DESKRIPSI KASUS

KELUHAN UTAMA
Benjolan di tepi dubur
 RIWAYAT PENYAKIT SEKARANG
Pasien pertama kali berobat pada tanggal 26 Desember 2018 di Poli Bedah RSA
dengan keluhan benjolan di tepi dubur. Pasien disarankan untuk menjalani
pemeriksaan lanjutan fistulografi.

Pada tanggal 15 Januari 2019 pasien datang kembali untuk berkonsultasi mengenai
pemeriksaan fistulografi.

Pada tanggal 17 Januari 2019 dilakukan informed consent dan pasien menjalani
pemeriksaan fistulografi.
 RIWAYAT PENYAKIT DAHULU
DM (-)
Hipertensi (-)
Asma/alergi (-)
 RIWAYAT PENYAKIT KELUARGA
DM (-)
Hipertensi (-)
Penyakit kardiovaskular (-)
Asma/alergi (-)
Keganasan (-)
PEMERIKSAAN FISIK
 KEADAAN UMUM, TANDA VITAL

KU: compos mentis

Tekanan Darah: 120/80 mmHg

Laju Nadi: 84x/menit
Laju Napas: 18x/menit
Suhu: 37,2oC
 PEMERIKSAAN KEPALA LEHER
Conjunctiva anemis (-)
Sclera icteric (-)
Pembesaran limfonodi daerah cervical (-)
 PEMERIKSAAN JANTUNG
Inspeksi Ictus cordis tak terlihat

Palpasi Ictus cordis teraba di SIC V LMCS

Perkusi Cardiomegali (-)

Auskultasi S1-S2 regular, tunggal, murmur (-)

 PEMERIKSAAN PULMO
Inspeksi Simetris, jejas trauma (-)

Fremitus taktil simetris, pengembangan dada

Palpasi
simetris, nyeri tekan (-)

Perkusi Sonor

Auskultasi Vesikuler, ronkhi (-) wheezing (-)

 PEMERIKSAAN ABDOMEN
Inspeksi Datar, ruam (-), bekas operasi (-)

Auskultasi Bising usus 8 x/menit

Perkusi Shifting dullness (-)

Palpasi Nyeri tekan (-), hepatomegali (-) splenomegali (-)

PEMERIKSAAN EKSTREMITAS
Ekstremitas Atas Ekstremitas Bawah
D S D S

Atrofi (-) Atrofi (-) Atrofi (-) Atrofi (-)

Ruam (-) Ruam (-) Ruam (-) Ruam (-)
Edema (-) Edema (-) Edema (-) Edema (-)
Akral hangat Akral hangat Akral hangat Akral hangat
WPK <2 s WPK <2 s WPK <2 s WPK <2 s
Anemis (-) Anemis (-) Anemis (-) Anemis (-)
 STATUS LOKALIS
Inspeksi: Terdapat benjolan di area perianal arah jam 7
Palpasi: Nyeri tekan (+)
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• Hasil Fistulografi
Dimasukkan kontras melalui stoma di perianal, passase
bahan kontras tidak lancar, tampak kontras mengisi
rectum.
• Kesan Fistulografi
Mengarah fistula rectocutaneus

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FISTULA PERIANAL
 INTRODUCTION
• Fistula → abnormal communication between two epithelial
surfaces.
• Anal fistula → communication between the anorectal canal
and the perianal skin that is lined with granulation tissue.

(Medscpae.com)
 EPIDEMIOLOGY
• In 2016, the Global Burden of Disease Study reported a prevalence of 251 million
cases of COPD globally. Around 90% of COPD deaths occur in low and middle-
income countries.
• The prevalence of emphysema in the United States is approximately 14 million
which includes 14% white male smokers and 3% white male nonsmokers. The
prevalence is slightly less for white female smokers and African Americans.

COPD includes patients with chronic bronchitis and emphysema. Although identified
as separate entities, most patients with COPD have features of both. COPD often
coexists with comorbidities, which affect the disease course.

Medscape.com
23
 ETIOLOGY
• Chronic and significant exposure to noxious gases, of which, cigarette
smoking remains the most common cause. However, in smokers, the
symptoms also depend on the intensity of smoking, years of exposure, and
baseline lung function. Symptoms usually begin after at least 20 pack per
year of tobacco exposure.
• Biomass fuels and other environmental pollutants such as sulfur dioxide
and particulate matter are recognized as an important cause in developing
countries affecting women and children greatly.
• Other etiological factors; passive smoking, lung infections, allergies and
low birth weight as a newborn makes one more prone to develop COPD
later in life.
(Bran W et al., 2015)
 PATHOGENESIS
Long-term exposure to noxious smoke
↓
Macrophages, neutrophils, and T lymphocytes are recruited
↓
Release multiple proteinases which destroy the epithelial cells
of the alveolar wall and lead to mucus hypersecretion.

(Herring et al., 2016)

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 CLASSIFICATION
Pulmonary emphysema can be
classified into three major
subtypes based on the disease
distribution within secondary
pulmonary lobules:
• Centriacinar emphysema
• Panacinar emphysema
• Distal acinar emphysema

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 CLINICAL MANIFESTATION
HISTORY
• Nonspecific symptoms of chronic shortness of breath and cough with or
without sputum production.
• Exertional dyspnea with significant physical activity with progression to
dyspnea with simple daily activities and even rest.
• Wheezing because of the airflow obstruction.
• Lose significant body weight due to systemic inflammation and increased
energy spent in work of breathing.
• Frequent intermittent exacerbations as the obstruction of the airways
increases.
• Smoking history
PHYSICAL EXAM
• In the early stages of the disease, the physical examination may be normal.
• Patients with emphysema are typically referred to as “pink puffers,” meaning cachectic
and non-cyanotic.
• Expiration through pursed lips (increases airway pressure and prevent airway collapse
during respiration)
• Use of accessory muscles of respiration are seen in advanced disease.
• Percussion may be normal early in the disease
• Prolonged expiration or wheezes on forced exhalation to increased resonance indicating
hyperinflation as the airway obstruction increases.
• Distant breath sounds, wheezes, crackles at the lung bases, and/or distant heart sounds
are heard on auscultation.
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 CHEST RADIOGRAPH
 A chest x-ray is only helpful in diagnosis if emphysema is severe, but
it is usually the first step when suspecting COPD to rule out other
causes.
 Destruction of alveoli and air trapping causes hyperinflation of lungs
with flattening of diaphragm and heart appears elongated and
tubular shaped.
 Loss of the regular vascular branching pattern, widened retrosternal
space, large focal lucencies indicating bullae, and bronchial wall
thickening.

Radiopaedia.org
Emphysema: chest radiographs, postero-anterior and lateral views, show hyperinflation of
the lungs (flattened diaphragm and widened retrosternal space), increased translucency in
the upper lungs with vascular attenuation and distorted arborization.

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Bullous emphysema: postero-anterior radiograph and coronal computed tomography
multiplanar reformation and maximum intensity projection images show a large bulla in the
right upper lobe with atelectasis of the adjacent lung (arrows).
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 CT
High-resolution computed tomography (HRCT) of the lung opened a new era in
radiologic-pathologic correlation. Because the detection of the structural
abnormalities of COPD (ie, emphysema) by ordinary chest radiograph was not
possible until disease had reached an advanced stage.
 MANAGEMENT
 Bronchodilator (beta2 agonists and anticholinergic medications)
 Inhaled corticosteroid (ICS)
 Antibiotics are beneficial especially if productive, purulent cough. Second
generation macrolides, extended spectrum fluoroquinolones,
cephalosporins and amoxicillin-clavulanate.

(Kharkanis V et al., 2012)

 REFERENCE
Parul Pahal et Sandeep Sharma, 2018. Emphysema.
StatPearls Publishing LLC.
American Thoracic Society, 2019. ATS Patient Education
Series: Chronic Obstructive Pulmonary Disease
(COPD). Am J Respir Crit Care Med Vol. 199, P1-P2,
2019.
Pipavath et al., 2009. Chronic Obstructive Pulmonary
Disease: Radiology-Pathology Correlation. J Thorac
Imaging 2009;24:171–180.