Total ileus obstruksi e.

c
band/adhesion ileus + torsi
ileus

{ William Bunga Datu

Pembimbing
dr. Putu A.I.S, Sp.B
Identitas pasien

Nama : Tn.U
Umur : 49 tahun
Jenis kelamin : laki-laki
Agama : Muslim
Suku : Bugis
No RM : 094704
Tanggal masuk : 20/09/2018 pukul 21.00 WIT
 Pasien laki-laki usia 49 tahun datang dengan keluhan
utama nyeri perut hebat. Keluhan dirasakan mendadak pada
sore hari sebelum masuk IGD, nyeri seperti diputar atau
dipelintir, nyeri dirasakan di bagian pusar dan meluas ke
semua area perut, muntah 1 kali isi makanan, mual (+),
demam (-), BAB bisa sebelum ke RS, BAK biasa.

Anamnesis
Riwayat pengobatan sebelumnya : tidak ada
Riwayat penyakit dahulu : pada tanggal 11/07/2017 pasien menjalani
operasi laparatomy + adhesiolisis + appendectomy ec
periappendicular infiltrat + adhesion. Riwayat Hipertensi disangkal,
riwayat DM disangkal.

Cont,..
  Kesadaran : compos mentis
 Keadaan umum : cukup
 Nadi : 89 kali/menit
 Tekanan darah : 90/60 mmHg
 Respirasi : 22 kali/menit
 Suhu badan : 36,5°C
 SpO2 : 100%
 VAS :5

Kepala : subjoncunctiva anemis-/- sclera ikterik -/-

deformitas -, pupil isokor bundar 2,5mm/2,5mm,
RCL+/+ RCTL+/+, pembesaran kelenjar getah bening –

Pemeriksaan fisik
 •Inspeksi : retraksi -/-, ekspansi paru simetris kanan dan kiri, massa – sikatriks-
ictus cordis tidak tampak
•Palpasi : taktil fremitus sama kanan dan kiri, ictus cordis teraba di SIC V
sejajar linea midclavicularis sinistra
•Perkusi : sonor dikedua lapang paru, batas jantung normal
thorax •Auskultasi : veskular +/+, ronkhi -/-, wheezing -/-, bunyi jantung I / II murni
reguler, murmur – gallop -

• Inspeksi : defans muscular +, bentuk datar, striae abdomen -,

massa -, sikatriks + pada quadran kanan bawah, venektasi -
• Auskultasi : bising usus ada kesan meningkat
• Perkusi : timpani di empat kuadran, batas hepar dan lien normal
Abdomen • Palpasi : massa -, nyeri tekan di regio kuadran kanan bawah dan
regio umbilikus, hepar dan lien tidak teraba

• Edema -/-, akral hangat, perfusi jaringan baik

Extremitas

Cont,
 Wbc: 16.47 x 10ᶺ3 Neutrofil % : 70,1

DDR
Hitung Jenis
Darah lengkap
RBC : 4,41 x 10ᶺ6 % Negatif
HGB : 14 g/dl Limfosit % : 21,1
%
HCT : 39 %
Monosit % : 6,0%
MCV : 88,4 fl
MCH : 31,7 pg Eosinoil % : 2,7%
MCHC : 35,8 g/dl Basofil % : 0,1%
Plt : 148 x 10ᶺ3

PPT : 10,5 detik Elektrolit :

APTT : 21,2 detik BUN Urea : 26,6 mg/dl
Na : 139,4 mmol/L Creatinin : 1,11 mg/dl
K : 3,36 mmol/L SGOT : 28,6 U/L
Cl : 105,5 mmol/L SGPT : 14,9 U/L
Albumine : 4,52 g/dl

Laboratorium
 Total ileus e.c adhesi band

Diagnosis kerja
  IVFD RL 1500 ml/24 jam
 Ketorolac 30 mg/8 jam
 Ceftriaxone 1 gr/12 jam iv
 Metronidazole 500 mg/8 jam iv
 Ranitidin 50 mg/8 jam iv
 Pasang folley kateter
 Pasang NGT
 OK cyto (laparatomy explorasi)

Tatalaksana awal di IGD

  Tindakan yang dilakukan : laparatomy explorasi +
adhesiolisis + reposisi ileum

 Pasien terbaring dengan posisi supine dibawah pengaruh

Anestesi umum
 Desinfeksi dan drapping
 Insisi midline sampai dengan cavum abdomen
 Tampak dilatasi ileum e.c obstruksi
 Obstruksi didapat dikarenakan torsi ileum e.c band/adhesion
ileum
 Release band
 Reposisi ileum yang tertorsi/terpuntir
 Cuci cavum abdomen
 Pasang drain di cavum douglas
 Jahit LDL
 Operasi selesai

Laporan operasi
Intra operatif
Total ileus obstruksi e.c
band/adhesion ileus + torsi ileus

Diagnosis post operatif

  IVFD RL : D5% : Panamin G : 1:1:1
 Inj. Ceftriaxone 1 gr/12 jam iv
 Inj metronidazole 500 mg/8 jam iv
 Ranitidin 50 mg/8 jam
 Tramadol 100 mg : ketorolac 60 mg dalam Nacl
0,9% 500 cc/24 jam
 Puasa
 Alirkan NGT
 Balance cairan observasi vital sign
 Rawat di HCU

Instruksi post operasi

Hari/tanggal S O A P
21/09/2018 Nyeri bekas operasi Kesadaran : Compos Post operasi hari - Edukasi
+, flatus -, mentis 0 laparatomy pasien
TD : 113/70 mmHg, explorasi + - IVFD RL :
N : 56 x/m RR : 20 adhesiolisis + D5% :
x/m SB : 36,6 SpO2: reposisi ielum ec Panamin G =
99%, Vas 3 total ileus 1:1:1
obstruksi e.c - Inj ceftriaxone
Kepala : Anemis -/- band/adhesion 1 gr/12 jam iv
ikterik-/- ileus + torsi ileus - Inj
Thorax : ronkhi-/- metronidazole
wheezing-/- 500 mg/8 jam
Abdomen : soefel +, iv
peristaltik + kesan - Inj ranitidin 50
normal, luka mg/8 jam iv
terawat. Drain 100 - Tramadol 100
cc, NGT : 300 cc/3 mg : ketorolac
jam warna hijau 60 mg dalam
jernih Nacl 0,9% 500
Ext: akral hangat, cc/24 jam
CRT <2 detik - Puasa
- Alirkan NGT
- Balance cairan

Follow up
Hari/tanggal S O A P
22/09/2018 Flatus +, BAB +, Kesadaran : Compos Post operasi hari 1 - Edukasi pasien
demam -, nyeri luka mentis laparatomy - IVFD RL : D5% :
post operasi +, TD : 101/62 mmHg, explorasi + Panamin G =
N : 70 x/m RR : 20 adhesiolisis + 1:1:1
x/m SB : 36,6 SpO2: reposisi ielum ec - Inj ceftriaxone 1
98%. Vas 2-3 total ileus obstruksi gr/12 jam iv
e.c band/adhesion - Inj
Kepala : Anemis -/- ileus + torsi ileus metronidazole
ikterik-/- 500 mg/8 jam iv
Thorax : ronkhi-/- - Inj ranitidin 50
wheezing-/- mg/8 jam iv
Abdomen : soefel +, - Tramadol 100
peristaltik + kesan mg : ketorolac 60
normal, luka mg dalam Nacl
terawat. Drain - cc, 0,9% 500 cc/24
NGT : 100 cc/24 jam jam
warna jernih - Diet clear fluid
Ext: akral hangat, bebas + diet susu
CRT <2 detik 6 x 100 ml
- Rawat luka tiap
hari
- Mobilisasi
duduk
- Klem NGT/24
jam
- Pindah observasi
bedah
Hari/tanggal S O A P

23/09/2018 Flatus +, BAB -, Kesadaran : Compos Post operasi hari 2 - Edukasi pasien
nyeri luka operasi + mentis laparatomy - IVFD RL : D5% :
(minimal) TD : 110/80 mmHg, explorasi + Panamin G =
N : 62 x/m RR : 20 adhesiolisis + 1:1:1
x/m SB : 36 SpO2: reposisi ielum ec - Inj ceftriaxone 1
98%. Vas 2-3 total ileus obstruksi gr/12 jam iv
e.c band/adhesion - Inj
Kepala : Anemis -/- ileus + torsi ileus metronidazole
ikterik-/- 500 mg/8 jam iv
Thorax : ronkhi-/- - Inj ranitidin 50
wheezing-/- mg/8 jam iv
Abdomen : soefel +, - Tramadol 100
peristaltik + kesan mg : ketorolac 60
normal, luka mg dalam Nacl
terawat. Drain - cc, 0,9% 500 cc/24
NGT : 30 cc/24 jam jam
serous - Diet clear fluid
Ext: akral hangat, bebas + diet susu
CRT <2 detik 6 x 100 ml
- Rawat luka tiap
hari
- Mobilisasi
duduk
- Aff NGT
Hari/tanggal S O A P
24/09/2018 Nyeri luka operasi Kesadaran : Post operasi hari 3 - Edukasi pasien
minimal, BAB +, Compos mentis laparatomy - Aff drain
BAK baik TD : 100/86 mmHg, explorasi + - Aff infus
N : 65 x/m RR : 20 adhesiolisis + - Aff DC
x/m SB : 36,7 SpO2: reposisi ielum ec - Pasien boleh
98%. Vas 2-3 total ileus obstruksi pulang kontrol 3
e.c band/adhesion hari kemudia di
Kepala : Anemis -/- ileus + torsi ileus poliklinik bedah
ikterik-/- - Cefadroxil
Thorax : ronkhi-/- 2x500 mg
wheezing-/- - Asam
Abdomen : soefel +, mefenamat
peristaltik + kesan 3x500 mg
normal, luka - Ranitidin 2x150
terawat. Drain - cc mg
Ext: akral hangat,
CRT <2 detik
Discussion
 Intraperitoneal adhesion is abnormal fibrous
(connective tissue) adhesion in between the surface of the
adjacent peritoneum, both between the peritoneum vicerale,
and between peritoneum vicerale and parietale.
The presence of these adhesions can cause adhesions
between intraperitoneal organs

Jennifer K, 2014

Definition
  These fibrous bands are thought to occur in up to 93% of
patients undergoing abdominal surgery and can
complicate future surgery considerably
 Adhesion formation can result in significant morbidity,
mortality and infertility in women, and adhesionrelated
complications are also responsible for up to 74% cases of
ASBO in adults and 30% of re-admissions at 4 years after
an incident intra-abdominal surgery

Catena fauston, et.al. 2016. Adhesive Small Bowel adhesions obstruction: Evolutions in
Diagnosis, Management and Prevention. World journal if Gastrointestinal Surgery ; 8(3)
:221-231.

Epidemiology
  Surgical trauma
 Tissue ischemia
 Infection, allergic reaction, and blood
 Irritating foreign object

Catena fauston, et.al. 2016. Adhesive Small Bowel adhesions obstruction: Evolutions in
Diagnosis, Management and Prevention. World journal if Gastrointestinal Surgery ; 8(3)
:221-231.

Etiology
Patogenesis
Weibel MA. Am J Surg 1973
Menzies D. Ann R Coll Surg Engl 1990
 Abdominal pain
 Nausea and vomiting
 Distension
 Obstipation

Clinically manifestasion
 Anamnesis
 Physical examination
 Laboratorium : CBC, Different count, electrolit, BUN ureum,
Creatinin, C-reactive protein, serum lactase, lactase
dehidrogenase, creatinin kinase.
 Imaging : X-ray and CT-scan

Diagnosis
 NOM
Randomized clinical trials
showed that there are no differences
between the use of nasogastric tubes
compared to the use of long tube
decompression.
Several studies investigated the
diagnostic-therapeutical role of WSCA
Gastrografin is the most com-
monly utilised contrast medium. It is a
mixture of sodium diatrizoate and
megluminediatrizoate. Its osmolarity is
2150 mOsm/L.
It activates movement of water
into the small bowel lumen. Gastrografin
also decreases oedema of the small bowel
wall and it may also enhance smooth
muscle contractile activity that can
generate effective peristalsis and overcome
the obstruction.

Catena fauston, et.al. 2016. Adhesive Small Bowel

adhesions obstruction: Evolutions in Diagnosis,
Management and Prevention. World journal if
Gastrointestinal Surgery ; 8(3) :221-231.

Treatment
 Oral therapy with magnesium oxide, L. acidophilus and
simethicone may be considered to help the resolution of NOM in
partial ASBO with positive results in shortening the hospital stay
 Lastly hyperbaric oxygen therapy may be an option in the
management of high anesthesiologic risk patients for whom
surgery should be avoided
Water-Soluble Contrast (WSCA) –
Diagnostic and Therapeutic role

Br J Surg. 2010 Apr;97(4):470-8.

• 50–100ml
Gastrografin or 40ml
Urografin
administered orally

• Abdominal plain
radiographs after 4 h,
8 h or 24 h to follow
contrast through the
GI-tract
 If the contrast reaches the colon within 4–24 h,
obstruction will resolve without operation in 99% of
patients.

Conclusion
 Water-soluble contrast was effective in
predicting the need for surgery in
adhesive SBO (sensitivity 96%,
specificity 98%)
 In addition, it reduced the need for
operation and shortened hospital stay.
 A meta-analysis by Li et al, found that there was no
statistically significant difference between open vs laparoscopic
adhesiolysis in the number of intraoperative bowel injuries, wound
infections, or overall mortality.
Conversely there was a statistically significant difference in
the incidence of overall and pulmonary complications and a
considerable reduction of prolonged ileus in the laparoscopic
group compared with the open group. The authors concluded that
laparoscopic approach is safer than the open procedure, but only
in the hands of experienced laparoscopic surgeons and in selected
patients.
  Surgical technique
 Anti-adhesive barrier

Prevention
  Unfortunately, there are not yet devices able to
totally prevent the intraperitoneal adhesion
formation after abdominal surgery; only the
use of correct surgical technique and the
avoidance of traumatic intraperitoneal organ
maneuvers may help to reduce postoperative
adhesion incidence.

Conclusion
Thank you