SGD LBM 3 Git

Primaswari Annisa Febriana/ 3rd LBM Gastrointestinal Tract/ SGD 8
1. How the anatomy,fisiology of intestinum tenue?

Intestinum Tenue :
a. Jejunum
b. Duodenum
c. Ileum
DUODENUM
1
2
JEJUNUM & ILEUM

HISTOLOGY OF JEJUNUM
3
HISTOLOGY OF ILEUM
Absorption mechanism of Glucose, lipid and protein
4
5
Source:
1. Principles of Anatomy and Physiology ; Gerard J Tortora; 14th
edition; Chapter 24; The Digestive System
2. Toronto Notes; Comprehensive Medical Reference and Review for
MCCQ I and USMLE II; Gastroenterology
2. Why the vomitte has a greenish color ?

Pathophysiology
Distention of the intestine is caused by the accumulation of gas and fluid proximal
to and within the obstructed segment. Between 70 and 80% of intestinal gas consists
of swallowed air, and because this is composed mainly of nitrogen, which is poorly
absorbed from the intestinal lumen, removal of air by continuous gastric suction is a
useful adjunct in the treatment of intestinal distention. The accumulation of fluid
proximal to the obstructing mechanism results not only from ingested fluid, swallowed
saliva, gastric juice, and biliary and pancreatic secretions but also from interference
with normal sodium and water transport. During the first 12–24 h of obstruction, a
marked depression of flux from lumen to blood of sodium and water occurs in the
distended proximal intestine. After 24 h, sodium and water move into the lumen,
contributing further to the distention and fluid losses. Intraluminal pressure rises from
a normal of 2–4 cmH2O to 8–10 cmH2O. The loss of fluids and electrolytes may be
extreme, and unless replacement is prompt, hypovolemia, renal insufficiency, and
shock may result. Vomiting, accumulation of fluids within the lumen, and the
sequestration of fluid into the edematous intestinal wall and peritoneal cavity as a
6
result of impairment of venous return from the intestine all contribute to massive loss
of fluid and electrolytes.
Accumulation of fluid (ingested fluid, gastric juice, swallowed saliva ,

billiary and pancreatic secretion) on proximal of
obstruction
Intraluminal pressure ↑↑↑
Vomiting
Hypovolemia
Billiary secretion  Greenish color
7
8
1. Harrison; Principles of Internal Medicine; 18 th ed.; Part 14 Gastrointestinal
System; Section 1 Disorder of Alimentary Tract; Chapter 299 Acute Intestinal
Obstruction.
2. Sibernagl/ Lang, Color Atlas of Patophysiology; Chapter6 Stomach, Intestine,
Liver; page 141-157
3. Guyton and Hall; Textbook of Medical Physiology; 12th ed; UNIT XII
Gastrointestinal Physiology; Chapter 66 Physiology of GI disorder; pg 803
9
3. Why in the anamnesis there’s decreasing urine, and the

patient has not passed stole flatus since two days ago?
Distention of the intestine is caused by the accumulation of gas and fluid proximal to
and within the obstructed segment. Between 70 and 80% of intestinal gas consists of
swallowed air, and because this is composed mainly of nitrogen, which is poorly
absorbed from the intestinal lumen, removal of air by continuous gastric suction is a
useful adjunct in the treatment of intestinal distention. The accumulation of fluid
proximal to the obstructing mechanism results not only from ingested fluid, swallowed
saliva, gastric juice, and biliary and pancreatic secretions but also from interference with
normal sodium and water transport. During the first 12–24 h of obstruction, a marked
depression of flux from lumen to blood of sodium and water occurs in the
fluid losses. Intraluminal pressure rises
contributing further to the distention and
from a normal of 2–4 cmH2O to 8–10 cmH2O. The loss of fluids and electrolytes
may be extreme, and unless replacement is prompt,
hypovolemia, renal insufficiency, and shock may result. Vomiting,
accumulation of fluids within the lumen, and the sequestration of fluid into the
edematous intestinal wall and peritoneal cavity as a result of impairment of venous
return from the intestine all contribute to massive loss of fluid and electrolytes.
Source:
Harrison; Principles of Internal Medicine; 18 th ed.; Part 14
Gastrointestinal System; Section 1 Disorder of Alimentary Tract;
Chapter 299 Acute Intestinal Obstruction.
10
4. Why the mass appears when the patient is in the standing

possions coughing and straining?
Inguinal hernias present with a lump in the groin that goes away with minimal pressure
or when the patient is lying down. Most cause mild to moderate discomfort that increases with
activity. A third of patients scheduled for surgery have no pain, and severe pain is uncommon
(1.5% at rest and 10.2% on movement).4
Coughing; Standing; Straining  Rises abdominal pressure  Contraction of
abdominal muscles  The mass is detected on the inguinal region
11
Source:
1. Clinical Anatomy by System; Richard S. Snell MD. PhD; Section 7 th; The Digestive
System; Chapter 19 The Abdominal Wall, the Peritoneal Cavity, the Retroperitoneal
Space, and the Alimentary Tract (point 4); pg 317
2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223000/
3. Inguinal hernias
4. John T Jenkins, specialist registrar in surgery 1 and Patrick J O’Dwyer, professor of gastrointestinal BMJ. 2008
Feb 2; 336(7638): 269–272.
12
5. Why we can found mass on the right inguinal regio?
13
fascial defect -+ protrusion of a viscus into an area in which it is not normally contained
14
1. Toronto Notes; Comprehensive Medical Reference and Review

for MCCQ I and USMLE II; General Surgery; Hernia.
2. Clinical Anatomy by System; Richard S. Snell MD. PhD; Section
7th; The Digestive System; Chapter 19 The Abdominal Wall, the
Peritoneal Cavity, the Retroperitoneal Space, and the Alimentary
Tract
6. Why the feses like goat stole?

accumulation of gas and fluid
Distention of the intestine is caused by the
proximal to and within the obstructed segment. Between 70 and 80%
of intestinal gas consists of swallowed air, and because this is composed mainly
of nitrogen, which is poorly absorbed from the intestinal lumen,
removal of air by continuous gastric suction is a useful adjunct in the treatment
of intestinal distention. The accumulation of fluid proximal to the obstructing
mechanism results not only from ingested fluid, swallowed saliva, gastric juice,
and biliary and pancreatic secretions but also from interference with normal
sodium and water transport. During the first 12–24 h of obstruction, a marked
depression of flux from lumen to blood of sodium and water occurs in the
contributing further to the distention and fluid losses. Intraluminal pressure rises
from a normal of 2–4 cmH2O to 8–10 cmH2O. The loss of fluids and
electrolytes may be extreme, and unless replacement is prompt, hypovolemia,
renal insufficiency, and shock may result. Vomiting, accumulation of fluids within
the lumen, and the sequestration of fluid into the edematous intestinal wall and
peritoneal cavity as a result of impairment of venous return from the intestine all
contribute to massive loss of fluid and electrolytes.
Obstruction  Accumulation of gas, fluid and chyme on proximal side of

obstruction  The chyme, gas and fluid was poorly absorbed by the intestinal
15
lumen  The chyme that not absorbed can’t go to colon and processed as feces
because of its obstruction + loss of fluid  there is no substrate that can be
processed by colon that makes the feces like a goat stole.
Harrison; Principles of Internal Medicine; 18 th ed.; Part 14
Gastrointestinal System; Section 1 Disorder of Alimentary Tract;
Chapter 299 Acute Intestinal Obstruction.
7. What is the relation between his job and the symptomps?

Risk Factors
o activities which increase intra-abdominal pressure:
obesity, chronic cough, pregnancy, constipation, straining on urination or
defecation, ascites,heavy lifting
o congenital abnormality (e.g. patent processus vaginalis)
o previous hernia repair
o Kuli pasar  menggunakan otot2 abdomen  terus menerus  kelemahan
otot – otot abdomen
Toronto Notes; Comprehensive Medical Reference and Review for
MCCQ I and USMLE II; General Surgery; Hernia.
8. Why the patient stomached, bloating, ?

Distention of the intestine is caused by the accumulation of gas and fluid
proximal to and within the obstructed segment. Between 70 and 80% of intestinal
gas consists of swallowed air, and because this is composed mainly of nitrogen,
which is poorly absorbed from the intestinal lumen, removal of air by continuous
gastric suction is a useful adjunct in the treatment of intestinal distention. The
16
accumulation of fluid proximal to the obstructing mechanism results not only from
ingested fluid, swallowed saliva, gastric juice, and biliary and pancreatic secretions
but also from interference with normal sodium and water transport. During the
first 12–24 h of obstruction, a marked depression of flux from lumen to blood of
sodium and water occurs in the distended proximal intestine. After 24 h, sodium
and water move into the lumen, contributing further to the distention and fluid
losses. Intraluminal pressure rises from a normal of 2–4 cmH2O to 8–10 cmH2O.
The loss of fluids and electrolytes may be extreme, and unless replacement is
prompt, hypovolemia, renal insufficiency, and shock may result. Vomiting,
accumulation of fluids within the lumen, and the sequestration of fluid into the
edematous intestinal wall and peritoneal cavity as a result of impairment of
venous return from the intestine all contribute to massive loss of fluid and
electrolytes
A protuberant abdomen that is tympanitic throughout suggests intestinal obstruction.
17
Source:
1. Bates Guide to Physical Examination and History; Chapter 9; The Abdomen
2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3435785/Spectral analysis
of bowel sounds in intestinal obstruction using an electronic
stethoscope; World Journal of Gastroenterology;

PMCID: PMC3435785; Siok Siong Ching and Yih Kai Tan
3. Harrison; Principles of Internal Medicine; 18 th ed.; Part 14 Gastrointestinal
System; Section 1 Disorder of Alimentary Tract; Chapter 299 Acute
Intestinal Obstruction.
9. What are etiology and risk factor the case of scenario?
18
Risk Factors
o activities which increase intra-abdominal pressure:
o congenital abnormality (e.g. patent processus vaginalis)
o previous hernia repair
MCCQ I and USMLE II; General Surgery; Hernia.
10. What the relation the age, history cronic cough with the
symptoms?
Risk Factor  Chronic Cough
1. activities which increase intra-abdominal pressure:
2. congenital abnormality (e.g. patent processus vaginalis)
3. previous hernia repair
4. It is common in old men with weak abdominal muscles and is rare in
women.
MCCQ I and USMLE II; General Surgery; Hernia.(point 1-3)
2. Clinical Anatomy by System; Richard S. Snell MD. PhD; Section 7 th;
The Digestive System; Chapter 19 The Abdominal Wall, the
Peritoneal Cavity, the Retroperitoneal Space, and the Alimentary
Tract (point 4)
19
11. How the mechanism defacation and flatus?

Mechanism of defecation
Intrinsic reflex; mediated by local

enteric nervous system on rectal wall
Parasympatic defecation reflex
20
21
Summary:
Intrinsic Reflex
Feces enter the rectum
Distention of the rectum
Sent impulse afferent signal that will spread to myenteric plexus
Peristaltic wave occurs to force feces toward the anus
When peristaltic wave approach the anus, internal calan sphincter

relaxed by inhibitory signal of myenteric plexus
when m. sphincter ani externus voluntary relaxed......
DEFECATION occurs
Caution:
The intrinsic myenteric defecation reflex functioning by itself normally is
relatively weak. To be effective in causing defecation, it usually
must be fortified by another type of defecation reflex, a parasympathetic
defecation reflex that involves the sacral segments of the spinal cord,
22
Mechanism of defecation through parasympathetic defecation

reflex
When the nerve ending in the rectum are stimulated...
Signal transmitted to spinal cord
The signal reflexly back to descending colon, sigmoid, rectum, anus, by

paraympathetic nerve fibers in pelvic nerve
That will greatly intensify the peristaltic waves and relax the internal
anal sphincter
Converting weak effort to a powerfull forces of defecation
when m. sphincter ani externus voluntary relaxed......
DEFECATION occurs
23
Flatus
24
Guyton and Hall; Textbook of Medical Physiology; 12 th edition; Unit XII
Gastrointestinal Physiology; Chapter63 Propulsion and Mixing of food in the
Alimentary Tract; pages 771 and 804
12. What is the diagnosis and DD the scenario?

 Diagnosis: Hernia Inguinalis Lateral  Scrotal Hernia
 Diff Diagnosis:
Scrotal Hernia with Ileus Obstruction
Based on:
1. Anamnesis
 Vomit with greenish color
 Decreasing urine
 Feces like a goat stole
 Bloating
2. Physical Examination
 Auscultation  Metallic Sound (Sign of Obtruction)
 Percussion  Hyper tympani (due to accumulation
of gas in the proximal side of obstruction)
 Palpation  there is found pain on abdomen
3. Physical Test
 X-Ray  to ensure the physical examination and
anamnesis, according to: metallic sound, hyper
25
tympani, pain, vomit with a greenish color, and

decreasing urine of a few days.
On small bowel obstruction we can found air fluid
level imagine, and distended of bowel on proximal
side of obstruction
26
https://www.nlm.nih.gov/medlineplus/ency/imagepag
es/1169.htm Ileus - x-ray of distended bowel and
stomach  A
https://www.nlm.nih.gov/medlineplus/ency/imagepages/3069.htm
Small bowel obstruction - x-ray  B air fluid
level
13. What are the interpretation of physical examination?

a. Auscultation
Bowel sounds are generated by contractions of the alimentary tract, and
mixing of gaseous and liquid contents[9]. The quality of bowel sounds varies
according to the state of bowel activity[10,11]. Bowel sounds are complex, and
each sound comprises a mixture of tones and is often a sequence of closely
connected sounds. Common descriptions of bowel sounds include gurgling or
rattling or rustling noise heard in a normal person, rumbling explosions heard
with gastroenteritis, succussion splash heard in gastric outlet obstruction,
diminished, i.e., infrequent, and soft sounds, and prolonged tinkling or high-
pitched metallic sounds that may be heard in bowel obstruction. Very
diminished or absent bowel sounds may be caused by bowel obstruction,
intestinal ischemia, paralytic ileus, and peritonitis.
b. Percussion
A protuberant abdomen that is tympanitic throughout suggests intestinal obstruction.
27
Hipertimpani and metallic sound due to intestinal obstruction and distention on

proximal of obstruction.
28
29
1. Bates Guide to Physical Examination and History; Chapter 9; The Abdomen
2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3435785/Spectral analysis of
bowel sounds in intestinal obstruction using an electronic
stethoscope; World Journal of Gastroenterology; PMCID: PMC3435785;
Siok Siong Ching and Yih Kai Tan
MCCQ I and USMLE II; General Surgery; Hernia
14. What are the and additional examination for the case?
Examination of a patient with a suspected inguinal hernia
1. Examine the patient first when he or she is standing

2. Demonstrate lump with cough impulse
3. Then do an abdominal examination with the patient lying down
4. No merit in trying to differentiate between direct and indirect hernias
5. Important differential diagnoses: saphena varix; femoral hernia (may be difficult
even for experienced clinicians); hydrocoele (differentiate from inguinoscrotal
hernia—can get above a hydrocoele on examination)
6. physical examination usually sufficient
7. ultrasound± CT (CT required for obturator hernias, internal abdominal hernias
and Spigelian femoral hernias in obese patients)
MCCQ I and USMLE II; General Surgery; Hernia (point 6-7)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223000/ (point 1-5) 30
Inguinal hernias
15. What are the treatment of the case?
MCCQ
16. What are the I and USMLE II;
complication ofGeneral Surgery; Hernia
the case?
Source:
31
MCCQ I and USMLE II; General Surgery; Hernia
32

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Primaswari Annisa Febriana/ 3rd LBM Gastrointestinal Tract/ SGD 8

1. How the anatomy,fisiology of intestinum tenue?

JEJUNUM & ILEUM

Absorption mechanism of Glucose, lipid and protein

edition; Chapter 24; The Digestive System

2. Toronto Notes; Comprehensive Medical Reference and Review for

MCCQ I and USMLE II; Gastroenterology

2. Why the vomitte has a greenish color ?

Accumulation of fluid (ingested fluid, gastric juice, swallowed saliva ,

Intraluminal pressure ↑↑↑

Billiary secretion  Greenish color

1. Harrison; Principles of Internal Medicine; 18 th ed.; Part 14 Gastrointestinal

System; Section 1 Disorder of Alimentary Tract; Chapter 299 Acute Intestinal

2. Sibernagl/ Lang, Color Atlas of Patophysiology; Chapter6 Stomach, Intestine,

Liver; page 141-157

Gastrointestinal Physiology; Chapter 66 Physiology of GI disorder; pg 803

3. Why in the anamnesis there’s decreasing urine, and the

Gastrointestinal System; Section 1 Disorder of Alimentary Tract;

Chapter 299 Acute Intestinal Obstruction.

4. Why the mass appears when the patient is in the standing

Feb 2; 336(7638): 269–272.

5. Why we can found mass on the right inguinal regio?

1. Toronto Notes; Comprehensive Medical Reference and Review

6. Why the feses like goat stole?

Obstruction  Accumulation of gas, fluid and chyme on proximal side of

Harrison; Principles of Internal Medicine; 18 th ed.; Part 14

Gastrointestinal System; Section 1 Disorder of Alimentary Tract;

Chapter 299 Acute Intestinal Obstruction.

7. What is the relation between his job and the symptomps?

Toronto Notes; Comprehensive Medical Reference and Review for

MCCQ I and USMLE II; General Surgery; Hernia.

8. Why the patient stomached, bloating, ?

of bowel sounds in intestinal obstruction using an electronic

stethoscope; World Journal of Gastroenterology;

3. Harrison; Principles of Internal Medicine; 18 th ed.; Part 14 Gastrointestinal

System; Section 1 Disorder of Alimentary Tract; Chapter 299 Acute

9. What are etiology and risk factor the case of scenario?

Toronto Notes; Comprehensive Medical Reference and Review for

MCCQ I and USMLE II; General Surgery; Hernia.

11. How the mechanism defacation and flatus?

Intrinsic reflex; mediated by local

Parasympatic defecation reflex

Distention of the rectum

Sent impulse afferent signal that will spread to myenteric plexus

Peristaltic wave occurs to force feces toward the anus

When peristaltic wave approach the anus, internal calan sphincter

when m. sphincter ani externus voluntary relaxed......

Mechanism of defecation through parasympathetic defecation

When the nerve ending in the rectum are stimulated...

Signal transmitted to spinal cord

The signal reflexly back to descending colon, sigmoid, rectum, anus, by

Converting weak effort to a powerfull forces of defecation

when m. sphincter ani externus voluntary relaxed......

Guyton and Hall; Textbook of Medical Physiology; 12 th edition; Unit XII

Gastrointestinal Physiology; Chapter63 Propulsion and Mixing of food in the

Alimentary Tract; pages 771 and 804

12. What is the diagnosis and DD the scenario?

tympani, pain, vomit with a greenish color, and

13. What are the interpretation of physical examination?

Hipertimpani and metallic sound due to intestinal obstruction and distention on

1. Bates Guide to Physical Examination and History; Chapter 9; The Abdomen

bowel sounds in intestinal obstruction using an electronic