refarat radiologi staghorn -

8/16/2019 Refarat Radiologi Staghorn -

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BAGIAN RADIOLOGI

FAKULTAS KEDOKTERAN Laporan Kasus

UNIVERSITAS MUSLIM INDONESIA Juni 2015

Nefrolithiasis

O!"#

S$a"i% Guna&an A 11021100'(

)!*+i*+in, #

%r- Ra"*a$an.i/ Sp- Ra%

DIBAAKAN DALAM RANGKA TUGAS KE)ANITERAAN KLINIK

BAGIAN RADIOLOGI FAKULTAS KEDOKTERAN

UNIVERSITAS MUSLIM INDONESIA

MAKASSAR

2015


2/33

HALAMAN PENGESAHAN

an, +!r.an%a .an,an %i+a&a" ini *!n$a.aan +a"&a #

Nama : Anita Octaviani Lestary

Stambuk :11!11!"

#u$ul La%oran &asus : 'leus Obstruktif

T!a" *!n$!!saian .u,as %aa* ran,a K!pani.!raan Kini pa%a +a,ian

Ra%ioo,i Fau.as K!%o.!ran Uni3!rsi.as Musi* In%on!sia-

Maassar/ M!i 2015

Pembimbin(

$r) Sri Asriyanti* S%) +a$

Pen(u,i

$r) Shofiyah Latirf* S%) +a$* M)&es


3/33

&A-A PENGAN-A+

)u4i s$uur a*i pan4a.an !"a%ira. Aa" Su+"ana"u a Taaa ar!na

a.as +!ra. %an ra"*a.N$a a" s!"in,,a s!,aa s!sua.u $an, +!rai.an %!n,an

p!n$usunan .uisan ini %apa. .!rasana- Ta upa pua p!nuis "a.uran saa&a.

%an saa* $an, .!r6ura" pa%a 4un4un,an Na+i Mu"a**a% S"aa"u Aai"i

asaa* $an, .!a" *!*+i*+in, *anusia %ari aa* !,!apan *!nu4u ! aa*

$an, .!ran, +!n%!ran,-

Tuisan ini +!r4u%u 7LA)ORAN KASUS ILEUS OBSTRUKTIF8 $an,

%i+ua. %an %isusun s!+a,ai .u,as !pani.!raan ini +a,ian ra%ioo,i-B!r+a,ai

!sui.an %an "a*+a.an p!nuis .!*ui/ na*un a.as +an.uan %an +i*+in,an %ari

+!r+a,ai pi"a/ a"irn$a .uisan ini %apa. .!rs!!saian-

Maassar/ M!i 2015

)!nuis


4/33

.A. '

&AS/S

Na*a )asi!n # Tn- AB

No- R!a*M!%i # 11(91'

U*ur # 5' .a"un

J!nis K!a*in # Laiai

Aa*a. # J- Trans )apua

T!*pa.:Tan,,a a"ir # Kaan/ ' F!+ruari1;5<

A,a*a # Isa*

K!+an,saan # In%on!sia

)!*!risaan # 11092015

)!ra&a.an Ba,ian # B!%a" Uroo,i Ru*a" Sai. I+nu Sina Maassar

1)1 Anamnesis

0 K!u"an u.a*a # N$!ri )in,,an, anan

Ana*n!sis .!rpi*pin# Diaa*i s!4a = 2 .a"un $an, au- N$!ri "ian, .i*+u-

Ri&a$a. *ua %an *un.a" %isan,a- Ri&a$a. !n6in, +!r%ara" %isan,a/ri&a$a. !n6in, +!rpasir 4u,a %isan,a- Ri&a$a. op!rasi s!+!u*n$a .i%a a%a-

Ana*n!sis Sis.!*a.is# Sai. !paa >?/ pusin, >?/ %!*a* >?/ p!n,i"a.an

a+ur >?/ n$!ri *!n!an >?/ +a.u >?/ s!sa >?/ n$!ri %a%a >?/ ri&a$a. .rau*a

>?-

Ri&a$a. p!n$ai. s!+!u*n$a# ri&a$a. %ia+!.!s *!i.us .i%a a%a/ "ip!r.!nsi

.i%a a%a

Ri&a$a. p!n,o+a.an# .i%a a%a

Ri&a$a. !uar,a# Ri&a$a. p!n$ai. $an, sa*a %aa* !uar,a %isan,a-

4


5/33

1)! Pemeriksaan isis

a) Status Generalis

K!a%aan u*u* # K!a%aan sai. s!%an,

K!sa%aran # @o*pos *!n.is >G@S 15?

b) -an$a 2ital

T!anan %ara" # 110:'0 **,

Na%i # ?/ K!rin, >?

Li%a" # Ko.or >?/ "ip!r!*is >?/ an%i%iasis ora >?

Farin, # ip!r!*is >?Tonsi # T1 C T1/ ip!r!*is >?

5


6/33

f) Leher

)!*+!saran !!n4ar ,!.a" +!nin, >?

Massa .u*or >? N$!ri .!an >?

)!*+!saran ."$roi% >:?

() Paru 3 %aru

0 'ns%eksi: si*!.ris >ai?/ .i%a *!n,,unaan o.o.o.o. +an.uan p!rnapasan/

"!*a.o* >?/ ua >?/ 4arin,an sia.ri >?-

0 Pal%asi: *assa .u*or >?/ n$!ri .!an >?/3o6a r!*i.us >ai?/ r!pi.asi >?

0 Perkusi# sonor/ +a.as paru "!par I@S VI %!.ra/ +un$i# p!a ! .i*pani-

0 Auskultasi# B) +ron6"o3!si6uar

.- "!!in, >:? Ron6"i >:?

6


7/33

h) #antun(

Insp!si # I.us or%is .i%a .a*pa

)apasi # I.us or%is .i%a .!ra+a

)!rusi # )!a

Ausu.asi #Bun$i 4an.un, I:II *urni r!,uar/ +un$i .a*+a"an

.i%a a%a

7


8/33

i) Ab$omen

Insp!si # %aa* +a.as nor*a/ .i%a a%a p!*+!saran "!par *aupun

i!n- Dis.!nsi a+%o*!n >?

)apasi # N$!ri .!an >H?/ *assa .u*or >?/"!par >.i%a .!ra+a?/ i!n

>.i%a .!ra+a? )!rusi # Ti*pani/ n$!ri !.o >H? pa%a 6os.o3!r.!+ra anan

Ausu.asi # )!ris.a.i >H? !san *!nin,a.

,) Ekstremitas

D!or*i.as >?

U%!* >?

Fra.ur >?

1)" Laboratorium

La+ora.oriu* >1052015?

Parameter Hasil +an(e /nit

4.5 '-5 -00 C 12-0 10(:**(

+.5 -;; -00 C -20 109:%L

HG. 15- 11-0 C 1'-0 ,:%L

@T '-5 (5-0 C 55-0

M@V ;5-1


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aal Gin,al

Ur!u* 29 M,:%L 10 C 50

Kr!a.inin 0-; M,:%L 1-(

aal Hati

SGOT 22 U: (<

SG)T 21 U: 1

Metabolisme &arbohi$rat

GDS ;9 M,:%L 10

&esan: un(si (in,al baik

un(si hati baik

Metabolisme karbohi$rat baik

9


10/33

1)6 Pemeriksaan +a$iolo(i

oto A7+ 8110920159

Hasil Pemeriksaan:

0 Ta*pa +a$an,an +a.u ra%iopa +!r+!n.u s.a,"orn pa%a sis.!*

p!3$6o6a$6!s r!n %!.!r s!.in,,i @V L1L(- R!n sinis.!r %aa* +a.as

nor*a-

10


11/33

)soas in! iri %an anan in.a!

Tuan,.uan, in.a!

K!san# Ba.u S.a,"orn pa%a R!n %!.ra-

1) ;ia(nosis

B!r%asaran ana*n!sis/ p!*!risaan isi/ p!*!risaan a+ora.oriu* %an

p!*!risaan ra%ioo,i/ *aa %ia,nosis %ari asus ini a%aa" +a.u s.a,"orn R!n

%!.ra-

1)< +encana

pi!oi.o.o*i

11


12/33

.A. !

-'N#A/AN P/S-A&A

!)1) Pen$ahuluan

I!us o+s.ru.i *!rupaan !,a&a.an %i +i%an, +!%a" %i,!s.i3! $an, s!rin,

%iaporan- Gan,,uan sauran 6!rna ini *!n%u%ui 20 %ari s!uru" asus n$!ri au.

a+%o*!n $an, .i%a .!r,oon, app!n%i6i.is au.a- S!i.ar 90 p!n$!+a+ o+s.rusi

i!us %is!+a+an o!" a%"!si $an, .!r4a%i pas6a op!rasi r!,io a+%o*ina %an op!rasi%i +i%an, o+s.!.ri ,in!oo,i- Insi%!nsi %ari i!us o+s.rusi pa%a .a"un 2011

%i!.a"ui *!n6apai 19 %ari popuasi %unia $an, %i!.a"ui *!aui s.u%i +!sar pa%a

+an$a popuasi->1?

Gan,,uan $an, .!r4a%i pa%a i!us o+s.ru.i +isa *!ipu.i su*+a.an s!+a,ian

(partial) a.au !s!uru"an (complete) %ari u*!n usus/ s!"in,,a *!n,ai+a.an isi

usus .a %apa. *!!&a.i u*!n i.u s!n%iri- a ini %apa. %is!+a+an o!" +!r+a,ai

*a6a* on%isi/ pain, s!rin, %iar!naan o!" a%"!si/ "!rnia/ +a"an .u*or->2?

!)! ;efinisi

I!us o+s.ru.i a%aa" "a*+a.an pasas! isi usus $an, %is!+a+an o!"

su*+a.an *!ani *isan$a o!" s.ran,uasi/ in3a,inasi/ a.au su*+a.an %i %aa*

u*!n usus- T!r%apa. %ua 4!nis o+s.rusi $ai.u/ o+s.rusi s!%!r"ana %an o+s.rusi

s.ran,uasi- O+s.rusi s!%!r"ana a%aa" o+s.rusi $an, .i%a %is!r.ai .!r4!pi.n$a

p!*+uu" %ara"- )a%a o+s.rusi s.ran,uasi a%a p!*+uu" %ara" $an, .!r4!pi.

s!"in,,a +isa .!r4a%i is!*ia $an, aan +!ra"ir %!n,an n!rosis a.au ,an,,r!n $an,

%i.an%ai %!n,an ,!4aa u*u* +!ra. $an, %is!+a+an o!" .osin %ari 4arin,an

,an,,r!n- O+s.rusi usus $an, %is!+a+an o!" "!rnia/ in3a,inasi/ a%"!si/ %an

3o3uus *un,in s!ai %is!r.ai s.ran,uasi- S!%an,an o+s.rusi o!" .u*or a.au

12


13/33

o+s.rusi o!" 6a6in, asaris a%aa" o+s.rusi s!%!r"ana $an, 4aran, *!n$!+a+an

s.ran,uasi->2/ (?

Fo.o poos a+%o*!n a%aa" *o%ai.as p!n6i.raan asi $an, %ipaai un.u

*!n,onir*asi %ia,nosis %ari o+s.rusi usus na*un/ s!i.ar 1:( %ari pasi!n $an,

%ip!riraan *!*pun$ai o+s.rusi *!ani pa%a p!n!*uan inis/ o.o poos

a+%o*!n .i%a %i.!*uan o+s.rusi- S!+ain$a/ s!i.ar 20 pasi!n .!rsan,a

ps!u%o+s.rusi 6oon *!*pun$ai o+s.rusi usus *!ani->?

!)" Anatomi

` Gambar 1) Sistem saluran %encernaan

Usus "aus *!rupaan .a+un, $an, o*p!s/ +!ripa.ipa. $an, *!*+!n.an,

%ari piorus sa*pai a.up i!os!a- )a%a oran, "i%up pan4an, usus "aus s!i.ar 12

ai- Usus ini *!n,isi +a,ian .!n,a" %an +a&a" a+%o*!n- U4un, prosi*an$a

+!r,aris .!n,a" s!i.ar (/< 6*/ .!.api s!*ain !+a&a" a*+a. aun ,aris .!n,a"n$a

+!ruran, sa*pai *!n4a%i s!i.ar 2/5 6*->5?

13

http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_2http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_2http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_5http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_5http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_2http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_5


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Gambar ! 5olon $an ileocaecalis

Usus +!sar *!rupaan .a+un, *usuar +!ron,,a %!n,an pan4an, s!i.ar 5

ai >s!i.ar 1/5 *? $an, .!r+!n.an, %ari s!u* sa*pai anais ani- Dia*!.!r usus

+!sar su%a" pas.i !+i" +!sar %aripa%a usus !6i- Ra.ara.a s!i.ar 2/5 in6i >s!i.ar 9/5

6*?/ .!.api *ain %!a. anus s!*ain !6i->9?

Usus +!sar %i+a,i *!n4a%i s!u*/ oon %an r!.u*- )a%a s!u* .!r%apa.

a.up i!o6a!6aa %an ap!n%is $an, *!!a. pa%a u4un, s!u*- S!u* *!n!*pa.i

s!i.ar %ua a.au .i,a in6i p!rs.a*a %ari usus +!sar- Ka.up i!o6a!6aa *!n,on.ro

airan i*us %ari i!u* ! s!u*- Koon %i+a,i a,i *!n4a%i oon as!n%!ns/

.rans3!rsu*/ %!s!n%!ns %an si,*oi%- Koon as6!n%!ns +!r4aan ! a.as %ari s!u* !

p!r*uaan in!rior o+us anan "a.i/ *!n%u%ui r!,io iia6a %an u*+ais anan-

S!.!a" *!n6apai "a.i/ oon as6!n%!ns *!*+!o ! iri *!*+!n.u !sura oi

%!s.ra >!sura "!pa.i?- Koon .rans3!rsu* *!n$ian, a+%o*!n pa%a r!,io

u*+iiais %ari !sura oi %!s.ra sa*pai !sura oi sinis.ra->5?

Koon .rans3!rsu*/ &a.u *!n6apai %a!ra" i*pa/ *!*+!n,o ! +a&a"/

*!*+!n.u !sura oisinis.ra >!sura i!nais? un.u !*u%ian *!n4a%i oon

%!s6!n%!ns- Koon si,*oi% *uai pa%a pin.u a.as pan,,u- Koon si,*oi% *!rupaan

an4u.an oon %!s6!n%!ns- Ia .!r,an.un, !+a&a" %aa* ron,,a p!3is %aa* +!n.u

14

http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_6http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_6http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_5http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_5http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_6http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_5


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!n,un,an- Koon si,*oi% +!rsa.u %!n,an r!.u* %i %!pan saru*- R!.u*

*!n%u%ui +a,ian pos.!rior ron,,a p!3is- R!.u* ! a.as %ian4u.an o!" oon

si,*oi% %an +!r4aan .urun %i %!pan s!u*/ *!nin,,aan p!3is %!n,an *!n!*+us

%asar p!3is- Disini r!.u* *!an4u.an %iri s!+a,ai anus %aan p!rin!u*->5?

!)6 &lasifikasi

B!r%asaran oasi o+s.rusin$a/ i!us o+s.ru.i a.au i!us *!ani %i+!%aan

*!n4a%i/ an.ara ain# > %ari i!u* .!r*ina

sa*pai r!6.u*?-

S!ain i.u/ i!us o+s.ru.i %apa. %i+!%aan *!n4a%i ( +!r%asaran s.a%iu*n$a/ an.ara ain#

1- O+s.rusi s!+a,ian >par.ia o+s.ru6.ion?# o+s.rusi .!r4a%i s!+a,ian s!"in,,a *aanan

*asi" +isa s!%ii. !&a./ %apa. a.us %an %!!asi s!%ii.-

2- O+s.rusi s!%!r"ana >si*p! o+s.ru6.ion?# o+s.rusi $an, .i%a %is!r.ai .!r4!pi.n$a

p!*+uu" %ara" >.i%a %is!r.ai ,an,,uan airan %ara"?

(- O+s.rusi s.ran,uasi >s.ran,ua.!% o+s.ru6.ion?# o+s.rusi %is!r.ai %!n,an .!r4!pi.n$a

p!*+uu"

%ara" s!"in,,a .!r4a%i is!*ia $an, aan +!ra"ir %!n,an n!rosis a.au ,an,,r!n-

!) Etiolo(i

O+s.rusi *!ani .!r"i.un, iraira 20 %ari .in%aan +!%a"/ uran, !+i"

2:( %ari asusn$a a%aa" ausa %ari usus "aus > small bowel ?- )!n$!+a+n$a

%apa. %i+a,i s!6ara u*u* $ai.u !s.rinsi %an in.rinsi- )!n$!+a+ !s.rinsi

a%aa" a%"!si >s!.!a" op!rasi a.au ina*asi p!ri.on!a?/ "!rnia >in,uinais/

!*orais?/ %an a%an$a *assa/ +iasa %i.!*uan disseminated peritoneal

malignancy->;/10/15?

15

http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_5http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_5http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_5


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)!n$!+a+ %ari o+s.rusi usus "aus pa%a n!,ara +!r!*+an, a%aa" a%"!si

post-op!rasi >90 %iiu.i o!" !,anasan/ p!n$ai. @ro"n/ +a.u !*p!%u/ %an

"!rnia/ &aaupun +!+!rapa s.u%i *!aporan p!n$ai. @ro"n *!*pun$ai a.or

!.ioo,i $an, !+i" .in,,i %i+an%in,an %!n,an n!opas*a-> ;/10/15 ?

)!n$!+a+ .!rs!rin, %ari o+s.rusi usus +!sar >large bowel obstruction? a%aa"

arsino*a/ uran, !+i" 90 .!r4a%i pa%a 6oon si,*oi%- Fr!u!nsi p!n$ai.

%i3!r.i6uar s!+a,ai p!n$!+a+ o+s.rusi su%a" *!nurun s!4a %i.!rapann$a %i!.

.in,,i s!ra.- Vo3uus %ari 6oon .!r"i.un, 10 %ari asus o+s.rusi usus +!sar

.api pa%a +!+!rapa n!,ara +!r!*+an, .!r"i.un,


17/33

Ra%iasi !n.!ri.is *!n$!+a+an o+s.rusi pa%a as! a"ir s!.!a" 1 .a"un .!rapi

ra%iasi pa%a pan,,u- O!" ar!na i.u/ loop i!u* a%aa" $an, pain, s!rin,

.!r!na- Ra%iasi !n.!ri.is *!n$!+a+an o+s.rusi .!ru.a*a an!ra *!*pro%usi

p!ru+a"an a%"!si3! %an i+rosis %aa* *!s!n.!riu*- A%a 4u,a p!ru+a"an $an,

%i"asian %aa* usus/ s!p!r.i p!n$!*pi.an u*!n %an %is*o.ii.as $an,

%is!+a+an o!" s!rosi.is ra%iasi- @T *!nun4uan p!n$!*pi.an u*!n-

K!*un,inan 4u,a a%a p!n!+aan %in%in, usus a+nor*a %i %a!ra" $an, .!a"

.!r!na ra%iasi-

? !*a.o*a

!*a.o*a usus "aus %apa. .!r4a%i o!" ar!na .!rapi an.ioa,uan/ in.!r3!nsi

ia.ro,!ni/ a.au .rau*a- O+s.rusi +iasan$a .!r4a%i ar!na p!n$!*pi.an u*!n-

Jia on%isi ini %i%u,a/ @T "arus %iauan/ ar!na aan *!nun4uan +!uan-

5? Vas6uar Ousi-

Vas6uar Ousi a.au s.!nosis ar.!ri *!s!n.!ria a.au pasoan p!*+uu" %ara"

3!na ! usus +iasan$a *!n,"asian is!*ia usus/ $an, !*u%ian

*!n$!+a+an p!n!+aan %in%in,/ s!"in,,a *!n$!+a+an o+s.rusi usus "aus-

@T *!nun4uan .ro*+osis a.au ousi p!*+uu" *!s!n.!ria %an 4u,a

p!n!+aan %ari %in%in, usus-

Fa.or !s.rinsi i!us o+s.ru.i # > ;/10/15 ?

1? A%"!si

A%"!si *!rupaan p!n$!+a+ u.a*a %ari o+s.rusi/ *uai %ari 50


18/33

!rnia %ian,,ap p!n$!+a+ !%ua o+s.rusi- Di N!,ara +!r!*+an, "!rnia

*asi" %ian,,ap p!n$!+a+ pain, u.a*a o+s.rusi- !rnia %iasiiasian

*!nuru. ana.o*i oasi u+an, $an, *!aui usus- M!r!a s!6ara uas

%iasiiasian s!+a,ai !s.!rna a.au in.!rna- !rnia !s.!rna .!r4a%i ar!na

a%an$a !ainan pa%a %in%in, p!ru. %an pan,,u $an, %is!+a+an o!"

!!*a"an +a&aan a.au op!rasi s!+!u*n$a- Dia,nosis "!rnia in.!rna "a*pir

s!au ra%ioo,is/ s!%an,an "!rnia !s.!rna %aa* +an$a asus $an, 4!as

pa%a p!*!risaan inis-

!)< Pato(enesis

O+s.rusi i!us *!rupaan p!n$u*+a.an in.!s.ina *!ani $an, .!r4a%i

ar!na a%an$a %a$a *!ani $an, +!!r4a a.au *!*p!n,aru"i %in%in, usus

s!"in,,a *!n$!+a+an p!n$!*pi.an:p!n$u*+a.an u*!n usus- a .!rs!+u.

*!n$!+a+an pasas! u*!n usus .!r,an,,u- Ai+a. ,an,,uan pasas! .!rs!+u.

.!r4a%i p!n,u*puan isi u*!n usus $an, +!rupa ,as %an 6airan pa%a +a,ian

proi*a .!*pa. p!n$u*+a.an- a ini *!n$!+a+an p!!+aran %in%in, usus

>%is.!nsi? %i +a,ian proi*a %ari su*+a.an- Su*+a.an usus %an %is.!nsi usus

*!n$!+a+an ran,san,an .!r4a%in$a "ip!rs!r!si !!n4ar p!n6!rnaan- D!n,an

%!*iian au*uasi 6airan %an ,as *ain +!r.a*+a" $an, *!n$!+a+an %is.!nsi

usus .i%a "an$a pa%a .!*pa. su*+a.an .!.api 4u,a %apa. *!n,!nai s!uru" usus

%i +a,ian proi*a su*+a.an- Su*+a.an ini *!n$!+a+an ,!raan usus $an,

*!nin,a. >"ip!rp!ris.a.i? s!+a,ai usa"a aa*ia"- S!+ain$a 4u,a .!r4a%i

,!raan an.ip!ris.a.i- a ini *!n$!+a+an .!r4a%i s!ran,an oi a+%o*!n %an

*un.a"*un.a"- )a%a o+s.rusi usus $an, an4u./ p!ris.a.i su%a" "ian, o!"

ar!na %in%in, usus !"ian,an %a$a on.rasin$a->11?

!)= Ge,ala &linik

Dia,nosis inis %ari o+s.rusi usus .!r,an.un, pa%a .!*uan ar%ina/ $ai.u #

n$!ri p!ru./ *un.a"/ ons.ipasi a.au o+s.ipasi/ %an %is.!nsi a+%o*ina- M!sipun

18

http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_11http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_11http://var/www/apps/conversion/tmp/scratch_3/HYPERLINK%23_ENREF_11


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%!*iian .!ra%an, %ia,nosis sui. un.u %i.!,aan ar!na p!n!*uan inis

$an, %i.!*uan +iasa +!r3ariasi .!r,an.un, %!ra4a. %an !3! %ari o+s.rusi $an,

.!r4a%i s!r.a s.a.us 3asu!r %ari s!,*!n $an, *!n,aa*i o+s.rusi->(/11?

)a%a o+s.rusi *!ani .ipia/ n$!ri a+%o*!n +!r*ani!s.asi s!p!r.i ra*

%an in.!nsi.asn$a *!nin,a. s!6ara +!r.a"ap- S!irin, &a.u *!nin,a.n$a

%is.!nsi usus *!n,"a*+a. *o.ii.as %an n$!ri *!n4a%i *!r!%a- S!an4u.n$a/ pa%a

pasi!n %!n,an pasi!n o+s.rusi usus %is!+a+an o!" an!r/ )asi!n +iasan$a

oran, .ua %an *!*pun$ai ,!4aa $an, +!r"u+un,an %!n,an oasi .u*or/ %!n,an

,!4aa au. $an, !+i" uran, %ari o+s.rusi usus "aus- N$!ri a+%o*!n

+!r*ani!s.asi s!p!r.i ra* %apa. *un6u %!n,an p!n$!+a+ ain %ari au.

a+%o*!n s!p!r.i oi r!na- Mun.a" a.au ons.ipasi .i%a sp!sii un.u

o+s.rusi *!ani- ->(/11?

!)> Gambaran +a$iolo(i

Un.u *!n%ia,nosis pasi!n i!us o+s.ru.i/ p!ru %iauan p!*!risaan

ra%ioo,i s!+a,ai +!riu.#

1- Kon3!nsiona>1/15?

)a%a p!*!risaan on3!nsioana/ %apa. %iauan p!*!risaan BNO ( posisi/

$ai.u#

a- Supin!/ sinar %ari ara" 3!r.i6a %!n,an pro$!si an.!ropos.!rior >A)?

+- Er!6. a.au s!*i !r!6./ sinar "orion.a pro$!si an.!ropos.!rior >A)?6- L!. a.!ra %!u+i.us >LLD?/ %!n,an sinar "orion.a pro$!si an.!ro

pos.!rior >A)?

a"a $an, %apa. %iniai a.au %i"asian %ari o.o .!rs!+u./ $ai.u# >'/1/15?

a- S*a Bo&! O+s.ru6.ion

O+s.rusi usus "aus *!n$!+a+an %ia.asi usus "aus %an au*uasi %ari

u%ara %an 6airan pa%a +a,ian prosi*a %ari .i.i .!r4a%in$a o+s.rusi- S!%an,an

+a,ian %is.a %ari .i.i .!r4a%in$a o+s.rusi .i%a *!n,aa*i %ia.asi:oaps-

)!ru+a"an o.o ra%io,rai poos +iasan$a *uai *un6u .i,a sa*pai i*a 4a* %ari

ons!. .!r4a%in$a o+s.rusi .o.a- )a%a o+s.rusi $an, +!u* .o.a/ !ainan

19


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ra%ioo,i +aru %apa. *un6u +!+!rapa 4a* "in,,a +!+!rapa "ari - Loop C loop

usus "aus $an, %ia.asi >%ia*!.!r *asi*a %ari usus "aus ( 6*? *!n,an%un,

6airan %an:a.au u%ara $an, %apa. %ii"a. pa%a o.o poos a+%o*!n posisi supin!-

)a%a o.o posisi erect %apa. %ii"a. air-fluid level $an, *u.ip! $an, +!rsia. .i%a

sp!sii $an, %apa. %i4u*pai pa%a i!us parai.i/ ,as.ro!n.!ri.is/ %i3!r.iuosis

4!4una/ %-

Ga*+aran herring bone *un6u pa%a o+s.rusi usus "aus ar!na a%an$a

s.ru.ur 3a3ua onni3!n.!s pa%a usus "aus >%uo%!nu*/ 4!4unu*/ %an i!u*?-

)a%a saa. .!r4a%i %ia.asi usus "aus > ( 6*? s.ru.ur ini aan .!ri"a. *!*+!rian

,a*+aran s!p!r.i herring bone appearance- Ga*+aran air-fluid level *!nun4uan a%an$a .in,a. u%ara $an, +!r%!nsi.as us!n %ia.as 6airan $an,

+!r%!nsi.as in.!r*!%ia.- A%an$a o+s.rusi *!nun4uan u%ara usus .i%a sa*pai

! %is.a-

Gambar " 'leus Obstruktif &onvensional

Ga*+ar iri *!nun4uan +!+!rapa %ia.asi loop usus !6i %i p!ru. +a,ian

a.as- Usus !6i .i%a proporsiona *!!+ar %i+an%in,an usus +!sar- Ga*+ar

anan *!nun4uan .in,a. u%ara6airan %i loop *!!+ar "as %ari o+s.rusi

usus "aus-

20


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Gambar 6 'leus Obstruktif oto .NO

)a%a posisi supin!# %is.!nsi usus "aus > ( 6*? %!n,an s!4u*a" 3a3ua oni3!n.!s

*!*+!rian ,a*+aran 7 stack of coins” a.au herring bone appearance

Gambar oto Polos Ab$omen Posisi Erect

M!nun4uan air-fluid levels $an, *u.ip! %!n,an !.in,,ian +!r+!%a/ *!*+!ri

,a*+aran step ladder %i %aa* looploop usus "aus $an, %ia.asi-

+- Lar,! Bo&! O+s.ru6.ion

Lar,! Bo&! O+s.ru6.ion *!rupaan o+s.rusi $an, .!r4a%i %i 6oon- Lar,!

+o&! o+s.rusi !+i" 4aran, .!r4a%i %i+an%in, %!n,a s*a +o&! o+s.ru6.ion-an$a 20 %ari an,a !4a%ian o+s.rusi usus- )!n$!+a+ .!rs!rin, %ari ar,!

+o&! o+s.ru6.ion a%aa" !,anasan 5090- Ga*+aran ra%ioo,i6 $an, +isa

%i%apa.an pa%a ar,! +o&! o+s.ru6.ion a%aa" %is.!nsi 6oon pa%a prosi*a

21


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"in,,a pa%a oasi o+s.rusi %an oaps pa%a +a,ian %is.a %an %is!r.ai ,a*+aran

"aus.ra $an, 4!as/ s!p!r.i pa%a ,a*+ar +!riu.#

Gambar < 8a9 Air flui$ level $en(an ketin((ian berbe$a $alam loop usus yan(

sama 3 ste% la$$er si(n $an 8b9 %osisi te(ak 3 strin( of %earls si(n 8%anah9

2- USG A+%o*!n

USG a+%o*!n %apa. %iauan pa%a pasi!n %!n,an 6uri,a s*a +o&! o+s.rusi-

USG %apa. *!n%!.!si a%an$a air ui% !3!/ %ia.asi usus prosi*a %an oaps

%is.a- USG +!rsia. op!ra.or %!p!n%!n. $ai.u san,a. +!r,an.un, pa%a !.!i.ian %an

p!n,aa*an op!ra.or- Ga*+aran ra%ioo,i $an, %i%apa.an %ari p!*!risaan USG

pa%a pasi!n %!n,an i!us o+s.rusi a%aa" s!+a,ai +!riu.#

22


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Gambar = 'leus Obstruktif oto /SG

Din%in, usus *!n!+a %!n,an poa +!r.in,a. !6"o >pana"? %an as6i.!s >A?

Gambar > Obstruksi /susa- Loop C loop usus +!risi 6airan %!n,an !$+oar% si,n- +- S.!p a%%!r si,n- po.on,an

.rans3!rsa >A? %an on,i.u%ina >B? *!nun4uan %ia.si *u.ip! loop C loop usus

"aus pa%a pasi!n %!n,an o+s.rusi pa%a %is.a usus "aus >?

(- @T S6an A+%o*!n

)!*!risaan ini %i!r4aan 4ia s!6ara inis %an o.o poos a+%o*!n

%i6uri,ai a%an$a s.ran,uasi- @TS6an aan *!*p!r.un4uan s!6ara !+i" .!i.i

a%an$a !ainan!ainan %in%in, usus/ *!s!n.!rius/ %an p!ri.on!u*- @TS6an"arus %iauan %!n,an *!*asuan a. on.ras !%aa* p!*+uu" %ara"- )a%a

p!*!risaan ini %apa. %i!.a"ui %!ra4a. %an oasi %ari o+s.rusi- B!riu.

,a*+aran $an, %i%apa.an pa%a pasi!n i!us o+s.rusi %!n,an p!*!risaan @T

S6an A+%o*!n#

23


24/33

Loop C loop usus +!risi 6airan %!n,an !$+oar% si,n- +- S.!p a%%!r si,n- po.on,an

.rans3!rsa >A? %an on,i.u%ina >B? *!nun4uan %ia.si *u.ip! loop C loop usus

"aus pa%a pasi!n %!n,an o+s.rusi pa%a %is.a usus "au

Gambar ? 5- scan a@ial $ari obstruksi usus

@T s6an aia *!nun4uan a%an$a 6airan %an %ia.asi loop usus !6i > pana" pu.i"?

%an run.u" usus > pana" *!ra" ? onsis.!n %!n,an o+s.rusi usus !6i *!ani-

Gambar 1 5- ab$omen

@T a+%o*!n *!nun4uan %ia.asi usus "aus ai+a. o+s.rusi >pana"? oon as!n%!n

%an %!s!n%!n *!n,aa*i oaps >pana"?>1?

24


25/33

!)? ;ia(nosis .an$in(

1- I!us )arai.i >/ 10?

I!us parai.i *!rupaan ,an,,uan a.i3i.as *o.orius s!"in,,a u%ara %an

6airan +!ru*pu %aa* usus $an, %a.a *!n,ai+a.an %is.!nsi a+%o*!n- Di.!*uan

%ia.asi usus >usus "aus ( 6*/ usus +!sar < 6*? .anpa .i.i .ransisi/ .!ri"a. air-

fluid level - B!rsia. au./ roni/ a.au in.!r*i..!n- D!n,an !.ioo,i s!p!r.i ,an,,uan

n!ura/ "u*ora/ *!.a+oi/ .rau*a/ p!n%ara"an r!.rop!ri.on!a/ %an ra.ur spina

a.au p!3is- A%apun ,a*+aran ra%ioo,is $an, +isa %i%apa.an pa%a i!us parai.i

a%aa" s!+a,ai +!riu.#

Gambar 11 oto Polos Ab$omen

Dia.asi usus "aus %an usus +!sar sa*pai r!6.u* %is!r.ai r!.!nsi u%ara %an 6airan

$an, +an$a- Air ui% !3! $an, pan4an,pan4an, %an 6!n%!run, .i%a +!r.in,a.-

Ti%a .a*pa "!rrin,+on! app!aran6!-

;ia(nosis .an$in( 'leus Obstruktif 'leus Paralitik

Air flui$ level B!r.in,a. M!*an4an,

Herrin( bone a%% A%a Ti%a a%a

;ilatasi loo%0loo% usus Ti%a *!ra.a/ "an$a Dia.asi *!ra.a/ %i.!*uan

25


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%ia.asi pa%a prosi*a

"in,,a oasi o+s.rusi/

%an oaps +a,ian

%is.an$a-

pa%a s!*ua oopoop

usus-

!)1 Penatalaksanaan

)!na.aasanaan o+s.rusi i!us a%aa" p!*+!%a"an %an %!o*pr!si- K!.!pa.an

&a.u pa%a p!nan,anan %!n,an 4!as .!a" *!nurunan an,a *or+i%i.as %an

*or.ai.as- a ini .!ru.a*a %is!+a+an .!a" %ipa"a*in$a %!n,an .!pa. pa."o,!n!sis

p!n$ai. s!r.a p!ru+a"an "o*!os.a.is s!+a,ai ai+a. o+s.rusi usus-)a%a u*u*n$a p!n%!ri.a *!n,iu.i pros!%ur p!na.aasanaa %aa* a.uran $an, .!.ap-1(

1- )!rsiapan p!n%!ri.a)!rsiapan p!n%!ri.a +!r4aan +!rsa*a %!n,an usa"a *!n!,aan %ia,nosis

o+s.rusi i!us s!6ara !n,ap %an .!pa.- S!rin, %!n,an p!rsiapan p!n%!ri.a $an,

+ai/o+s.rusin$a +!ruran, a.au "ian, sa*a s!ai-)!rsiapan p!n%!ri.a *!ipu.i

#

a- )!n%!ri.a %i ra&a. %i ru*a" sai.- +- )!n%!ri.a %ipuasaan

6- Kon.ro s.a.us air&a$/+r!a."in, %an siruasi%- Ko*pr!si %!n,an naso,as.ri .u+!

!- In.ra3!nous ui%s %an !!.roi.- Dipasan, a.!.!r urin un.u *!n,"i.un, +aan6! 6airan-

2- Op!ra.i

Bia .!a" %ipu.usan un.u .in%aan op!rasi/ a%a ( "a $an, p!ru a- B!rapa a*a o+s.rusin$a su%a" +!ran,sun,

+- Ba,ai*ana !a%aan: un,si or,an 3i.a ainn$a/ +ai s!+a,ian ai+a.

o+s.rusin$a *aupun on%isi s!+!u* sai.-6- Apaa" a%a r!sio sran,uasi

K!&aspa%aan aan r!sio s.ran,uasi san,a. p!n.in,- )a%a o+s.rusi

i!u* $an, %i.oon, %!n,an 6ara op!ra.i pa%a saa. $an, .!pa.-/an,a

!*a.iann$a a%aa" 1 pa%a 2 4a* p!r.a*a/ s!%an,an pa%a s.ran,uasi

an,a !*a.ian .!rs!+u. (1 -

26


27/33

)a%a u*u*n$a %i!na *a6a* > 6ara ? .in%aan +!%a" $an, %i!r4aan

pa%a o+s.rusi i!us #

a- Kor!si s!%!r"ana- a ini *!rupaan .in%aan +!%a" s!%!r"an

aun.u *!*+!+asan usus %ari 4!pi.an/ *isan$a pa%a "!rnia

in63ar6!ra.a non s.ran,uasi/ 4!pi.an o!" s.r!n, : a%"!si a.au

3o3uus rin,an-

+- Tin%aan op!ra.i +$ pass- M!*+ua. sauran usus $an, +aru $an,

7*!!&a.i8 +a,ian usus $an, .!rsu*+a./ *isan$a pa%a .u*or

in.rau*inar/ @ro"n %is!as!/ %an s!+a,ain$a-

6- M!*+ua. is.ua !n.!ro6u.an!us pa%a +a,ian proi*a %ari

.!*pa. o+s.rusi/*isan$a pa%a @a s.a%i* an4u.-%- M!auan r!s!si usus $an, .!rsu*+a. %an *!*+ua. anos.o*os!

u4un, C u4un, usus un.u *!*p!r.a"anan on.uini.as u*!n

usus/ *isan$a pa%a 6ar6ino*a 6oon/ in3a,inasi s.ran,ua.! %an

s!+a,ain$a-

(- Sua.u pro+!*a.i6 $an, sui. pa%a!a%aan pas6a +!%a" a%aa" %is.!nsi usus $an,

*asi" a%a- )a%a .in%aan op!ra.i %!o*pr!si usus/ ,as %an 6airan .!ru*pu

%aa* u*!n usus .i%a +o!" %i+!rsi"an sa*a s!ai o!" ar!na 6a.a.an

.!rs!+u. *!n,an%un, +an$a +a"an +a"an %i,!s.i3! $an, san,a. %ip!ruan-

)as6a +!%a" .i%a %apa. %i"arapan un,si usus !*+ai nor*a/ &aaupun

.!r%!n,ar +isin, usus- a i.u +uan +!rar.i p!ris.a.i6 usus su%a" !*+ai

+!run,si %!n,an !isi!n/ s!*!n.ara !sr!si *!nin,,i %an a+sor+s sa*a s!ai

+!u* +ai -1(

S!rin, %i%apa.i p!n%!ri.a %aa* !a%aa *asi" %is.!nsi %an %is!r.ai %iar! pas6a

+!%a"- Tin%aan %!o*pr!si usus %an or!si air %an !!.roi. s!r.a *!n4a,a

!s!i*+an,an asa* %an +asa %ara" %aa* +a.as nor*a .!.ap %iasanaan pa%a

pas6a +!%a"n$a- )a%a o+s.$rusi $an, !+i" an4u./ apaa,i +ia .!a" .!r4a%i

s.ran,uasi/ *oni.orin, pas6a +!%a" $an, %i.!i.i %ip!ruan sa*pai s!a*a 9 C '

"ari pas6a +!%a"- Ba"a$a ain pa%a *asa pas6a +!%a" a%aa" .osin!*ia %an

s!psis- Ga*+aran inin$a +iasan$a *uai Na*pa pa%a "ari ! 5 pas6a

27


28/33

+!%a"- )!*+!rian an.i+io.i6 %!n,an sp!6.ru* uas %is!suaian %!n,an "asi

u.ur u*an san,a.a" p!n.in,-1(

!)11 &om%likasi

Ko*piasi i!us o+s.ru.i s!+a,ai +!riu.#>1(?

1- N!rosis usus

2- )!rorasi usus

M!rupaan o*piasi $an, pain, s!rin, .!r4a%i pa%a pasi!n i!us o+s.rusi-

)!*!risaan ra%ioo,i $an, %apa. %iauan un.u *!n%apa.an ,a*+aran ra%ioo,i

pa%a p!rorasi usus/ saa" sa.un$a a%aa" o.o poos a+%o*!n/ %!n,an posisi LLD

>L!. La.!ra D!6u+i.us? %apa. %iauan 4ia posisi !r!6. .i%a %apa. %iauan-

Ga*+aran u%ara +!+as +!ra%a %i .!pi a.!ra %ari "a.i- K!.ia .!r%apa. u%ara

+!+as %aa* a+%o*!n/ usus *!n4a%i !+i" 4!as .!ri"a. %!n,an a%an$a u%ara pa%a

!%ua sisi %in%in, usus- Ini %is!+u. s!+a,ai Riggler’s sign/ double wall sign

Gambar 1! Gambaran Perforasi /sus

28


29/33

Tan%a.an%a pn!u*op!ri.on!u* pa%a .!r!n.an,- Fi* poos a+%o*!n

>pana"?# 7in% .an%a8 a.au 7+!riau .an%a "a.i 7/ su+"!pa.i6 u%ara +!+as

s!+a,ai para! in!ar p!n,u*puan/ .an%a i,a*!n +!n,o 7u+a"8-

(- S!psis

- S$o%!"i%rasi

5- A+s!s

9- Sin%ro* usus p!n%! %!n,an *aa+sorpsi %an *anu.risi

'- )n!u*onia aspirasi %ari pros!s *un.a"

1(?

29


30/33

.A. "

;'S&/S'

")1 +esume &linis

S!oran, pria/ 25 .a"un MRS %!n,an !u"an u.a*a n$!ri p!ru.- Diaa*i s!4a

= 2 *in,,u $an, au s!+!u* *asu ru*a" sai.- M!*+!ra. s!4a 2 "ari $an, au-

)asi!n *!rasaan n$!ri p!ru. %is!uru" +a,ian p!ru. %an .!*+us !+!aan,- N$!ri

p!ru. $an, %iaa*i %is!r.ai *ua %an *un.a"- )asi!n 4u,a *!n,!u"an BAB !n6!r

s!+an$a ( ai s!"ari %an BAK an6ar- Ri&a$a. pasi!n pos. op!rasi

p!n,an,a.an ra"i* S!p.!*+!r 201- K!*o.!rapi su%a" 9 ai s!.!a" op!rasi

an,a. ra"i*- Ri&a$a. p!n$ai. s!+!u*n$a %ans ri&a$a. !uar,a %isan,a- Dari

s.a.us ,!n!rais/ pasi!n %aa* !a%aan sai. s!%an,/ 6o*pos*!n.is/ %an s.a.us ,ii

uran,- )a%a p!*!risaan ra%ioo,i o.o BNO ( posisi %i.!*uan i!us o+s.ru.i-

")! Pembahasan

Dari ana*n!sis %!n,an !u"an u.a*a n$!ri p!ru. .!*+us !+!aan, $an,

%irasaan =2 *in,,u s!+!u* *asu Ru*a" Sai. %is!r.ai *ua %an *un.a"-

Di%apa.an pa%a p!*!risaan isi .!anan %ara" 1'0:120 **,/ na%i


31/33

%a%a/ paru C paru %an 4an.un, %aa* +a.as nor*a- a ini s!suai %!n,an .!ori $an,

*!n,a.aan +a"&a pa%a o+s.rusi usus "aus %i%apa.an p!n,!uaran +an$a

6airan %an !!.roi. +ai %i %aa* u*!n usus +a,ian ora %ari o+s.rusi/*aupun

o!" *un.a"-

G!4aa p!n$u*+a.an usus *!ipu.i n$!ri ra* pa%a p!ru./ %is!r.ai !*+un,-

Tan%a 3i.a nor*a pa%a .a"ap a&a/ na*un aan +!ran4u. %!n,an %!"i%rasi ai+a.

!"ian,an 6airan %an !!.roi.- Su"u .u+u" +isa nor*a sa*pai %!*a*- Dis.!nsi

a+%o*!n %apa. *ini*a a.au .i%a a%a pa%a o+s.rusi prosi*a %an s!*ain 4!as

pa%a su*+a.an %i %a!ra" %is.a- Bisin, usus $an, *!nin,a. %an 7metallic sound 8

%apa. %i%!n,ar s!suai %!n,an .i*+un$a n$!ri pa%a o+s.rusi %i %a!ra" %is.a-

Dari "asi p!*!risaan a+ora.oriu* %i%apa.an !san an!*ia *irosi.i

"iporo* %an +!u* a%a p!nurunan un,si ,in4a *aupun !s!i*+an,an !!.roi.

$an, .!r,an,,u- a ini s!suai %!n,an .!ori $an, *!n,a.aan +a"&a niai

a+ora.oriu* pa%a a&an$a nor*a/ !*u%ian aan .!r4a%i "!*oons!n.rasi/

!uosi.osis/ %an ,an,,uan !!.roi.-

Dari "asi p!*!risaan o.o a+%o*!n ( posisi %i.!*uan u%ara usus .i%a

.!r%is.ri+usi sa*pai ! %is.a 6oon/ .a*pa %ia.asi loop-loop usus %is!r.ai

,a*+aran herring bone %an .a*pa air fluid level $an, +!r.in,a..in,a. %an

*!*+!rian ,a*+aran step-ladder / !%ua psoas in! in.a!/ pr!pr!ri.on!a a. in!

anan %an iri .!r3isuaisasi in.a!/ %an .uan,.uan, ainn$a in.a %!n,an !san

,a*+aran i!us o+s.ru.i- a ini s!suai %!n,an .!ori $an, *!n,a.aan +a"&a

,a*+aran ra%ioo,i i!us o+s.ru.i +!rupa %ia.asi usus %!n,an air fluid levels-

)a%a posisi supin! %is.!nsi usus "aus *!*+!rian ,a*+aran stack of coins a.au

herring bone appearance- )a%a posis .!,a:a.!ra %!6u+i.us .a*pa multiple air

fluid levels %!n,an !.in,,ian +!r+!%a pa%a loop usus $an, sa*a *!*+!rian

,a*+aran step ladder

31


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;A-A+ P/S-A&A

1- Su..on D- T!.+oo o Ra%ioo,$ an% I*a,in, S!3!n." E%i.ion- Uni.!%

Kin,%o*# @"ur6"i Li3in,s.on! 200(-

2- Si3a A@- S*a Bo&! O+s.ru6.ion- Si3a !. a- 200;2;#2((;- Epu+ *ar!.

200;-

(- Mau!a G- Rus%$ - Ra%ioo,i Dia,nos.i- Jo,$aar.a # )us.aa @!n%iia

pr!ss 2009

- So!.ino D- Ris.ania"- Ra%ioo,i E*!r,!n6i- @!.aan p!r.a*a- 2011-a-1<

5- R )/ R )- Ana.o*i Sis.!* )!n6!rnaan A.as Ana.o*i Manusia- Jaar.a# EG@

200'- p- 1-

9- Spa.!"o/ -# an% A.as O u*an Ana.o*$/ S!3!n." E%i.ion in

En,is"

'- S4a"ri!r Rasa%- E%i.or- Ra%ioo,i Dia,nos.i- E%isi K!%ua


33/33

12- A"u4a/ Ani T !. a- @as! S.u%i!s in M!%i6a I*a,in,- N!& or#

@a*+ri%,! Uni3!rsi.$ )r!ss 2009-p- 2'92''

1(- Raini- I!us O+s.ru.i- Ba,ian I*u B!%a" Fau.as K!%o.!ran Uni3!rsi.as

Trisa.i- 2012#21(-

1- Mur.aa B- I!us O+s.ru.i %an I!us )arai.i- Ra%ioo,i Trau*a %an

E*!r,!nsi- Bo,or# I)B )r!ss 2012- p- 15;9

refarat radiologi staghorn -

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