sambil angkat kedua kaki seakan
lindungi perut, pucat,kejang surut scr. dramatis
bermain kembali
O/k kolik 5-20 mnt bertahap,frek.sering muntah scr.
reflektoris
Pasca serangan bayi tampak lemah,lesu, tertidur
Permulaan invaginasi,tdk ada edema, feses biasa
Invaginasi lanjut feses darah(+) lendir(+)
Obstruksi total darah(+) lendir(+) feses (-)
Defekasi berdarah tanpa feses
(berak darah campur lendir)
 PEMERIKSAAN FISIK
Patofisiologis

Stadium Dini fungsi & tanda vital normal

Jika perut bertambah kembung disertai muntah kehilangan cairan & bakteriemi
takikardi & demam
Dokter Potts Lihat ekspresi wajah saat serangan kaget & ketakutan
Babies with intussesception dont smile

Jika tdk kembung teraba massa di perut kanan tepi bawah hepar,tumor (+)
diepigastrium/perut kiri,teraba saat serangan,perut kanan teraba kosong
sekum&kolon ascendens keatas invaginasi Dance Sign
Pem.darah mesenterial terjepit aliran balik vena terganggu edema laserasi
mukosa berak lendir berdarah6-8 jam

18-24 jam sejak serangan usus obstruksi parsialis sumbatan totalis

edema RS dgn obstruksi sal.cerna : perut buncit (peristaltik usus meningkat)
muntah with cairan empedu dehidrasi syok
Sangat kembung tumor tdk teraba defek campur lendir & darah muntah
mengandung feses,demam,asidosis,toksis gangren usus perforasi &
peritonitis
 PEMERIKSAAN FISIK

Trias gejala invaginasi :

1. Nyeri yg bersifat kolik

2. Teraba massa tumor
3. Defekasi mengandung lendir &
darah
Tanda & Gejala Klinik

Bayi laki-laki, umur 6 bln dgn

Invaginasi
Red Currant jelly stool.
(Berak darah campur lendir)
 PX PENUNJANG
1. Laboratorium :

2. Radiologi :
@ USG Abdomen
@ Foto Polos Abdomen
@ Foto Barium Enema
 LABORATORIUM

CBC ,typing: to document anemia and

hemoconcentration
Fecalysis: presence of amebic
trophozoites does not exclude
intussusception
Electrolytes: if abnormal losses have
been incurred
 RADIOLOGI
Plain abdomen: check for obstruction or free air
Foto polos abdomen tegak tanda obstruksi sal.cerna
distribusi udara tidak merata perselubungan perut kanan
bawah,tengah,atas udara menempati perut kiri atas
multiple air-fluid levels

Ultrasound: doughnut or pseudokidney sign;

Color Doppler will show blood flow through the
intussuscepted bowel.

Barium enema : both for diagnosis and possible

treatment: contraindicated in presence of
peritonitis or complete intestinal obstruction,
shock
Kontras barium enema tampak :
- Bentuk coiled spring appearance
- Bentuk cupping appearance
FOTO POLOS ABDOMEN (BNO)
Multipel dilatasi
usus.
Akibat obstruksi
usus total

BNO Foto
Penderita
invaginasi yg
belum tereposisi
FOTO POLOS ABDOMEN (BNO)
Massa di perut
kanan atas

Pada penderita
invaginasi tipe
ileocolica

Tampak massa di
sebelah bawah
sudut liver pada
(BNO foto)
 USG Abdomen

Ileum telescoping
(masuk) ke kolon

Terlihat pada USG

Abdomen
Barium Enema
 KOMPLIKASI
1. Recurrence
Hydrostatic reduction carries arecurrence rate
of up to 10%. Arepeat hydrostatic reduction
maybe performed if none of the contraindications
are present. A lead point, such as a polyp or
Meckels diverticulum may be present .

2. Wound infection

3. Anastomotic leaks
 PENANGANAN
In the absence of peritonitis, perforation, complete intestinal obstruction, or
shock , hydrostatic or pneumatic reduction may be attempted. Generally ,
reduction is less likely to be successful when the condition has persisted
beyond 12 hours.

Technique of reduction:

The procedure is done under double set-up , that is, antibiotics have been
started, the patient is already hydrated , and prepared for possible
laparotomy. At the radiology suite, A Fr 18 Foley catheter is inserted into
the rectum and the balloon inflated . Barium sulfate 20%wt/vol is
suspended 3 feet above the table and allowed to flow by gravity under
fluoroscopic guidance. The reduction is allowed for three minutes duration
for a maximum of three times (rule of 3s). Reduction is successful if
barium refluxes into the terminal ileum. Too aggressive attempts at
reduction may lead to perforation with resultant barium peritonitis. If
reduction fails, the patient is brought to the operating suite for surgery.
The same procedure may be done using water soluble contrast, saline, or
air. With whatever medium or technique, the intraluminal pressure
generated should not exceed 120 mmHg to avoid iatrogenic perforation.
Successful ultrasound guided reduction has been reported . This
eliminates the use of ionizing radiation altogether and may be the future
gold standard.
 TERAPI
BARIUM ENEMA
Bayi tdk kembung Reposisi tek.hidrostatik
barium enema
Bayi panas & kembung K I barium enema
ditakutkan perforasi usus perforasi
barium masuk ke rongga peritoneum

Pem.Barium enema dihentikan jika barium

masuk ileum
 TERAPI
Barium enema tdk berhasil mendorong
intususeptum pembedahan

Terapi barium enema berhasil jika

barium masuk ke ileum dst,
bila pipa rektal ditarik dari anus barium
akan keluar dgn feses & udara pemeriksaan
fisik perut kempes + tumor hilang lakukan
tes dgn mberi tablet norit peroral keluar
dgn
feses
 TERAPI
Bayi positif invaginasi UGD pasang infus &
pipa nasogatrik.
Bayi demam antibiotik spektrum luas
Bayi dioperasi jika
- KU baik
- Perfusi ke jaringan baik
(prod.urine 0,5-1 ml/kgBB/jam via cateter,
suhu < 380 C, nadi <120x/mnt, R < 40x/mnt
turgor baik,akral normal)
 TERAPI
Cairan 50% dari ebutuhan(koreksi+keb.normal)
Dasar pengobatan dilakukan reposisi usus yg
masuk ke lumen usus lain barium
enema/pembedahan.75% barium enema berhasil
mereduksi invaginasi.
Pemberian sedatif membantu keberhasilan
reduksi hidrostatik,hal ini untuk menghindari bayi
mengangkat kaki krn kesakitan
Penggunaan balon kateter tidak terlalu besar
TERAPI
Reposisi via pembedahan
laparotomi
Perut dibuka tindakan sesuai
temuan manual diperas
(milking) secara perlahan
!!!jgn menarik bag.usus yg masuk
kedlm usus lainnya,tp diperas dr
pihak lainnya
Jika terjadi kebocoran sebelum or
sesudah milking reseksi usus
anastomose end to end
 TERAPI
Milking berhasil # fiksasi sekum.Jika
ditemukan divertikulum/duplikasi reseksi
Milking berhasil penderita dpt
meninggalkan RS pd hari 4 & 5 pasca
bedah
Penderita yg berhasil direduksi dgn barium
enema atau milking dpt terjadi rekurensi
Barium Enema rekurensi laparotomi
Milking rekurensi reseksi & fiksasi
Reduksi Barium
 TINDAKAN BEDAH
In the event of failed reduction or if the patient has signs of overt
obstruction, shock, peritonitis, and perforation,
surgery remains the cornerstone of treatment.
A t ransverse supraumbilical incision is made and the
intussusception identified.
In the absence of turbid or frankly purulent peritoneal fluid,
gentle milking of the intussusception is made to release the
obstruction.
Manual reduction may be all that is needed if the intestines are
viable.
The appendix is often congested after being impinged and is thus
removed.
The intussusceptum (the segment which entered the colon) is
usually the segment with ischemia or gangrene resection with
assurance of viable margins is performed in such cases.
The decision to anastomose or exteriorize depends on the
clinical condition of the patient and local tissue factors.
SURGICAL REDUKSI