Dr. H. Dr. H. Guntur Surya AlamGuntur Surya Alam, SpB, , SpB, SpBASpBA

• Riwayat Pendidikan : Riwayat Pendidikan : Dokter Umum FKUDokter Umum FKUGMGM(19(199393))Dokter Spesialis Bedah FKDokter Spesialis Bedah FKUGMUGM ( (20022002))Dokter Spesialis Bedah Anak FKUDokter Spesialis Bedah Anak FKUGMGM((2007)2007)

ABDOMINAL DISTENTIONABDOMINAL DISTENTION inin

Newborn baby and Newborn baby and childrenchildren

SURGERY SURGERY CASESCASES or or NOT ?NOT ? and TIMING of Operation ?and TIMING of Operation ?

Guntur Surya Alam, Guntur Surya Alam, Pediatric SurgeonPediatric Surgeon

Dr. Moewardi Teaching Dr. Moewardi Teaching HospitalHospital

S u r a k a r t aS u r a k a r t a

• Obstruksi usus dapat mengenai mulai Obstruksi usus dapat mengenai mulai gaster sampai anusgaster sampai anus

• Penyebab terbanyak kelainan Penyebab terbanyak kelainan gastrointestinal pada pasien pediatrikgastrointestinal pada pasien pediatrik

• Penyebab gawat darurat bedahPenyebab gawat darurat bedah• Tidak ditangani dengan benar Tidak ditangani dengan benar

menyebabkan morbiditas / mortalitas menyebabkan morbiditas / mortalitas tinggitinggi

• Obstruksi usus pada neonatusObstruksi usus pada neonatus• Paling sering merupakan gawat Paling sering merupakan gawat

darurat bedahdarurat bedah• Tantangan para Dokter Bedah AnakTantangan para Dokter Bedah Anak• Neonatus sangat rentan terhadap Neonatus sangat rentan terhadap

perubahan hemostasis, temperaturperubahan hemostasis, temperatur• Prognosis tergantung diagnosis Prognosis tergantung diagnosis

cepat dan terapi segera cepat dan terapi segera

• Umumnya datang pertama kepada Umumnya datang pertama kepada Dokter AnakDokter Anak/dokter umum/ Bidan/dokter umum/ Bidan

• Perlu mengenali cepat bahwa itu Perlu mengenali cepat bahwa itu pasien bedah dan segera merujukpasien bedah dan segera merujuk

• Segera mendapat penanganan bedah Segera mendapat penanganan bedah • Terlambat Terlambat berakhir dengan berakhir dengan

morbiditas atau mortalitas tinggimorbiditas atau mortalitas tinggi• Akan dibahas diagnosis dan Akan dibahas diagnosis dan

tatalaksana obstruksi usus pada pasien tatalaksana obstruksi usus pada pasien pediatrikpediatrik

Abdominal distension :Abdominal distension :is a enlargement of the abdomen is a enlargement of the abdomen

…….. a common complaint.. a common complaint

A prominent “potbelly”contour

is normal in infants and young children.

- I’m normal lho mom.- I’m overeating .. Ha, ha,ha

Normally :Normally : - - overeatingovereating - obesity- obesity

Pathologically :Pathologically :

NON SURGICAL CASES

Pathologic enlargement of the abdomen is a problem :Pathologic enlargement of the abdomen is a problem : - reduced breathing

- reduced tone of the wall musculature - abdominal compartement syndrome

SURGICAL CASES

Physiologically :Physiologically : - pregnant woment- pregnant woment

PROBLEM ABD DISTPROBLEM ABD DIST

1.1. RESPIRATORY DISTRESSRESPIRATORY DISTRESS

2.2. ABDOMINAL COMPARTEMENTABDOMINAL COMPARTEMENT

3.3. INDICATION FOR OPERATIONINDICATION FOR OPERATION

4.4. TIMING FOR OPERATIONTIMING FOR OPERATION

5.5. OPERATIVE OF CHOICEOPERATIVE OF CHOICE

6.6. ANAESTHESIAANAESTHESIA

7.7. OPERATIVE TECHNICSOPERATIVE TECHNICS

8.8. POSTPOST OPERATIVE CARE OPERATIVE CARE

Must be evaluated carefully and Must be evaluated carefully and systematically systematically

to rule out serious and lifethreatening to rule out serious and lifethreatening conditions.conditions.

A careful history and physical examination A careful history and physical examination are necessary to develop an appropriate are necessary to develop an appropriate differential upon which to base a diagnostic differential upon which to base a diagnostic plan.plan.

Acute-onset abdominal distension is a Acute-onset abdominal distension is a

sign that should be taken seriously sign that should be taken seriously especially when accompanied by bilious especially when accompanied by bilious vomitingvomiting..

ABDOMINAL DISTENSION

History include :History include :

Age ? , Duration ?Fever ? , Pain ?

Vomitus ? , Flatus ?Last Bowel movement ?

Diarrhea ?Trauma ?, Systemic Dis ?

Weight loss ?

IN NEONATUSPrenatal ? , Birth history /

delivery process?Gestational age ?

passage of meconium ?passage of meconium ?Adult ( women) :

- last menstrual ?, - sexual history ?,

Abd Distent +-Acute Mass

- Fever- Pain

- Vomitus- Can’t flatus

- Can’t defecation- Trauma

STRANGUTATIONHEMORRHAGE

SIMPLE OBSTRUCTIONINFECTION

NEOPLASMAOTHER

EMERGENCY

URGENTURGENT

ELECTIVE

IN CHILD

SURGICAL CASES

Differential Diagnosis for failure to pass meconiumDifferential Diagnosis for failure to pass meconium: : • Disorders of the small intestineDisorders of the small intestine

– Duodenal atresia Duodenal atresia – Jejunoileal atresia Jejunoileal atresia – Malrotation and volvulus Malrotation and volvulus – Meconium ileus Meconium ileus

• Disorders of the large intestineDisorders of the large intestine – Meconium plug syndrome Meconium plug syndrome – Anorectal malformation Anorectal malformation – Hirschsprungs disease Hirschsprungs disease – Small left colon syndrome Small left colon syndrome

• Other causesOther causes – Narcotics Narcotics – Electrolyte abnormalities; hypermagnesemia, hypokalemia, Electrolyte abnormalities; hypermagnesemia, hypokalemia,

hypercalcemia hypercalcemia – Hypothyroidism Hypothyroidism – Sepsis Sepsis – Congestive heart failure Congestive heart failure

Physical exam :Physical exam : full abdominal exam

full abdominal exam

for hernias ?, masses ?, for hernias ?, masses ?, pelvic exam ( women ), pelvic exam ( women ),

signs of cirrhosis / signs of cirrhosis / portal hypertension, portal hypertension,

abdominal tenderness ?, abdominal tenderness ?, and fluid wave or free air ?and fluid wave or free air ?

Plain KUB X-rays :Plain KUB X-rays :

bowel obstruction ?bowel obstruction ?mass ?,fecal material ?, mass ?,fecal material ?,

free luidfree luidInfectionInfection

air swallowing, paralytic ileus ?, air swallowing, paralytic ileus ?, pneumo peritoneum ?pneumo peritoneum ?

Contrast study ?Contrast study ?

Other examinations ? USG CT Scan MRI

ABDOMINAL DISTENSION IN NEW BORN

PATHOLOGIS ?

NORMAL

SURGICALCASES ?

NOT ALWAYS

LowerGI

UpperGI

WithoutAbd Disten

Esof AtresiaGastric outlet obstr

Duodenal obstr

Yeyuno ileal atresiaMekonium ileus

Hirschsprung DisColonic stenosis / atresia

DuplicaturAnorectal malformation

NOTOBSTRUCTION

NEC,hemorrhage

Neonatal ascitesNeoplasma

GI obstruction

?

- Acute, vomiting- Delayed passed mekonium- Polyhydramnion ?- Tendernes / erythema ?- Mass ?, Free fuid ?

Bowel Obstruction in the NewbornBowel Obstruction in the Newborn

is one of the most common newborn surgical emergencies. Successful management depends on timely diagnosis and prompt therapy. The diagnosis can usually be made based on history and physical examination and corroborated by simple radiographic studies.

Kind of Disease

UPPER / LOWER GI/Abd Dist ?

MANAGEMENTSYMPTOM DIAGNOS

TICTransporta

tionOPERATION

Technic Timing

1Esofageal

atresiaUpper GI /

Not Distension

- Drolling, - hypersalivation,

- Insert NGT- Babygram Thermoregul

ation

-Gastrostomy ?- Primary Anast ?

THORACOTOMY

Urgent Preoperative

Care

Kind of Dis

Local ? / Abd Dist ?

MANAGEMENT

Symtom Preoperative

Care

Transport

OPERATION

Technic Timing

Gastric

outlet Obstr

UPPER GI / NOT Distens

Water & electrolit resus citation

Thermo regulation

IHPS : pyloromyotomi Atresia : e/e anast. Bezoir : konserv

Urgent

Vomiting Projectile Non bilius Not dist Gastric wave

Diagnostic

Plain foto Abd UGI USG

Kind of Dis

Local ? / Abd Dist ?

MANAGEMENT

Symtom Preoperative

Care

Transport

OPERATION

Technic Timing

Duodenal

obstruction

UPPER GI / NOT Distens

Water & electrolit resus citation

Thermo regulation

Laparotomi :-Ladd’s procedr-Duodeno - duo denostomi -Duodenoplasty

Urgent

Bilius vom abd flat Meko: delay

Plain foto Abd“ DOUBLE BUBLE “ Colon inloop

Diagnostic

Kind of Kind of DiseaseDisease

PROBLEMPROBLEM MANAGEMENTMANAGEMENT

DIAGNOSTICDIAGNOSTIC PreoperatiPreoperativeve

CareCare

TRANSPORTATITRANSPORTATIONON

OPERATIONOPERATION

TechnicTechnic TIMINGTIMING

NECNEC

NOT NOT OBSRUCTIONOBSRUCTION

UnkwonUnkwon

DelayedDelayed

SepsisSepsis

Cinical signCinical sign

Abd plain Abd plain photo:pneumophoto:pneumointestinalintestinal

Culture : Culture : blood & blood & peritoneal peritoneal fluidfluid

Water & Water & electrolit electrolit resuscitationresuscitation

Fasting, Fasting,

DecompresioDecompresion,n,

TPN,TPN,

AntibiotikaAntibiotika

ThermoregulatiThermoregulationon

ConservativConservativee

( new )( new )

Fail : Fail : operation operation

( perforatio( perforation ) n )

CitoCito

Kind of Kind of DiseaseDisease

PROBLEMPROBLEM MANAGEMENTMANAGEMENT

DIAGNOSTICDIAGNOSTIC PreoperatiPreoperativeve

CareCare

TRANSPORTATITRANSPORTATIONON

OPERATIONOPERATION

TechnicTechnic TIMINGTIMING

Gastric Gastric rupturerupture

NOT NOT OBSRUCTIONOBSRUCTION

UnkwonUnkwon

DelayedDelayed

SepsisSepsis

Cinical signCinical signAbd plainAbd plain

photo:pneumophoto:pneumoperitonealperitoneal

Water & Water & electrolit , electrolit , Respiration Respiration resuscitationresuscitation

Fasting, Fasting,

DecompresioDecompresion,n,

TPN,TPN,

AntibiotikaAntibiotika

ThermoregulatiThermoregulationon OPERATIONOPERATION

CitoCito

Kind of Dis

Local ? / Abd Dist ?

MANAGEMENT

Symtoms Preoperative

Care

Transport

OPERATION

Technic Timing

Jejuno- ileal obstr

Mid Gut/DISTENS

Water & electrolit resus citation

Thermo regulation

Laparotomi :-Direct anast.- delayed anast

Urgent

Fecal vom DISTENS Meko : del

DIAGNOSTIC

Plain foto Abd Colon inloop

Kind of Dis

Local ? / Abd Dist ?

MANAGEMENT

Symtoms Preoperative

Care

Transport

OPERATION

Technic Timing

Hirschsprung Dis

Colon /DISTENS

Water & electrolit resus citationDecompr & washout

Thermo regulation

colostomi Pullthrough

ACUTE Urgent

Delayed meko Bilious vom Abd distens

DIAGNOSTIC

Plain foto Colon inlp Suction biopManometri

Manometri Manometri

CONTRACION

RELAXATION

Suction biopsy

PA

Kind of Dis

Local ? / Abd Dist ?

MANAGEMENT

Symtoms Preoperative

Care

Transport

OPERATION

Technic Timing

MARAnorectal/DISTENS

Water & electrolit resus citation. Decomp

Thermo regulation

Depend of AMF types Low : anoplasty High : Colostomy

ACUTE Urgent

Without meko Bilious vom Abd distens +/-

DIAGNOSTIC

Plain foto( invertogram ) USG

- ANUS MEMBRAN- LOW AMF … < 1 cm

- HIGH AMF ….. > 1 cm

AMF WITH FISTELAMF WITH FISTEL

LOW FISTEL :-Recto cutan / perineal - Anterior anus - Bucket handle High

fistel

CLOACAFEMALE :

LOW FISTEL :- VESTBULAR fistel

MALE

FEMALE

ABDOMINAL DISTENSION

IN CHILDCHILD

PATHOLOGIS

NOT

SURGICALCASES ?

Strangulated herniaIntussuception

VolvulusAdhesion

STRANGULATION !!!

INFECTION

TRAUMA

AppendicitisPeritonitis

Inflam Bowel Dis

OBSTRUCTION

Adhesion

Hirsch Dis

Intest Paralysis

Corp alienum

Duplicatur

Ascariasis

- Fever - Pain- Acute- Vomiting - Can’t flatus- Can’t defecation- Abd discomfort - Diarrhe- Tendernes- Mass- Abnorm feses ( bloody/ mucus )

NON SURG:- Ascites

- DHF

Kind of Kind of DiseaseDisease

PROBLEMPROBLEM MANAGEMENTMANAGEMENT

DIAGNOSTICDIAGNOSTIC PreoperatiPreoperativeve

CareCare

TRANSPORTATITRANSPORTATIONON

OPERATIONOPERATION

TechnicTechnic TIMINGTIMING

66

IntussuceptiIntussuceptionon

StrangulatioStrangulation,n,

Intestinal Intestinal obs- obs- truction, truction,

DelayedDelayed

Trias Trias

Colon inloopColon inloopWater & Water & electrolit electrolit resuscitationresuscitation

ThermoregulatiThermoregulationon

Reposition :Reposition :

Non Non operative operative ( new ) ( new )

OperativeOperative

CitoCito

77

Strangulated Strangulated HerniaHernia

StrangulatioStrangulation Recidifn Recidif

Clinical sign Clinical sign Water & Water & electrolit electrolit resuscitationresuscitation

Sedativum.Sedativum.

ThermoregulatiThermoregulationon

Fowler positionFowler position

ConservativConservativee

( new )( new )

Fail : Fail : operationoperation

CitoCito

Kind of Kind of DiseaseDisease PROBLEMPROBLEM

MANAGEMENTMANAGEMENT

DIAGNOSTICSDIAGNOSTICS PreoperatiPreoperativeve

CareCare

TRANSPORTTRANSPORTATIONATION

OPERATIONOPERATION

TechnicTechnic TIMINGTIMING

99

PeritonitisPeritonitis

e/ce/c Rupture Rupture

AppendicitisAppendicitis Typhoid Typhoid

DelayedDelayed

SepsisSepsis

Clinical signClinical sign

Abd plain Abd plain photophoto

Blood Blood examinationexamination

Water & Water & electrolit electrolit resuscitationresuscitation,,

AntibioticsAntibiotics

ThermoregulThermoregulaa

tiontion

Laparotomi Laparotomi AppendisektoAppendisektomi mi CitoCito

Abd disten children and Abd discomfortAbd disten in children and Abd disten

Abd disten in children and Abd guarding Abd distens children and Abd mass

Abdo disten in children and Abd pain Abd disten in children and Inflammatory bowel diseaseAbdominal distension in children and Abdominal rigidity

Abd distension in children and Abdominal swellingAbdominal distension in children and others symptoms Abdominal distension in children and Abd tenderness Abdominal distension in children and Abdominal tumor

Abdominal distension in children and Abn pulse Abdominal distension in children and Abnormal sensations

Abd disten children and Abnormal skin textureAbd disten children and Abnormal stool texture in children

Abd disten children and uterine bleeding Abd disten children and vaginal bleeding

Abd disten children and decreased urinationAbd disten children and Abscessed teeth

Abd distensi and Alternating constipation and diarrheaAbdominal distension in children and Alternating constipation and diarrhoea

Abdominal distension in children and Amenorrhea (4 causes) Abdominal distension in children and Anal symptoms (4 causes)

Abdominal distension in children and Anatomic obstruction (2 causes) Abdominal distension in children and Anemia (2 causes)

Abdominal distension in children and Angina pectoris (1 cause) Abdominal distension in children and Angular cheilitis (1 cause) Abdominal distension in children and Anorectal pain (2 causes)

Abdominal distension in children and Anorectal pain in children (1 cause) Abdominal distension in children and Aphthous Ulcer (1 cause)

Abdominal distension in children and Apnea (2 causes) Abdominal distension in children and Apnea in children (1 cause) Abdominal distension in children and Apnea in infants (1 cause)

Abdominal distension in children and Apnea in premature infants (1 cause) Abdominal distension in children and Appetite changes (6 causes)

Abdominal distension in children and Areas of depigmentation (1 cause) Abdominal distension in children and Arm numbness (1 cause) Abdominal distension in children and Arm paresthesia (1 cause) Abdominal distension in children and Arm symptoms (2 causes) Abdominal distension in children and Arm weakness (1 cause)

Abdominal distension in children and Arrhythmia (1 cause) Abdominal distension in children and Arrhythmias (1 cause)

Abdominal distension in children and Arterial hypertension (1 cause) Abdominal distension in children and Arthralgia (1 cause)

Abdominal distension in children and Absence of bowel movement Abdominal distension in children and Absent bowel sounds

Abdominal distension in children and Acanthosis nigricans in childrenAbdominal distension in children and Accumulation of adipose tissue

Abdominal distension in children and Aches Abdominal distension in children and Aching pain

Abdominal distension in children and Acidosis Abdominal distension in children and Acute abdominal pain

Abdominal distension in children and Acute asthma-like breathing attacks Abdominal distension in children and Acute asthma-like breathing difficulty

Abdominal distension in children and Acute asthma-like symptoms Abdominal distension in children and Acute asthma-like symptoms at night

Abdominal distension in children and Acute colitis-like abdominal painAbdominal distension in children and Acute COPD-like cough symptoms

Abdominal distension in children and Acute COPD-like symptoms Abdominal distension in children and Acute Crohns-like diarrhea symptoms

Abdominal distension in children and Acute Crohns-like symptomsAbdominal distension in children and Acute Crohns-like weight loss symptoms

Abdominal distension in children and Acute croup-like breathing difficulty Abdominal distension in children and Acute croup-like wheezing symptoms

Abdominal distension in children and Acute diarrhea in children Abdominal distension in children and Acute diarrhoea (1 cause)

Abdominal distension in children and Acute emphysema-like cough symptomsAbdominal distension in children and Acute emphysema-like symptoms

Abdominal distension in children and Acute episodic COPD-like symptomsAbdo distension in children and Acute episodic emphysema-like symptomsAbdominal distension in children and Acute expiratory wheeze in infants Abdominal distension in children and Acute fever in children (3 causes)

Abdominal distension in children and Acute flank pain (1 cause) Abdominal distension in children and Acute ibd-like abdominal pain (2 causes)

Abdominal distension in children and Acute ibd-like diarrhea (1 cause) Abdominal distension in children and Acute ibs-like abdominal pain (1 cause)

Abdominal distension in children and Acute ibs-like symptoms (2 causes) Abdominal distension in children and Acute pain from intercourse (1 cause) Abdominal distension in children and Acute pelvic pain in children (1 cause)

Abdominal distension in children and Acute prostate pain symptomsAbdominal distension in children and Acute prostate symptoms

Abdominal distension in children and Acute prostatitis-like symptomsAbdominal distension in children and Acute recurring COPD-like symptomsAbd distension in children and Acute recurring emphysema-like symptoms Abdomdistension in children and Acute wheezing worse when lying down

Abdominal distension in children and Additional Heart Sounds

Abdominal distension in children and other symptoms

Abd disten children and Abd discomfortAbd disten in children and Abd disten

Abd disten in children and Abd guarding Abd distens children and Abd mass

Abdo disten in children and Abd pain Abd disten in children and Inflammatory bowel diseaseAbdominal distension in children and Abdominal rigidity

Abd distension in children and Abdominal swellingAbdominal distension in children and others symptoms Abdominal distension in children and Abd tenderness Abdominal distension in children and Abdominal tumor

Abdominal distension in children and Abn pulse Abdominal distension in children and Abnormal sensations

Abd disten children and Abnormal skin textureAbd disten children and Abnormal stool texture in children

Abd disten children and uterine bleeding Abd disten children and vaginal bleeding

Abd disten children and decreased urinationAbd disten children and Abscessed teeth

Abd distensi and Alternating constipation and diarrheaAbdominal distension in children and Alternating constipation and diarrhoea

Abdominal distension in children and Amenorrhea (4 causes) Abdominal distension in children and Anal symptoms (4 causes)

Abdominal distension in children and Anatomic obstruction (2 causes) Abdominal distension in children and Anemia (2 causes)

Abdominal distension in children and Angina pectoris (1 cause) Abdominal distension in children and Angular cheilitis (1 cause) Abdominal distension in children and Anorectal pain (2 causes)

Abdominal distension in children and Anorectal pain in children (1 cause) Abdominal distension in children and Aphthous Ulcer (1 cause)

Abdominal distension in children and Apnea (2 causes) Abdominal distension in children and Apnea in children (1 cause) Abdominal distension in children and Apnea in infants (1 cause)

Abdominal distension in children and Apnea in premature infants (1 cause) Abdominal distension in children and Appetite changes (6 causes)

Abdominal distension in children and Areas of depigmentation (1 cause) Abdominal distension in children and Arm numbness (1 cause) Abdominal distension in children and Arm paresthesia (1 cause) Abdominal distension in children and Arm symptoms (2 causes) Abdominal distension in children and Arm weakness (1 cause)

Abdominal distension in children and Arrhythmia (1 cause) Abdominal distension in children and Arrhythmias (1 cause)

Abdominal distension in children and Arterial hypertension (1 cause) Abdominal distension in children and Arthralgia (1 cause)

Abdominal distension in children and Absence of bowel movement Abdominal distension in children and Absent bowel sounds

Abdominal distension in children and Acanthosis nigricans in childrenAbdominal distension in children and Accumulation of adipose tissue

Abdominal distension in children and Aches Abdominal distension in children and Aching pain

Abdominal distension in children and Acidosis Abdominal distension in children and Acute abdominal pain

Abdominal distension in children and Acute asthma-like breathing attacks Abdominal distension in children and Acute asthma-like breathing difficulty

Abdominal distension in children and Acute asthma-like symptoms Abdominal distension in children and Acute asthma-like symptoms at night

Abdominal distension in children and Acute colitis-like abdominal painAbdominal distension in children and Acute COPD-like cough symptoms

Abdominal distension in children and Acute COPD-like symptoms Abdominal distension in children and Acute Crohns-like diarrhea symptoms

Abdominal distension in children and Acute Crohns-like symptomsAbdominal distension in children and Acute Crohns-like weight loss symptoms

Abdominal distension in children and Acute croup-like breathing difficulty Abdominal distension in children and Acute croup-like wheezing symptoms

Abdominal distension in children and Acute diarrhea in children Abdominal distension in children and Acute diarrhoea (1 cause)

Abdominal distension in children and Acute emphysema-like cough symptomsAbdominal distension in children and Acute emphysema-like symptoms

Abdominal distension in children and Acute episodic COPD-like symptomsAbdo distension in children and Acute episodic emphysema-like symptomsAbdominal distension in children and Acute expiratory wheeze in infants Abdominal distension in children and Acute fever in children (3 causes)

Abdominal distension in children and Acute flank pain (1 cause) Abdominal distension in children and Acute ibd-like abdominal pain (2 causes)

Abdominal distension in children and Acute ibd-like diarrhea (1 cause) Abdominal distension in children and Acute ibs-like abdominal pain (1 cause)

Abdominal distension in children and Acute ibs-like symptoms (2 causes) Abdominal distension in children and Acute pain from intercourse (1 cause) Abdominal distension in children and Acute pelvic pain in children (1 cause)

Abdominal distension in children and Acute prostate pain symptomsAbdominal distension in children and Acute prostate symptoms

Abdominal distension in children and Acute prostatitis-like symptomsAbdominal distension in children and Acute recurring COPD-like symptomsAbd distension in children and Acute recurring emphysema-like symptoms Abdomdistension in children and Acute wheezing worse when lying down

Abdominal distension in children and Additional Heart Sounds

SUMMARY

1. ANY KINDS AND CONDITIONS MAY CAUSED ABDOMINAL DISTENSION

2. ABD DISTENSION NOT ALWAYS CAUSED BY BOWEL OBSTRUCTION

3. BOWEL OBSTRUCTION NOT ALWAYS TO RESULT ABDOMINAL DISTENSION

4. HISTORY, SYSTEMATIC PHYSICAL EXAM ….APPROPRIATE DIAGNOSTIC EXAM

5. LIFE THREATENING

6. ABD DISTENS : * ACUTE * * VOMITING *** TENDERNESS5. ABD DISTENSION ***** BOWEL PROBLEM

SURGICAL

THANKS

WITH YOUR ATTENTIONS