CURRICULUM VITAE

DATA PRIBADI

Nama : dr. Hermanto, SpB, SpBA

Tempat/Tanggal lahir : Cirebon , 7 Juli 1966

Agama : Islam

Status Perkawinan : Menikah

Kepegawaian : PNS

Jabatan : -Kepala SMF Bedah, RSUD dr Soedarso Pontianak

- Kepala Instalasi Gawat Darurat, RSUD dr Soedarso, Pontianak

Kalimantan Barat

Telepon : 0818858360

Email : hermantospba2009@gmail.com

Alamat : Jl. Sungai Raya Dalam, Kompleks Gading Premier A7,

Pontianak, Kalimantan Barat

RIWAYAT PENDIDIKAN

Tahun 1973 – 1979 : SD Negeri 2 Ciledug Cirebon

Tahun 1979 – 1982 : SMP Negeri 2 Ciledug Cirebon

Tahun 1982 – 1985 : SMA Negeri Sindang Laut Cirebon

Tahun 1985 – 1992 : FKUI Jakarta, Dokter Umum

Tahun 1996 – 2002 : FKUI Jakarta. Spesialis Bedah

Tahun 2007 – 2009 : FKUI Jakarta, Spesialis Bedah Anak

RIWAYAT PEKERJAAN

Tahun 1992 -1995 : Dokter PTT Di Puskesmas Nanga Tepuai, Kabupaten Kapuas Hulu,

Kalimantan Barat

Tahun 2003 – 2006 : Dokter Spesialis Bedah, RSUD dr Rubini Mempawah,

Kalimantan Barat

Tahun 2009 – Sekarang : Dokter Sepesiais Bedah, Konsultan Bedah Anak, RSUD dr Soedarso

Pontianak, Kalimantan Barat

Abdominal Pain In Children

Surgery or Not

Dr. Hermanto. SpB, SpBA

Dokter Spesialis Bedah Konsultan Bedah Anak

Rumah Sakit Umum Daerah Dr. Soedarso
Pontianak, Kalimantan Barat
Singkawang, 3 Maret 2018
•Abdominal pain is extremely common in
children and may reflect a variety of conditions
•The cause cannot be determined with
certainty,
Caused by pathology unrelated to the
abdomen.

•Pain which lasts for more than 4–6 h,

becoming worse
persistent vomiting
prolonged diarrhoea,

•Should be taken seriously

•Surgical cause excluded.
Unknown cause

•The symptoms resolve

spontaneously over several
hours.

•At the other end of the

spectrum, abdominal pain
may reflect signficant
pathology and necessitate
precise

•Clinical assessment before

the appropriate therapeutic
measures can be undertaken
In young children, infection outside the
abdomen (e.g. lung, hip) may be
interpreted as abdominal pain.

This pain must be distinguished from

pain arising within the abdomen.
Influence of Age on the Incidence of
Acute Abdominal Disease
The Location of Pain
•Inflammation or distension of the bowel or its
coverings causes pain which is transmitted
through two separate pathways.

•Distension of the bowel and inflammation of

the visceral peritoneum stimulate sympathetic
pathways, and the perceived location is
dependent on the level of bowel involved

•Pain arising in the foregut projects to the

epigastrium, in the midgut to the umbilicus
and in the hindgut to the infra-umbilical or
hypogastric region.
 Type of pain
Visceral pain
Stimulation of visceral organs,
due to injury or inflammation

The visceral peritonium

enveloping the abdominal organs
is innervated by the autonomic
nervous system
Not sensitive to touch or
incision

Sensitive to pull, strain and

excessive contractions cause
ischemia such as colic and
inflammation, pain may arise
 Type of pain
Somatic pain:
Stimulation of the peripheral
innervated nerves

Stimulation on the parietal

peritoneum and injury to the
abdominal wall

Pain as stabbed or cut

The location of the pain can be

pointed appropriately
Stimulation pain in the form of touch,
pressure, chemical, and inflammation
Colicky pain
Visceral pain due to spasm
of hollow innocent muscle due
to barrier obstacles, bowel
obstruction, ureteral stones,
gallstones etc.

Pain is caused by hypoxia of

the affected organ. Because
peristaltic pause, so the pain
felt lost arise
Ischemic pain
Severe pain, persisting
and not reduced

It is a sign of tissue

threatened by necrosis

Tachycardia and shock

due to absorption of
necrotic tissue toxins
Inflammatory pain

Pain due to stimulation of

peritoneum parietale will be
felt continuously

peritonitis, local tenderness

Muscle rigidity : reflex

contraction of the abdominal
wall to protect the inflamed
part from local pressure
Abdominal pain intensity
Colicky pain intensity
Characteristics of the
pain
History
Extra-abdominal illnesses
causing abdominal pain
Differential diagnosis for acute
abdominal pain
Physical examination
Significant abdominal pain
are anxious and scared.

Uncooperative.

Patience and skill are

needed to assess the
abdomen accurately to avoid
the disaster of not
recognizing significant intra-
abdominal pathology.
The vast majority of children
with abdominal pain of unknown
cause,

The symptoms resolve

spontaneously over several hours.

At the other end of the

spectrum, abdominal pain may
reflect significant pathology and
necessitate precise clinical
assessment before the
appropriate
The ‘appendix shuffle’.
Movement of adjacent
inflamed peritoneal surfaces
makes the pain worse.

The pain can be minimized

by adopting this posture
whilst walking
Associated Features
Vomiting commonly companies
abdominal pain in children
because autonomic reflexes
stimulate vomiting in response to
any inflammation or severe pain.

1. The relationship of its onset to

the development of pain
2. It’s frequency
3. The nature of the vomitus
In appendicitis,
vomiting generally commences
several hours after the onset of
pain.

In acute colic of the ureter,

the onset of vomiting coincides
with that of pain,
both being sudden and dramatic.

In obstruction of the intestinal

tract, the onset of vomiting is
dependent
Relationship between type of vomitus
and its underlying cause
Relationship between abnormal stools
and their underlying cause
Non-specific Signs of
Peritonitis
1) Facial expression will show the child in pain, pale.
2) The cheeks are red in association with perioral pallor.
3) Vomiting,Pyrexia, fetor and furred tongue
4) A tachycardia
5) In long-standing peritonitis, septicaemic shock
6) Loops of intestine become distended and paretic, causing
abdominal distension.
7) The abdomen is silent on auscultation.
8) Vomiting of small bowel contents develops, and the
respiratory rate becomes rapid.
The inexperienced clinician may be misled
by the apparent paucity of signs.
Where the appendix occupies a position in the
pelvis,
The area of maximal tenderness is vague and
lower than McBurney’s point.

There is no guarding of the peritoneum of the

lower abdomen.

Clues to the presence of pelvic appendicitis

include:
(1) complaints of pain in the abdomen during
micturition (this is not urethral dysuria but is pain
caused by movement of the peritoneum over the
bladder) as the bladder empties,
(2) Passage of loose bowel actions owing to
irritation of the rectum
Digital Rectal Examnination ?
Does There Have to Be Evidence of Localized
Peritonitis Before a Diagnosis
of Appendicitis Is Made?
It is in the patient’s interest that
a diagnosis is made on clinical
grounds before peritonitis
develops.

Peritonitis is a sign of advanced

disease, and in most cases, a
history consistent with
appendicitis,

combined with marked localized

tenderness in the right iliac fossa,
provides sufficient grounds for a
diagnosis of appendicitis to be
made.
When Does Diarrhea Occur with
Appendicitis?
If the inflamed appendix lies against the rectum,the
irritation it causes produces mild diarrhoea .

Retro-ileal and retrocaecal appendicitis may also

produce loose bowel actions.
If the appendix perforates, the infected material
released collects
Retrovesical pouch in the male
Retrouterine recess in the female
Pelvic abscess develops.

As the abscess increases in size, it causes irritation

of the rectum and can be palpated
as a hot, tender bulge of the anterior rectal wall.
Does Appendicitis Produce a
Fever?
In most children with appendicitis, the
temperature is slightly elevated (37.5–38
°C).

A normal or slightly subnormal

temperature does not preclude the
diagnosis of appendicitis – nor does a
grossly elevated temperature (39–40 °C),
although this is unlikely unless peritonitis
is present.

Unfortunately, most of the other

conditions from which appendicitis must
be distinguished are inflammatory or
infective in nature and produce elevation
of the temperature.
A Mass in the Right Iliac Fossa
It can be felt as a tender,
Immobile Inflammatory phlegmon
of an infected appendix, stuck by
inflammatory exudate

Oedematous loops of small

bowel, and greater omentum.

In girls, a large ovarian cyst may

be palpable as a smooth surfaced
mass in the right iliac fossa.

The mass is non-tender and

mobile, unless there is torsion of
its pedicle.
In the child under 2 years of age, the
mass may be an intussusception.

The sudden onset of a

colicky pain
Vomiting, pallor, lethargy
and short duration of
symptoms with or without
rectal bleeding with
generalized anorexia, malaise
and marked abdominal
tenderness would make one
more suspicious of
appendicitis.
Other Patologies
1 Viral Enteritis (‘Mesenteric Adenitis’)
In addition to the localized collection of
lymphoid tissue seen in the terminal ileum
(Peyer’spatches)

There are numerous lymph nodes at

the mesenteric edge of the bowel and
within the mesentery of both small and
large intestine.

Tenderness is often maximal in the right

iliac fossa and is simply a reflection of the
location of the enlarged nodesrepeated in
a few hours.
2. Gastroenteritis

This common condition is characterized by

vomiting and diarrhoea.

The diarrhoea usually commences as the first

symptom or shortly after the onset of vomiting.

There may be associated abdominal

pain which tends to be cramping and diffuse.

In the majority of children, symptoms are

improving within 24–72 h.

Persistence of either vomiting or diarrhoea

should make one suspicious of alternative
diagnoses, of which appendicitis is one.
3. Constipation
Poor diet, a constitutional predisposition
Poor bowel training

Anal fissure there is a long history of

infrequent passage of hard bowel actions
over a long period.

The pain is often colicky and may be

relieved by a bowel action.

Examination of the abdomen reveals faecal

Material,There is no peritonitis.

Digital examination of the rectum will reveal

a capacious rectum full of faecal material.
4. Urinary Tract Infection or
Obstruction
These conditions may produce
abdominal pain and be difficult to
separate from appendicitis.

A high index of suspicion and

urinary examination will exclude
this important cause.

The child has a higher fever and

fewer localizing Occasionally,
abdominal pain may be the first
manifestation of one of the rare
conditions
Rare causes of abdominal pain
Abdominal Pain In Children :
Surgery or Not ?
The end