Pemicu 5 blok GIT.pptx

Pemicu 5
Blok GIT
Felecia Christy
405140077

Defecation
• Defecation is the process of passing out stool
(feces) through the anus. This eliminates
waste material from the rectum and colon.
The process of defecation should be painless,
regular and to a certain degree, it is under
voluntary control.

Defecation reflexes
• An involuntary response of the lower bowels to
various stimuli thereby promoting or even inhibiting
a bowel movement.
• These reflexes are under the control of the
autonomic system and play an integral role in the
defecation process along with the somatic system
that is responsible for voluntary control
of defecation.
• The two main defecation reflexes are known as the
intrinsic myenteric defecation reflex and
parasympathetic defecation reflex.

Other Defecation Reflexes
• Apart from the two main defecation reflexes mentioned above,
other reflexes can also influence the defecation process.
– Gastrocolic reflex – distention of the stomach while eating or
immediately after a meal triggers mass movements in the colon.
– Gastroileal reflex – distention of the stomach while eating or
immediately after eating triggers the relaxation of the ileocecal
sphincter and speeds up peristalsis in the ileum (end portion of
the small intestine). This causes the contents of the ileum to
rapidly empty into the colon.
– Enterogastric reflex – distention and/or acidic chyme in the
duodenum slows stomach emptying and reduces peristalsis.
– Duodenocolic reflex – distention of the duodenum a short while
after eating triggers mass movements in the colon.

Physiology of the large intestine
• Reabsorption in the large intestine includes :
– Water
– Vitamins – K, biotin, and B5
– Organic wastes – urobilinogens and sterobilinogens
– Bile salts
– Toxins
• Mass movements of material through colon and
rectum
– Defecation reflex triggered by distention of rectal walls

Large Intestine, H2O Absorption &
Defecation
• Small intestine reabsorbs  7.5 L/day of water
• Large Intestine reabsorbs 1.4 L/day

PENYAKIT LOWER ABDOMEN PADA
ORANG DEWASA
LO 2

Ulcerative colitis
Definition
• Ulcerative colitis is a type of inflammatory bowel disease that affects the large
intestine and rectum.
Causes
• The cause of ulcerative colitis is unknown. It may affect any age group, although
there are peaks at ages 15 - 30 and then again at ages 50 – 70.
• The disease usually begins in the rectal area and may eventually extend through
the entire large intestine. Repeated swelling (inflammation) leads to thickening of
the wall of the intestine and rectum with scar tissue. Death of colon tissue or
sepsis may occur with severe disease.
• The symptoms vary in severity and may start slowly or suddenly. Many factors can
lead to attacks, including respiratory infections or physical stress.
• Risk factors include a family history of ulcerative colitis, or Jewish ancestry. The
incidence is 10 to 15 out of 100,000 people.

Symptoms
* Abdominal pain and cramping that usually disappears after a bowel movement
* Abdominal sounds (a gurgling or splashing sound heard over the intestine)
* Diarrhea, from only a few episodes to very often throughout the day (blood and
mucus may be present)
* Fever
* Tenesmus
* Weight loss
• Other symptoms that may occur with ulcerative colitis include the following:
* Gastrointestinal bleeding
* Joint pain
* Nausea and vomiting
Exams and Tests
* Barium enema
* Colonoscopy with biopsy
• Your doctor may also order the following blood tests:
* Complete blood count (CBC)
* C-reactive protein (CRP)
* Sedimentation rate (ESR)

Treatment
• The goals of treatment are to:
* Control the acute attacks
* Prevent repeated attacks
* Help the colon heal
• Hospitalization is often required for severe attacks. Your doctor may prescribe
corticosteroids to reduce inflammation.
• Medications that may be used to decrease the number of attacks include:
* 5-aminosalicylates such as mesalamine
* Immunomodulators such as azathioprine and 6-mercaptopurine
• An intravenous medicine called infliximab has also been shown to improve
symptoms of ulcerative colitis.
• Surgery to remove the colon will cure ulcerative colitis and removes the threat of
colon cancer. Patients may need an ostomy (a surgical opening in the abdominal
wall), or a procedure that connects the small intestine to the anus to help the
patient gain more normal bowel function.
• Surgery is usually for patients who have colitis that does not respond to complete
medical therapy, or patients who have serious complications such as:
* Rupture (perforation) of the colon
* Severe bleeding (hemorrhage)
* Toxic megacolon

Possible Complications
• Ankylosing spondylitis
• Cancer
• Colon narrowing
• Complications of corticosteroid therapy
• Impaired growth and sexual development in children
• Inflammation of the joints
• Lesions in the eye
• Liver disease
• Massive bleeding in the colon
• Mouth ulcers
• Pyoderma gangrenosum (skin ulcer)
• Tears or holes (perforation) in the colon
Prevention
• Because the cause is unknown, prevention is also unknown.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) may make symptoms worse.
• Due to the risk of colon cancer associated with ulcerative colitis, screening with colonoscopy
is recommended.
• The American Cancer Society recommends having your first screening:
* 8 years after you are diagnosed with severe disease, or when most of, or the entire, large
intestine is involved
* 12 - 15 years after diagnosis when only the left side of the large intestine is involved
• Have follow-up examinations every 1 - 2 years.

Definition
• Definition :
– Constipation is a symptom
– issues of stool consistency (hard, painful stools)
– issues of defecating behavior
• Infrequency (<3x per week)
• Difficulty in defecation
• Straining during defecation (>25% bowel movement)
• Subjective sensation of hard stool
• Incomplete bowel evacuation

– For surgical purposes :
• Change in the bowel habit
• Defecatory behavior that results in acute or chronic
symptoms
• Diseases that would be resolved with relief of the
constipation
– Health care providers :
• Frequency of bowel movements (ie, less than 3 bowel
movements per week) to define constipation

• According to Rome III (at least 2 symptoms
over the past 3 months) :
– Less than 3 bowel movements per week
– Straining
– Lumpy/hard stools
– Sensation of anorectal obstruction
– Sensation of incomplete defecation
– Manual maneuvering required to defecate

Causes
Common causes of constipation
are:
• not enough fiber in the diet
• lack of physical activity (especially in the
elderly)
• medications
• milk
• irritable bowel syndrome

Classification
• 2 main groups :
– Primary Constipation
– Secondary Constipation

Primary Constipation
• Primary (idiopathic, functional) constipation
can generally be classified into 3 categories:
– Normal-transit constipation (NTC)
• Patients perceive difficulty in evacuating their bowels
– Slow-transit constipation (STC) 
• Infrequent bowel movements, decreased urgency, or
straining to defecate. (mild abdominal distention or
palpable stool in the sigmoid colon)
– Pelvic floor dysfunction (ie, pelvic floor
dyssynergia) 

Secondary Constipation
• Diet and exercise
• Structural
• Endocrinopathic and metabolic
• Drugs
• Neurologic
• Connective-tissue disorders
• Toxicologic
• Psychologic

Types of Constipation and Causes Examples
Recent onset :
- colonic obstruction Neoplasm, stricture, ischemic, diverticular,
inflammatory
- Anal sphincter spasm Anal fissure, painful hemorrhoids
- Medications
Chronic
- IBS Constipation-predominant, alternating
- Medications Ca²⁺ blockers, antidepressants
- colonic pseudo-obstruction Slow transit constipation, megacolon (rare
Hirschsprung’s, chagas)
- Disorders of rectal evacuation Pelvic floor dysfunction,anismus,descending
perineum syndrom,rectal mucosal prolapse,
rectocele
- Endocrinopathies Hypothyroidism, hypercalcemia, pregnancy
- Psychiatric disorders Depression, eating disorders, drugs
- neurologic disease Parkinsonism, multiple sclerosis, spinal cord
injury
- generalized muscle disease Progressive systemic sclerosis

Pathophysiology
• Constipation occurs if defecation is delayed for too
long
• The longer colonic contents being retained, the more
amount of H2O is absorbed  hard & dry in
consistency

• Nausea +/- vomiting
• Abdominal and Rectal pain
• Flatulence
• Loss of appetite
• Lethargy
• Depression
Symptoms

Diagnose
Medical History
 Duration of symptoms
 Frequency of bowel movements
 Consistency of stools
 Presence of blood in the stool, and
 Toilet habits—how often and where one has bowel
movements.
 A record of eating habits
 Medication
 Level of physical activity will also help the doctor
determine the cause of constipation

The clinical definition of constipation is having any two of the
following symptoms for at least 12 weeks—not always
consecutive—in the previous 12 months:
• straining during bowel movements
• lumpy or hard stool
• sensation of incomplete evacuation
• sensation of anorectal blockage/obstruction
• fewer than three bowel movements per week

Physical Examination
 Rectal exam with a gloved, lubricated finger to evaluate
the tone of the muscle that closes off the anus - also
called anal sphincter
• To detect tenderness
• Obstruction
• Blood and thyroid tests
- may be necessary to look for thyroid disease and serum calcium or
to rule out inflammatory, metabolic, and other disorders

• Extensive testing usually is reserved for people with severe
symptoms, for those with sudden changes in the number and
consistency of bowel movements or blood in the stool, and
older adults. Additional tests that may be used to evaluate
constipation include:
• a colorectal transit study
• anorectal function tests
• a defecography
- Because of an increased risk of colorectal cancer in older
adults, the doctor may use tests to rule out a diagnosis of
cancer, including a
• barium enema x ray
• sigmoidoscopy or colonoscopy

Functional constipation (rome III)
1. Must include two or more of the following :
a. Straining during at least 25% of defecation
b. Lumpy or hard stools in at least 25% of defecation
c. Sensation of incomplete evacuation for at least 25% of
defecation
d. Sensation of anorectal obstruction/blockage for at least 25% of
defecation
e. Manual manuver to facilitate at least 25% of defecation
f. Fewer than three defecations per week
2. Loose stools are rarely present without the use of laxative
3. Insufficient criteria for irritable bowel syndrome

TREATMENT
Diet
• A diet with enough fiber (20 to 35 grams each day) helps the
body form soft, bulky stool
• High-fiber foods include beans, whole grains and bran
cereals, fresh fruits, and vegetables such as asparagus,
brussels sprouts, cabbage, and carrots
• For people prone to constipation, limiting foods that have
little or no fiber, such as ice cream, cheese, meat, and
processed foods, is also important

Lifestyle Changes
• Other changes that may help treat and prevent constipation
include drinking enough water and other liquids, such as
fruit and vegetable juices and clear soups, so as not to
become dehydrated, engaging in daily exercise, and
reserving enough time to have a bowel movement

Laxatives
• Bulk-forming laxatives
• Stimulants
• Osmotics
• Stool softeners
• Lubricants
• Saline laxatives
• Chloride channel activators

Reference: Australian Journal of Hospital Pharmacy, 1998

 Patient education
 Diet and Fluid Intake
 Exercise
 Effective Bowel Habits
 Toileting Facilities
 Medication Review
 Ensure a laxative is prescribed
with opioids
Prevention
An Effective Fibre Supplement
3 TBS unsweetened apple puree
1 TBS unprocessed bran
2-3 TBS prune juice
Add 1 TBS to breakfast cereal
Imaginative ways to increase fibre:-
• Add dry, fresh or canned fruit to cereal
• Add legumes to soups and casseroles
• Include grated vegetables in rissoles & soups
• Choose fruit desserts
• High fibre snacks eg raisin bread, date scones,
carrot muffins

Anal Fissure (Fissure in Ano; Anal Ulcer)
• Anal fissure is a small laceration of the mucocutaneous
junction of the anus. It is an acquired lesion secondary to the
forceful passage of a hard stool, mainly seen in infancy.
Fissures may be the consequence and not the cause of
constipation.
• Anal fissures are believed to result from laceration by a hard
or large stool, with secondary infection. Trauma (eg, anal
intercourse) is a rare cause. The fissure may cause internal
sphincter spasm, decreasing blood supply and perpetuating
the fissure.

Symptoms and Signs
• Anal fissures usually lie in the posterior midline but may occur in the
anterior midline. Those off the midline may have specific etiologies,
particularly Crohn's disease. An external skin tag (the sentinel pile) may be
present at the lower end of the fissure, and an enlarged (hypertrophic)
papilla may be present at the upper end.
• Infants may develop acute fissures, but chronic fissures are rare. Chronic
fissures must be differentiated from cancer, primary lesions of syphilis, TB,
and ulceration from Crohn's disease.
• Fissures cause pain and bleeding. The pain typically occurs with or shortly
after defecation, lasts for several hours, and subsides until the next bowel
movement. Examination must be gentle but with adequate spreading of
the buttocks to allow visualization.

Clinical Manifestations
• Usually, a history of constipation is elicited. At
some point, the patient had a painful bowel
movement, which may correspond to the
actual event of fissure formation after the
passing of hard stool.
• Then, in addition to the primary cause of
constipation, the patient retains stool
voluntarily to avoid a painful bowel
movement. This exacerbates the constipation,
and, eventually, the passing of harder and

Diagnosis
• Inspection of the anal area
For this examination, the infant's hips are
held in acute flexion, the buttocks are separated
to expand the folds of the perianal skin, and the
fissure becomes evident as a minor laceration.
Sometimes, peripheral to the laceration, the
patient has a little skin appendage that actually
represents epithelialized granulomatous tissue,
secondary to the chronic inflammation; this is
usually known as a “tag.”

Treatment
• Fissures often respond to conservative measures that
minimize trauma during defecation (eg, stool
softeners, psyllium, fiber). Healing is aided by use of
protective zinc oxide ointments or bland
suppositories (eg, glycerin) that lubricate the lower
rectum and soften stool. Topical anesthetics (eg,
benzocaine, lidocaine ) and warm (not hot) sitz baths
for 10 or 15 min after each bowel movement and prn
give temporary relief.

• Topical nitroglycerin 0.2% ointment, nifedipine
cream 0.2% or 0.3%, arginine gel, and
injections of botulinum toxin type A into the
internal sphincter relax the anal sphincter and
decrease maximum anal resting pressure,
allowing healing. When conservative
measures fail, surgery (internal anal
sphincterotomy or controlled anal dilation) is
needed to interfere with the cycle of internal
anal sphincter spasm

Definition
• Cancer of the colon or rectum is also called
colorectal cancer.
• In the United States, it is the fourth most
common cancer in men and women. Caught
early, it is often curable.
http://www.nlm.nih.gov/

Signs and symptoms
• A change in bowel habits such as diarrhea,
constipation or narrowing of the stool that lasts for
more than a few days.
• Rectal bleeding or blood in the stool.
• Cramping or gnawing stomach pain.
• Decreased appetite.
• Vomiting.
• Weakness and fatigue.
• Jaundice (yellowish coloring) of the skin or sclera of
the eye.
http://www.massey.vcu.edu/

Risk Factors
• Age – most people who have colorectal cancer are over age 50, however, it can
occur at any age.
• Polyps – benign growths on the wall of the colon or rectum are common in people
over age 50, and are believed to lead to colorectal cancer.
• Personal history – people who have had colorectal cancer, as well as ovarian,
uterine or breast cancers, have a slightly increased risk for colorectal cancer.
• Family history – people with a strong family history of colorectal cancer or
adenomatous polyps in a first-degree relative (in a parent or sibling before the age
of 60 or in two first-degree relatives of any age), have an increased risk for
colorectal cancer.
• Ulcerative colitis – people who have ulcerative colitis, an inflamed lining of the
colon, have an increased risk for colorectal cancer.
• Obesity.
• Physical inactivity.
• High-fat and/or low-fiber diet.
• Alcohol consumption.
• Smoking.

Diagnostic procedures
• Digital rectal examination (DRE) – a physician or health care
provider inserts a gloved and lubricated finger into the rectum
to feel for anything unusual or abnormal. This test can detect
cancers of the rectum, but not the colon.
• Fecal occult blood test – checks for hidden (occult) blood in
the stool. It involves placing a very small amount of stool on a
special card, which is then tested in the physician’s office or
sent to a laboratory.
• Sigmoidoscopy – a diagnostic procedure that allows the
physician to examine the inside of a portion of the large
intestine. A short, flexible, lighted tube, called a
sigmoidoscope, is inserted into the intestine through the
rectum. The scope blows air into the intestine to inflate it and
make viewing the inside easier.

• Colonoscopy – a procedure that allows the physician to view
the entire length of the large intestine. It involves inserting a
colonoscope, a long, flexible, lighted tube, in through the
rectum up into the colon. The colonoscope allows the
physician to see the lining of the colon, remove tissue for
further examination and possibly treat some problems that
are discovered.
• Barium enema – a fluid called barium (a metallic, chemical,
chalky liquid used to coat the inside of organs so that they will
show up on an X-ray) is given into the rectum to partially fill
up the colon. An X-ray of the abdomen shows strictures
(narrowed areas), obstructions (blockages) and other
problems.
• Biopsy – a procedure in which tissue samples are removed
(with a needle or during surgery) from the body for
examination under a microscope to determine if cancer or
other abnormal cells are present.
• Blood count – to check for anemia (a result of bleeding from a
tumor).

Staging
Stage 0 (Cancer in Situ) The cancer is found in the innermost lining
of the colon.
Stage I (also called Dukes’ A colon
cancer)
The cancer has spread beyond the
innermost lining of the colon to the second
and third layers and the inside wall of the
colon. The cancer has not spread to the
outer wall of the colon or outside of the
colon.
Stage II (also called Dukes’ B colon
cancer)
The cancer has spread outside the colon to
nearby tissue. However, the lymph nodes
are not involved.
Stage III (also called Dukes’ C colon
cancer)
The cancer has spread to nearby lymph
nodes, but has not spread to other organs
in the body.
Stage IV (also called Dukes’ D colon
cancer)
The cancer has spread to other parts of the
body, such as lungs.

Treatments
• After surgery, chemotherapy (the use of anticancer drugs to
destroy cancer cells) may be given to kill any cancerous cells
that remain in the body. Chemotherapy controls the spread of
the disease and improves survival rates over time. The
following chemotherapeutic medications are often used alone
or in combination to treat colorectal cancer:
– FOLFOX -- a type of combination chemotherapy used to treat
colorectal cancer. It includes the drugs fluorouracil, leucovorin, and
oxaliplatin.
– Camptosar -- used when colon cancer has spread (metastasized) or
returned; may be combined with other drugs.
– Bevacizumab (Avastin) -- used when colorectal cancer has spread, it
starves tumors of blood and oxygen.
– Cetuximab (Erbitux) -- used when colorectal cancer has spread despite
the use of another drug, irinotecan (Camptosar), or when patients
cannot take Camptosar alone. It works to stop cancer cells from
reproducing.
– Panitumumab (Vectibix) -- used when colorectal cancer has spread
despite chemotherapy. It works similar to Erbitux.

Prevention
• Diet and exercise
It is important to manage the risk factors you can
control, such as diet and exercise. Eating more fruits,
vegetables and whole grain foods, and avoiding high-
fat, low-fiber foods. Appropriate exercise, even small
amounts on a regular basis, can be helpful.
• Drug therapy
Recent studies of people with colorectal cancer have
suggested that two factors may help reduce the risk
of developing this cancer: estrogen replacement
therapy and nonsteroidal anti-inflammatory drugs,
such as aspirin.

• Screening
Colorectal cancer is highly preventable, even curable,
when detected early. Regular screening for colorectal
cancer detects polyps before they become cancerous.
Current guidelines recommend these screening options,
starting at age 50 for people who have an average risk of
colon cancer:
– Annual fecal occult blood testing -- tests for blood in the stool
– Stool DNA testing -- tests for DNA markers shed by cancer cells
of precancerous polyps
– Flexible sigmoidoscopy, every 5 years -- examination of the
rectum and lower colon using a lighted instrument
– Colonoscopy, every 10 years -- examination of the rectum and
entire colon using a lighted instrument
– Double-contrast barium enema, every 5 years -- examination
using a series of x-rays that reveal outlines of the colon and
rectum
– Virtual colonoscopy (CT colonography), every 5 years -- uses a
CT scan to take images of the colon

Hemorrhoids
• Hemorrhoids are enlarged veins located in the
lower part of the rectum and the anus.
• They become swollen because of increased
pressure within them, usually due to straining
at stools and during pregnancy because of the
pressure of the enlarged uterus.

Internal Hemorrhoids
• Internal
hemorrhoids are
located in the inside
lining of the rectum
and cannot be felt.
• They are usually
painless and make
their presence
known by causing
bleeding with a
bowel movement.
• Grading of Internal
Hemorrhoids
– Grade I: The hemorrhoids
do not prolapse.
– Grade II: The hemorrhoids
prolapse upon defecation
but spontaneously reduce.
– Grade III: The
hemorrhoids prolapse
upon defecation, but must
be manually reduced.
– Grade IV: The

External Hemorrhoids
• External hemorrhoids are located underneath
the skin that surrounds the anus.
• They can be felt when they swell and may
cause itching or pain with a bowel movement,
as well as bleeding.
• A thrombosed external hemorrhoid occurs
when blood within the vein clots, and can
cause significant pain.

Hemorrhoid Causes
• Hemorrhoids are associated with constipation and
straining at bowel movements.
• Pregnancy is also associated with hemorrhoids.
• These conditions lead to increased pressure within the
hemorrhoidal veins causing them to swell.
• Other conditions, for example chronic liver disease,
may also cause increased venous pressure and may be
associated with hemorrhoid formation.
• Hemorrhoids are very common and are estimated to
occur in up to one-half of the population by age 50.

Hemorrhoid Symptoms
• The most common symptom and sign from
hemorrhoids is painless bleeding.
• There may be bright red blood on the outside of the
stools, on the toilet paper, or dripping into the toilet.
• The bleeding usually is self-limiting.
• Bleeding with a bowel movement is never normal and
should prompt a visit to a health care practitioner.
• While hemorrhoids are the most common cause of
bleeding with a bowel movement, there may be other
reasons to have bleeding including inflammatory bowel
disease, infection, and tumors.

Prolapsed Internal Hemorrhoids
• Prolapse of an internal hemorrhoid occurs when the
internal hemorrhoids swell and extend from their location
in the rectum through the anus. A prolapsed internal
hemorrhoid:
– can be felt as a lump outside the anus;
– can be gently pushed back through the anus, this may resolve
the problem of prolapse but does not fix the hemorrhoid itself;
– may enlarge and swell even more if they cannot be pushed
back;
– may become entrapped, which requires medical attention.
• Hemorrhoids may also cause pruritus ani or itching around
the anus, and a constant feeling of needing to have a bowel
movement.

Thrombosed External Hemorrhoids
• Thrombosed external hemorrhoids are a painful
condition. These occurs when a blood clot
develops in the hemorrhoid causing swelling and
inflammation.
– When a blood clot occurs in a hemorrhoid, the
hemorrhoid will become even more swollen. This
swelling leads to increased pain.
– The pain is usually worse with bowel movements and
may increase with sitting.
– Thrombosed external hemorrhoids often need
medical care and treatment.

Exams and Tests
• Diagnosis of hemorrhoids is usually made by history and
physical examination by the health care practitioner.
• Inspection of the anus and a digital rectal examination are
often performed.
• Sometimes anoscopy may be required where a small, lighted
scope is introduced into the anus to examine the inner lining
of the anus and rectum.
• If there is concern that significant bleeding has occurred, a
CBC (complete blood count) to measure hemoglobin and
hematocrit levels is obtained.
• If the patient is on warfarin (Coumadin), a prothrombin time
(PT) or INR may be done to measure the blood clotting levels.

Hemorrhoid Treatment
• Warm Sitz Baths
– Sitting in a few inches of warm water three times a day for 15-
20 minutes may help decrease the inflammation of the
hemorrhoids.
– It is important to dry off the anal area completely after each Sitz
bath to minimize irritation of the skin surrounding the anus.
• Dietary Changes
– Increased fluid intake and dietary fiber (roughage) will decrease
the potential for constipation and lessen the pressure on the
rectum and anus during a bowel movement, minimizing further
swelling, discomfort, and bleeding. Dietary fiber supplements
may also help bulk up the stools.
• Stool Softeners
– Stool softeners may help but once hemorrhoids are present,
liquid stools may cause inflammation and infection of the anus.
Your health care practitioner and pharmacist are good resources
to discuss their use.

• Activity Suggestions
– Individuals with hemorrhoids should not sit for long periods of
time and may benefit from sitting on an air or rubber donut
available at most local pharmacies.
– Exercise is helpful in relieving constipation and in decreasing
pressure on the hemorrhoidal veins. Individuals should be
encouraged to have a bowel movement as soon as possible
after the urge arises. Once that urge passes, stools can become
constipated and straining with a bowel movement may occur.
• Over-the-Counter Medications
– Many creams, ointments, and suppositories are available for
symptom relief and may be used for comfort. However, they do
not "cure" hemorrhoids. Often they contain a numbing
medication or a corticosteroid to decrease inflammation and
swelling.

• Prolapsed Internal Hemorrhoids
– Most prolapsed internal hemorrhoids can be
pushed back into the anus but occasionally your
care provider may need to reduce them by gently
pushing them with constant pressure.
– If the hemorrhoids remain swollen and trapped
outside the anus and nothing is done about it, the
hemorrhoid tissue may not receive enough blood
and can become infected. In such situations,
surgery may be required to resolve the problem.

• Thrombosed Hemorrhoids
– Thrombosed external hemorrhoids can be painful and are
associated with a hard lump that is felt at the anus and cannot
be pushed back inside. Most often the clot within the
hemorrhoid will need to be removed with a small incision.
– After local anesthetic is placed under the skin surrounding the
hemorrhoid, a scalpel is used to cut into the area and the clot is
removed. There is almost instant relief of the sharp pain but a
dull ache may continue.
– There may be some mild bleeding from the hemorrhoid for a
couple of days. Sitz baths and over-the-counter pain
medications may be recommended.
– The use of a rubber or air rubber donut may help with the pain
as well. Preventing constipation is also a priority.

Surgery
• Rubber band ligation:
Rubber band ligation of
internal hemorrhoids can
be done in the office. The
surgeon places a couple of
tight rubber bands around
the base of the
hemorrhoidal vein causing
it to lose its blood supply.
There may be some fullness
or discomfort for 1-2 days
after the procedure and a
minor amount of bleeding
may be experienced.
• Sclerotherapy:
Sclerotherapy
describes a
procedure when a
chemical is injected
into the
hemorrhoid causing
it to scar.
• Laser therapy:
Laser therapy can
be used to scar and
harden internal
hemorrhoids.

• Hemorrhoidectomy:
Hemorrhoidectomy is a
surgical procedure done in
the operating room with
an anesthetic agent
(general, spinal or local
with sedation) where the
whole hemorrhoid is
removed
(ectomy=removal). This is
the most aggressive
approach and there is a
markedly decreased
chance of the
hemorrhoids returning.
However, there is also an
increase in the
complication rate.
• Stapled
hemorrhoidectomy:
Stapled hemorrhoidectomy is
the newest surgical technique
for treating hemorrhoids, and
it has rapidly become the
treatment of choice for third-
degree hemorrhoids. Stapled
hemorrhoidectomy is a
misnomer since the surgery
does not remove the
hemorrhoids but, rather, the
abnormally lax and expanded
hemorrhoidal supporting
tissue that has allowed the
hemorrhoids to prolapse
downward. Stapled
hemorrhoidectomy is faster
than traditional
hemorrhoidectomy, taking
approximately 30 minutes. It
is associated with much less
pain than traditional
hemorrhoidectomy and
patients usually return earlier
to work.

Complications
• The blood in the enlarged veins may form clots, and
the tissue surrounding the hemorrhoids can die.
Hemorrhoids with clots generally require surgical
removal.
• Severe bleeding may also occur. Iron deficiency
anemia can result from prolonged loss of blood.
Significant bleeding from hemorrhoids is unusual,
however.

Prevention
• The risk of hemorrhoids can be decreased by
eating a high fiber diet, staying well hydrated,
getting regular exercise, and trying to have a
bowel movement as soon as possible after the
urge arises.

Differential Diagnoses
• Anal fissure or fistula
• Condylomata acuminata
• External hemorrhoids
• External skin tag
• Hypertrophied anal papilla
• Internal hemorrhoids
• Perirectal abscess
• Rectal cavernous hemangioma
• Rectal or anal cancer
• Rectal polyp
• Rectal prolapse
• Rectal varices

Etiology
• Infections, including those caused by a virus,
parasite, and food poisoning due to bacteria
• Ulcerative colitis and Crohn disease
• Lack of blood flow (ischemic colitis)
• Past radiation to the large bowel
• Pseudomembranous colitis

Symptoms
Symptoms can include:
• Abdominal pain and bloating that may be
constant, or come and go
• Bloody stools
• Constant urge to have a bowel movement
• Dehydration
• Watery Diarrhea
• Fever

Diagnosis
• Examination of the abdomen includes
palpating or feeling for tenderness and masses
in the abdomen
• The exam also may include a rectal
examination to test the stool for blood and
feel for a possible rectal mass

Complication
Complications may include:
• Bleeding
• Hole in the colon
• Ulceration

Definition
• condition in which there are small pouches or
pockets in the wall or lining of any portion of
the digestive tract

Definisi
• Adanya nyeri perut, distensi dan gangguan
pola defekasi tanpa gangguan organik
• Tidak ada pemeriksaan fisik dan laboratorium
yang spesifik

Etiologi
• Gangguan motilitas
• Intoleransi makanan
• Abnormalitas sensoris
• Hipersensitivitas viseral
• Paska infeksi usus
• Infeksi : virus, giardia, amoeba

Kriteria diagnosis
Kriteria IBS berdasarkan Rome III
Nyeri diperut yang berulang sedikitnya 3 hari perbulan selama 3 bulan terakhir
disertai :
• Membaik dengan defekasi
• Onset berhubungan dengan perubahan frekuensi defekasi
• Onset berhubungan perubahan bentuk feses
Kriteria Manning
Gejala yang sering pada IBS
• Feses cair pada saat nyeri
• Frekuensi buang air besar bertambah saat nyeri
• Nyeri berkurang setelah defekasi
• Tampak abdomen distensi
Dua gejala tambahan yang sering muncul pada pasien IBS
• Lendir saat buang air besar
• Perasaan tidak lampias saat buang air besar

Subgrup IBS
IBS predominan nyeri
• tidak dapat tegas menunjukkan lokasi sakitnya
• Nyeri dirasakan > 6 bulan
• Nyeri hilang setelah defekasi
• Nyeri meningkat saat stress dan menstruasi
• Nyeri dirasakan persisten jika kambuh terasa lebih sakit
IBS predominan diare
• Diare pada pagi hari sering dengan urgensi
• Biasanya disertai rasa sakit dan hilang setelah defekasi
IBS predominan konstipasi
• Terutama wanita
• Defekasi tidak lampias
• Biasanya feses disertai lendir tanpa darah
IBS alternating pattern
• Pola defekasi yang berubah-ubah
• Sering dengan feses dipagi hari keras dan menjadi cair di sore hari

Proctitis
• Inflammation of the rectum
• Proctitis can cause rectal pain
• Proctitis symptoms can be short-lived, or they
can become chronic
• common in people who have inflammatory bowel
diseases
• Sexually transmitted infections are another
frequent cause.
• Proctitis also can be a side effect of radiation
therapy for cancers.

Symptoms
• A frequent or continuous feeling that you need to
have a bowel movement
• Rectal bleeding
• The passing of mucus through your rectum
• Rectal pain
• Pain on the left side of your abdomen
• A feeling of fullness in your rectum
• Diarrhea
• Pain with bowel movements

Etiology
• Inflammatory Bowel disease
• Infections : Sexually transmitted infections, spread
particularly by people who engage in anal intercourse.
Sexually transmitted infections that can cause proctitis
include gonorrhea, genital herpes and chlamydia.
• Radiation therapy for cancer : Radiation therapy directed at
your rectum or nearby areas, such as the prostate, can
cause inflammation of the lining of your rectum
• Antibiotics
• Food protein induced procitis : This can occur in infants
who drink either cow's milk- or soy-based formula, and in
those who are breastfed by mothers who eat dairy
products.

Diagnosis
• Blood test
• Stool test : determine if caused by bacterial
infection
• Sigmoidoscopy: a procedure used to see
inside the sigmoid colon and rectum

Treatment
• Caused by infection
– Antibiotics : doxycycline
– Antivirals : ancyclovir
• Caused by radiation therapy
– Medication : Medications are given in pill, suppository
or enema form
sucralfate, sulfasalazine, metronidazole
• Caused by inflammatory bowel disease
– Medications to control rectal inflammation : mouth or
as a suppository or enema
– Surgery

Complication
• Anemia. Chronic bleeding from your rectum can
cause anemia.
• Ulcers. Chronic inflammation in the rectum can
lead to open sores (ulcers) on the inside lining of
the rectum.
• Fistulas. Sometimes ulcers extend completely
through the intestinal wall, creating a fistula, an
abnormal connection that can occur between
different parts of your intestine, between your
intestine and skin, or between your intestine and
other organs, such as the bladder and vagina.

Prevention
• Limiting your number of sex partners
• Using a latex condom during each sexual
contact
• Not having sex with anyone who has any
unusual sores or discharge in the genital area

PENYAKIT LOWER ABDOMEN PADA
ANAK
LO 3

Hirschsprung's disease
• Hirschsprung's is a disease of the large
intestine.
• Hirschsprung's disease usually occurs in
children.
• It causes constipation, which means that
bowel movements are difficult.
• Some children with Hirschsprung's disease
can't have bowel movements at all.
The stool creates a blockage in the intestine.

Epidemiology
• Incidence – 1/5000 live births
• Short segment (rectosigmoid)
– Male : female = 3.9 : 1
– Multifactorial inheritance - ?recessive
• Longer segment
– Decreased sex ratio
– Increased sibling risk
– ? Dominant

• Associated anomalies
– CHD – 4-5%
– Down’s – 4-5%
– Neurofibromatosis
– Ganglioneuromatosis
– Neuroblastoma
– Smith-Lemli-Opitz Syndrome
– Waardenburg’s Syndrome

Why does Hirschsprung's disease
cause constipation?
• Normally, muscles in the
intestine push stool to the
anus, where stool leaves
the body. Special nerve
cells in the intestine called
ganglion cells, make the
muscles push.
• A person with
Hirschsprung's disease
does not have these nerve
cells in the last part of the
large intestine.

Symptoms
• Symptoms in Newborns
– Newborns with Hirschsprung's disease don't have
their first bowel movement when they should.
These babies may also throw up a green liquid
called bile after eating and their abdomens may
swell. Discomfort from gas or constipation might
make them fussy. Sometimes, babies with
Hirschsprung's disease develop infections in their
intestines.

• Symptoms in Young Children
– Constipation
– Diarrhea
– Anemia, a shortage of red blood cells, because blood is lost
in the stool. Also, many babies with Hirschsprung's disease
grow and develop more slowly than they should.
• Symptoms in Teenagers and Adults
• Like younger children, teenagers and adults with
Hirschsprung's disease usually have had severe
constipation all their lives. They might also have
anemia.

Diagnostic evaluation
• Barium enema x ray
– For a barium enema x ray , the doctor puts barium through the
anus into the intestine before taking the picture. Barium is a
liquid that makes the intestine show up better on the x ray.
– In places where the nerve cells are missing, the intestine looks
too narrow.
• Manometry
The doctor inflates a small balloon inside the rectum.
Normally, the anal muscle will relax.
• Biopsy
– This is the most accurate test for Hirschsprung's disease. The
doctor removes and looks at a tiny piece of the intestine under a
microscope

Differential Diagnosis
• Neonates
– Small left colon
– Meconium plug
– Meconium ileus
– Megacystis – megacolon - intestinal hypoperistalsis
syndrome
– Intestinal dysmotility
– Hollow viscous myopathy
– Chronic intestinal pseudo-obstruction

• Infants and children
– Functional constipation
– May need to evaluate for hypothyroidism and
hypercalcemia

Treatment
• Before surgery: The diseased section is the
part of the intestine that doesn't work.
• Step 1: The doctor removes the diseased
section.

• Step 2: The healthy section is attached to the rectum or anus.
• Colostomy and Ileostomy
• If the doctor removes the entire large intestine and connects the small
intestine to the stoma, the surgery is called an ileostomy.
• If the doctor leaves part of the large intestine and connects that to the
stoma, the surgery is called a colonostomy.
• In an ostomy, the doctor takes out the diseased part of the intestine. Then
the doctor cuts a small hole in the baby's abdomen. The hole is called a
stoma

Diet and Nutrition
• Drinking plenty of liquids is important after
surgery for Hirschsprung's disease.
– Since child's intestine is shorter, it absorbs less.
Child will need to drink more to make the body
gets enough fluids.
• Eating high-fiber foods can help reduce
constipation and diarrhea.

Functional Constipation
• Diagnostic criteria : Must include one month of at least two of
the following in indants up to 4 years of age
1. Two or fewer defecations per week
2. At least one episode/week of incontinence after the
acquisition of toileting skills
3. History of excessive stool retention
4. History of painful or hard bowel movements
5. Presence of a large fecal mass in the rectum
6. History a large diameter stools which may obstruct the toilet
Accompanying symptoms may include irritability, decreaseed
appetite, and/or early satiety. The accompanying symptoms
disappear immediately follwoing passage of a large stool.

Evaluation
• History of present illness
– In neonates, should determine whether meconium has been passed at
all and if so, when.
– For older infants and children, history should note onset and duration
of constipation, frequency and consistency of stools and whether
symptoms began after a specific event,such as introduction of certain
foods or a stressor that could lead to stool retention (eg, introduction
of toilet training)
– Important associated symptoms include soiling (stool incontinence),
discomfort on defecation, and blood on or in the stool
– The composition of the diet, especially the amount of fluid and fiber
should be noted.

• Review of systems
– Should ask about symptoms that suggest an
organic cause, including new onset of poor suck,
hypotonia, and ingestion of honey before age 12
months (infantile botulism); cold intolerance, dry
skin, fatigue, hypotonia, porlonged neonatal
hyperbilirubinemia, urinary frequency, and
excessive thrist (endocrinopathies); change in gait,
pain or weakness in lower extremities, and urinary
incontinence (spinal cord defects); night sweats,
fever, and weight loss (cancer); and vomiting,
abdominal pain, poor growth, intermittent
diarrhea, and constipation (intestinal disorders)

• Past medical history
– Should ask about known disorders that can cause
constipation, including cystic fibrosis and celiac sprue.
– Exposure to constipating drugs or lead paint dust should
be noted.
– Reports of delayed passage of meconium within the first
24 to 48 hours of life should be obtained, as well as
previous episodes of constipation and family history of
constipation.

Physical Examination
• General assessment of the child’s level of discomfort or
distress and overall appearance (including skin and hair
condition).
• Height and weight should be measured and plotted on
growth charts.
• Examination should focus on the abdomen and anus
and on the neurologic examination.
• The abdomen is inspected for distention, auscultated
for bowel sounds, and palpated for masses and
tenderness.

• The anus is inspected for fissure (taking care not to
spread the buttocks so forcefully as to cause one)
• A digital rectal examination is done gently yo check
stool consistency and obtain a sample for occult blood
testing.
• Rectal examination should note tge tightness of the
rectal opening and presence or absence of stool in the
rectal vault.
• Examination includes placement of the anus and
presence of any hair tuft or pit superior to the sacrum
• In the infant, neurologic examination focuses on tone
and muscle strength.
• In the older child, the focus is on gait, deep tendon
reflexes, and signs of weakness in the lower
extremities.

Tests
• Barium enema, rectal manometry, and biopsy (Hirschsprung’s
disease)
• Plain X-rays of lumosacral spine; MRI considered (tethered
spinal cord or tumor)
• Thyroid-stimulating hormone and thyroxine (hypothyroidism)
• Blood lead level (lead poisoning)
• Stool for botulinim toxin (infant botulism)
• Sweat test and genetic testing (cystic fibrosis)
• Ca and electrolytes (metabolic derangement)
• IgA and IgG anti-gliadin antibodies, IgA anti-endomysium
antibodies, IgA anti-tissue glutaminase (celiac disease)

Treatment
• Dietary changes
– Adding prune juice to formula for infants
– Increasing fruits and vegetables for older infants and
children
– Increasing water intake
– Decreasing the amount of constipating foods 9eg, milk,
cheese)
• Behavior modification
– For older childrean involves encouraging regular stool
passage after meals if they are toilet trained and providing
a reinforcement chart and encouragement to the child.
– For children who are in the process of toilet training, it is
sometimes worthwhile to give them a break from training
until the constipation concern has passed.

Medical Nutrition Therapy
• Primary nutrition therapy for constipation is adequate
amount of soluble and non soluble dietary fiber.
• Adequate fiber : 14g/1000kkal
– Woman : 25g
– Man : 38g
– Children : 19-25g
• Function of fiber:
– Increases colonic fecal fluid
– Increases microbial mass
– Increases stool weight and frequency
– Increases rate of colonic transit
– Softens stools and make them easier to pass

Medical Nutrition Therapy
• Fiber can be provided in the form of:
– Whole grains
– Fruit
– Vegetables
– Legumens
– Seeds
– Nuts

Type of Therapy Agent Dose Adverse Effects
DISIMPACTION
Oral
Oral “high-dose” mineral oil
(should not be used in
neurologically impaired children
in case of aspiration)
15-20 mL/yr of age
(maximum 240 mL/day) for 3
days or until stool appears
Fecal incontinence,
malabsorption of fat-
soluble vitamins (if
repeated treatments are
given)
Oral polyethylene glycol-
electrolyte solution
25 mL/kg/h (maximum 1000
mL/h) by NGT until stool
appears or 20 mL/kg/h for 4
h/day
Nausea, vomiting,
cramping, bloating
Oral polyethylene glycol
without electrolytes
1-1,5 g/kg dissolved in 10
mL/kg water once/day for 3
days
Fecal incontinence
Rectal
Glycerin suppositories
Infants and older children : ½
- 1 suppository once/day for
3 days or until stool appears
None
Rectal mineral oil enema
2-12 yr: 2,25 oz once/day for
≥ 12 yr: 4,5 oz once/day for 3
Fecal incontinence,
mechanical trauma
Rectal phosphate Na enema
2- <5 yr: 1,13 oz once/day for
5-12 yr: 2,25 oz once/day for
≥ 12 yr: 4,5 oz once/day for 3
Mechanical trauma,
hyperphosphatemia

MAINTENANCE AGENTS
Oral osmotic and
lubricant laxatives
Lactulose
1 mL/kg once/day or bid
(maximum 60 mL/day)
Abdominal cramping, flatus
Magnesium hydroxide 1-2 mL/kg once/day
If overdosem risk of
hypermagnesemia,
hypophosphatemia, or
secondary hypocalcemia
Mineral oil 1-3 mL/kg once/day Fecal incontinence
Polyethylene glycol 3350 powder (in
8 oz of water)
1-18 mo; 2,5-5 mL (0,5-1 tsp)
once/day
> 18 mo-3 yr: 10-15 mL (2-3 tsp)
once/day
≥ 3 yr:10-20 mL (2-4 tsp)
once/day
Fecal incontinence
Sorbitol (syrup, 70% solution)
1-12 yr: 1 mL/kg once/day or bid
≥ 12 yr: 15-30 mL once/day or
bid
Abdominal cramping, flatus
Oral stimulant
laxatives (to be used
for a limited period of
time)
Bisacodyl (5 mg tablets)
2-12 yr: 1-2 tablets once/day
≥ 12 yr: 1-3 tablets once/day
Fecal incontinence,
hypokalemia, abdominal
cramps
Zsenna syrup: n8,8 mg
sennosides/5mL
Senna tablets: 8,6 mg
sennosides/tablet
1-2 yr: 1,25 mL once/day up to
2,25 mL bid
≥ 2-6 yr: 2,5 mL once/day up to
3,75 mL bid
≥ 6-12 yr: 5 mL once/day up to
7,5 mL bid
≥ 12 yr: 1 tablet once/day up to 2
tablets bid
Abdominal cramping,
melanosis coli

MAINTENANCE DIET SUPPLEMENTS
Dietary fiber
supplements
Methylcellulose
< 6 yr: 3,5-7,5 mL (1/4-1/2
tbsp) once/day
≥ 6-12 yr : 7,5 mL (1/2 tbsp)
once/day
≥ 12 yr: 15 mL (1 rpunded
tbsp) in 8 oz water 1-3
times/day
Less bloating than other
fiber supplements
Psyllium
5-15 mL (1 tsp-1tbsp
[depending on concentration
and formulation]) in 8 oz
water
• 6-12 yr: once/day
• ≥ 12 yr : 1-3 times/day
Bloating, flatus
Sorbitol-containing fruit juices
(eg, prune, pear, apple)
Infants and older children : 1-
4 oz/day
Flatus

DEFINITION
• Intestinal obstruction is significant mechanical
impairment or complete arrest of the passage
of contents through the intestine

Classification
Mechanical obstructions
• The bowel is physically
blocked and its contents can
not pass the point of the
obstruction.
• This happens when the
bowel twists on itself
(volvulus) or as the result of
hernias, impacted feces,
abnormal tissue growth, or
the presence of foreign
bodies in the intestines.
Non-mechanical obstruction
• Called ileus or paralytic ileus,
occurs because peristalsis
stops.
• Peristalsis is the rhythmic
contraction that moves
material through the bowel.
• Ileus is most often associated
with an infection of the
peritoneum (the membrane
lining the abdomen). It is one
of the major causes of bowel
obstruction in infants and
children.

• Mechanical obstruction is divided into:
– obstruction of the small bowel (including the
duodenum)
– obstruction of the large bowel
• Obstruction may be partial or complete.

Causes of Intestinal Obstruction
Location Causes
Colon Tumors (usually in left colon), diverticulitis
(usually in sigmoid), volvulus of sigmoid or
cecum, fecal impaction, Hirschsprung's disease
Duodenum
(Adults)
Cancer of the duodenum or head of pancreas,
ulcer disease
Duodenum
(Neonates)
Atresia, volvulus, bands, annular pancreas
Jejunum and ileum
(Adults)
Hernias, adhesions (common), tumors, foreign
body, Meckel's diverticulum, Crohn's disease
(uncommon), Ascaris infestation, midgut
volvulus, intussusception by tumor (rare)
Jejunum and Ileum
(Neonates)
Meconium ileus, volvulus of a malrotated gut,
atresia, intussusception

Examples of Causes of Intestinal
Obstruction
Obstruction due to
adhesions
Obstruction due to
mesenteric occlusion
Obstruction due to
volvulus
Obstruction due
to hernia
Obstruction due to
tumor
Obstruction due to
intussusception

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