CASE REPORT

Thursday, December 22, 2005

Name : Mr. Z, 49 yo
MR no. : 1218853
Address : Celenan, Jagalan, Banguntapan, Bantul

Patient was referred from The Private Clinic in Kota

Gede, Jogyakarta, diagnosed with: Bowel Obstruction

Chief of complaint: distension of abdomen and unable

of defecation

History of Present Illness:

About two months before admitted to Dr. Sardjito
General Hospital, he felt dificult in defecation, small and
hard, sometimes with bloddy and mucous, no nausea
and no vomiting, no distension of abdomen. He felt loss
of body weight.
About 2 weeks before admitted to Dr. Sardjito
General Hospital he felt unable to flatus and defecation,
with nausea and vomiting, and slight distension of
abdomen. Then he went to Bantul Distric Hospital,
suggested for operation but he refused and he went
home.
The day admitted to Dr. Sardjito General Hospital, his
complain got worse, still unable to flatus and
defecation, his abdomen very distension, vomiting more
severe, the contain like faeces and sometimes with
abdominal pain, no fever, urinate was normal. The family
brought him to The Private Clinic in Kota Gede, got an IV
line and Urine Catheter, then he was referred to Dr.
Sardjito General Hospital.

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History of Past Illness:
-loss of body weight abouth 10 kg in two months.
-with hypertension
-no DM

Physical examination:

Vital Sign:
Blood Pressure : 170/90 mmHg
Respiratory Rate : 26 X/minute, regular, normal
breathing pattern
Pulse Rate : 100 X/minute fully palpable, regular
Body temperature : 36,2oC

General condition : weakness, fully alert

Head Area:
Pupil diameter equal ∅ 3 mm
Light reflex and corneal reflex positive both side
Conjunctiva no anemic
Sclera no ichteric
NGT with faeces product

Neck Area:
JVP no increased

Thoracic area:
Inspection : Symmetrical
Palpation : Normal Fremitus
Percussion : Sonor
Auscultation : Normal breathing sound (vesicular)
Equal, No abnormal sound

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Abdominal area:
Inspection:
Distended,
Bowel contour appearance was found,
Bowel movement appearance was found
Palpation:
No tenderness
No muscular defense
Percussion:
Hypertympanic
Auscultation:
Bowel sound was increased with metallic sound
and borborygmi sound

Digital Rectal Examination :

Anal Sphincter muscle tone within normal limit, Ampula
was collaps. Mass 7 cm from anal verge, circular, fixed,
hard, nodules, diameter of rectal lumen smaller than
one finger, glove: mucous (+), blood (+), faeces (-).

Assessment:
Bowel Obstruction due to carcinoma of the rectum

Planning:
Pro Emergency Exploratory Laparotomy Colostomy
1. Stop oral intake
2. Intravenous fluid and drugs :
Ringer lactate infusion
Ceftriaxon injection 1 g
Metronidazole infus 500 mg
Ranitidin injection 100 mg
3. EKG and Radiologic examination: Thorax rontgen,
Abdomen 3 position

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4. Laboratory examination : routine blood analysis, BUN,
creatinin, electrolyte
5. Informed consent
Consult to Digestive Surgeon: Pro Emergency
Exploratory Laparotomy Colostomy
8. Consult to Anesthesiology Department

Laboratory Result
Haemoglobin : 15.5 g/dL
Hematocryt : 48.6 %
Erithrocyte count : 6.12 x 106 cell/µL
Thrombocyte count: 254 x 103 cell/µL
Leucocyte count : 8.8 x 103 cell/µL
Neutrophyl : 72.4%
Lymphocyte : 16.5%
Monocyte : 11.0%
Eosinophyl : 0.0%
Basophyl : 0.1%

Bleeding Time : 2 minute

Clotting Time : 9 minute
Blood Group : B

Total Protein : 6.90 g/dL

Albumin : 3.82 g/dL

BUN : 24.1 mg/dL

Creatinine : 0.81 mg/dL
Blood Glucose : 131 mg/dL
Natrium : 130 mmol/l
Kalium : 3.4 mol/l
Chloride : 90 mmol/l

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Rontgen:
Thorax : lung and cor within normal limit
3 position abdomen: hearing bone appearance (+)
air fluid level (+)

Preoperative Diagnosis:
Bowel Obstruction due to carcinoma of the rectum

Operation Report

-In anesthetic phase

-Surgical preparation
-Aseptic and antiseptic procedure
-Median incision performed in layers until peritoneum
-Peritoneum was opened, flew out clear fluid
-Identification, we found distension of small and large
intestine from lig. of Treitz until sigmoid colon.
Decompression from ileotomy
-Exploratory:
-We found a tumour in sigmoid colon, about 15 cm
proximal from peritoneal reflection of rectum. The
diameter: 5 cm , intraluminair, circular, hard, nodules
and fixed. The passage was stopped in proximal to
the tumour. In the distal of the tumor, the colon
(sigmoid and the rectum) were collaps.
-We found the tumour in rectum, in the peritoneal
reflection of rectum, intraluminair, circular, hard,
nodules and fixed
-We found adhesion between ileum about 15 cm
proximal from ileocecal junction and the tumour in the
rectum.The passage was good.
-We found multiple nodules, 5 mm in diameter, almost
on the wall of intestine, on mesenteric area, omentum.

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 -We found nodules in liver
-Paraaortic and paracolic lymph node was palpable.
-We Consult to Digestive Surgeon: decided to performed
left transverse colostomy and shunting
ileoascendestomy side to side, and biopsy the sigmoid
tumor.
-We biopsy one of the nodule in omentum.
-Abdominal cavity was washed with warm normal saline
-Bleeding control
-Close abdominal wall in layers
-Biopsy from anal region
-Operation was done.

Postoperative Diagnosis:
Bowel Obstruction due to carcinoma of the sigmoid and
rectum

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 LAPORAN KASUS
Selasa, 30 Agustus 2005

Nama : Bp. S, 70 th
No. RM : 1.20.21.55
Alamat : Depok, Kalibawang, Wonosobo

Pasien rujukan dari RS Swasta tipe C Wonosobo,

dengan diagnosis Ileus Obstruksi e.c Ca Anorektum
(pasien terpasang infus, NGT dan DC)

Keluhan Utama: Perut kembung dan tidak bisa buang air

besar

Riwayat Penyakit Sekarang:

Dua bulan sebelum masuk RS Sardjito pasien mengeluh

bila BAB sering sulit, keras dan mringkil, lendir (+),
darah (+), tidak mual, tidak muntah, tidak kembung,
terdapat benjolan di anus yang menetap, nyeri dan
berdarah pada benjolan terutama saat BAB.
Sepuluh hari sebelum masuk RS Sardjito pasien
mengeluh tidak bisa BAB, flatus (+), tidak mual, tidak
muntah, kadang kembung, benjolan di anus menetap.
Satu minggu sebelum masuk RS Sardjito pasien
mengeluh tidak bisa BAB, flatus (-), mual, tidak muntah,
kembung (+), benjolan di anus menetap, pasien
kemudian dirawat di RS Swasta tipe C Wonosobo
selama 3 hari, dilakukan rongent Abdomen dan
dikatakan menderita tumor di usus bagian bawah dan
anus, pasien disarankan untuk operasi tetapi menolak
dan pasien pulang APS dengan membawa surat rujukan
ke RS Sardjito serta terpasang infus, NGT dan DC.
Hari masuk RS Sardjito pasien mengeluh tetap tidak
bisa BAB dan tidak bisa flatus, perut makin kembung,

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nyeri perut (+) hilang timbul, mual (+), muntah (+) seperti
feses, tidak demam, kemudian pasien berobat ke RS
Sardjito.

Riwayat Penyakit Dahulu:

-Pasien mengeluh perubahan kebiasaan BAB sejak 1
tahun yll
-Pasien mengeluh benjolan di anus sejak 6 bulan,
menetap, nyeri dan berdarah terutama saat BAB.
-Pasien mengeluh penurunan BB dalam waktu 3 bulan.
-Hipertensi (-)
-DM (-)
-Penyakit Jantung (-)

Pemeriksaan Fisik:
Keadaan Umum : Lemah, Composmentis, Gizi cukup
Tanda Vital : T : 110/70 mmHg N : 100 x/menit
R : 20 x/menit S : 380 C
Status Umum :
Kepala : Conjungtiva anemis (-), sklera ikterik (-)
NGT produk (+) feses cair
Leher : JVP tak meningkat
Dada : C/P dbn
Status Lokalis :
Abdomen :
I : Distensi, DC (+), DS (+)
P : Tegang, NT (-), DM (-), massa (-)
P : Timpani meningkat
A : Peristaltik (+) meningkat, BR (+), MS (+)

Digital Rectal Examination :

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Mass in anal verge, circular, nodules, hard, diameter
anal lumen smaller than one finger, pain.
Anal Sphincter muscle tone couldn’t evaluated,

Assessment:
Obstructive Ileus due to Anal Carcinoma

Planning:
Emergency Laparotomy Colostomy
6. Stop oral intake
7. Intravenous fluid and drugs :
Ringer lactate infusion
Ceftriaxon injection 1 g
Metronidazole infus 500 mg
Ranitidin injection 100 mg
8. Laboratory examination : routine blood analysis, BUN,
creatinin, electrolyte
9. Informed consent
10. Consult to Digestive Surgeon
11. Consult to Anesthesiology Department

Laboratory Result
Haemoglobin : 7.3 g/dL
Hematocryt : 25.8 %
Erithrocyte count : 4.13 x 106 cell/µL
Thrombocyte count: 510.000 cell/µL
Leucocyte count : 8.0 x 103 cell/µL
Neutrophyl : 63.9%
Lymphocyte : 32.6%
Monocyte : 3.3%
Eosinophyl : 0.2%
Basophyl : 0.0%

Bleeding Time : 2.5 minute

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Clotting Time : 9 minute
Blood Group : O

Total Protein : 6.02 g/dL

Albumin : 2.20 g/dL

BUN : 20.7 mg/dL

Creatinine : 0.78 mg/dL
Blood Glucose : 116 mg/dL
Natrium : 138 mmol/l
Kalium : 3.9 mol/l
Chloride : 101 mmol/l

Preoperative Diagnosis:
Obstructive ileus due to Anal Carcinoma

Operation Report

In anesthetic phase
Surgical preparation
Aseptic and antiseptic procedure
Median incision performed in layers until peritoneum.
Peritoneum was opened, flew out clear fluid
Identification, we found distension intestine and colon
until descending colon. Decompression from ileotomy.
We found multiple nodules in mesenteric area and
omentum. Appendix vermiformis in distal one third
become a mass with omentum, we perform
appendectomy. Liver and spleen smooth. Paraaortic and
paracolic lymph node was palpable.

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In further exploration sigmoid colon, uterus and ovary
compound become a mass in pelvic region (frozen
pelvic)
The passage was stopped in sigmoid colon.
We decided to performed left transverse colostomy
Abdominal cavity was washed with warm normal saline
Bleeding control
Close abdominal wall in layers
Biopsy from anal region
Operation was done.

Postoperative Diagnosis:
Obstructive ileus due to Anal Carcinoma

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