ABDOMINAL DISTENTION

OR
MASSES
Atan Baas Sinuhaji
Sub Division of Pediatrics Gastroentero-Hepatology
Department of ChildHealth,School of Medicine
University of Sumatera Utara/Adam Malik Hospital
Medan

PCM
ABDOMINAL
WALL

PRUNE BELLY
SYNDR.
OBESITY

ABDOMINAL
DISTENTION

GASES
ABDOMINAL
CONTENT

FLUIDS
ABD. MASS

PRUNE BELLY SYNDROME

= EAGLE BARRET SYNDROME
= TRIAD SYNDROME

- DEFICIENT ABDOMINAL MUSCLE

- URINARY TRACT ABNORMALITY
UROPATHY NON OBSTRUCTIVE
- CRYPTORCHIDISM

OUT

GASES

BOWEL

PERFORATION

PNEUMOPERITONEUM

OBSTRUCTION

IN

MALABSORPTION
AEROPHAGIA

BOWEL OBSTRUCTION :
1. MECHANICAL/PARALYTIC
2. INCOMPLETE/COMPLETE
3. CONGENITAL/ACQUIRED

MECHANICAL

SIMPLE
STRANGULATION

OBSTRUCTION

VASCULAR
COMPROMISE

PARALYTIC
= ILEUS
=INTESTINAL PSEUDOOBSTRUCTION

SPASMOLYTIC

ACUTE

HYPOKALEMIA
PNEUMONIA

ILEUS

CHRONIC

MUSCLE & NEURON

(CHRONIC INTESTINAL PSEUDO

OBSTRUCTION)

OBSTRUCTION
ACCUMULATION OF
BOWEL CONTENTS
OVERGROWTH
MICROORG.

GUT CIRCULATION

MUCOSAL DAMAGE
ENTEROCOLITIS
SEPSIS

ABD. CAVITY

ABD.MASS

PELVIC

RETROPERITONEAL
-KIDNEYS :

-WILMS TUMOR
-NEUROBLASTOMA
-CYSTE

-PANCREAS

PANCREATIC CYST

TRUE
DELINEATED BY EPITHELIAL WALL

PSEUDO
DELINEATED BY FIBROUS WALL

PANCREATITIS FAIL TO RESOLVE

RESECTION
DRAINAGE

OVARIAL CYST

HEMATOCOLPOS

PELVIC

TUBOOVARIAN ABSCESS

TERATOMA

FETUS

IN

WORMS > 100

FECAL IMPACTION
TUMOR

ABD. CAV.

GUT
OUT

FOREIGN BODY
APP. ABSCESS

TUMOR
- KISTA MESENTERIUM
ORGANOMEGALY

TUMORS OF THE GUT

1.POLYPS
2.HEMANGIOMA
3.LEIOMYOMA
4.CARCINOMA
5.LIMPHOSARCOMA
6.CARCINOID:
- CHRONIC DIARRHOEA
- VASOMOTOR
- BRONCHOCONSTRICTION

POLYP
Any mass projecting into lumen of GI Tract

Neoplastic

=Benigna adenoma
=Malignant carcinoma

Non neoplastic

=Juvenile
=Inflammatory
=Hyperplastic

POLYPS OF THE GUT

JUVENILE

HAMARTOMA

FAMILIAL

ADENOMA

PREMALIGNANT

INTESTINAL JUVENILE POLYPS

NON SYNDROMIC

SYNDROMIC

EXTRAINTESTINAL FEATURES

SOLITARY

(-)
AMPUTATED

JPS

(+)

= BRRS
= CS

INTESTINAL JUVENILE POLYPS

NONSYNDROMIC

NON MALIGNANT

JUVENILE POLYPOSIS SYNDROME

( JPS )

PREMALIGNANT

JUVENILE POLYPOSIS SYNDROME

- 5 JUVENILE POLYPS OF THE COLON OR RECTUM

-JUVENILE POLYPS IN OTHER PARTS OF GI TRACT OR
-ANY NUMBER OF JUVENILE POLYPS AND A POSITIVE FAMILY HISTORY

BANNAYAN RILEY RUCULCABA SYNDROME

( BRRS )

ADDITIONAL FEATURES
= MENTAL RETARDASI
= MACROCEPHALY
= LIPOMATOSIS
= HEMANGIOMAS AND
= GENITAL PIGMENTATION

COWDEN SYNDROME
( CS )

ADDITIONAL PATHOGNOMONIC FEATURES OF MUCOCUTANEOUS

LESION (FACIAL TRICHILEMMOMA,ORAL FIBROMA,ACRAL KERATOSIS)
AND ASSOCIATED TUMOR OF THE THYROID, BREAST AND ENDOMETRIUM

DIAGNOSIS OF POLYPS

INVASIVE

ENDOSCOPY

NONINVASIVE

MATRIX METALLOPROTEINASES IN URINE

MMP
(MATRIX METALLOPROTEINASE)

VEGF
(VASCULAR ENDOTHELIAL GROWTH FACTOR)

ANGIOGENESIS

PHYSIOLOGICAL

-DEVELOPMENT
-TISSUE REPAIR
-REPRODUCTION

PATHOLOGICAL

-TUMOR GROWTH
-METASTASIS

GROWTH

ANGIOGENESIS

MMP(+) IN URINE

Table 1 Lower Gastrointestinal surveillance strategies

Recomendations by Howe et

From age 15 or ealier if

symptoms:
Do full blood examination and
endoscopy
If normal,repeat 3 yearly
If polyps are found,remove
and screen annually until
polyps free ,then 3 yearly

Recommendations by Dunlop

From age 15-18 or earlier

if symptoms
Interval 1-2 years

Gene carriers or affected continue

surveillance until age 70

Table 2 Upper gastrointestinal surveillance strategies

Recommendation by
Howe et al

Recommendation by
Dunlop

Recommendation by
Sayed et al

Contemporaneously with
colonoscopy

From age 25

Frequency :SMAD4+
patients :1-3 yearly

Biliary and/or pancreatic

duct bruishings
recommended if elevated
amylase or abnormal
liver function test

Frequency :1-2yearly
contemporaneously
with colonoscopy

Mutation negative or
BMPR1A+ patients :
5 yearly

HEPATOMEGALY
1. INFLAMMATION

HEPATITIS

2. CONGESTION : DECOMPENSATION,
CONTRICTIVE PERICARDITIS
3. BLOOD DISORDERS :
HEMOLYSIS

: THALASSEMIA

MALIGNANCY : LEUKEMIA
4. TUMORS :CHOLEDOCHAL CYST
HEPATOMA
5. METABOLIC DISORDERS : FATTY LIVER

FATTY LIVER
1. NUTRITIONAL : OBESITY, KWASHIORKOR
2. DRUGS : ESTROGEN, STEROID
3. INTOXICATION : ALCOHOL
4. ALTERATION OF GI ANATOMY :
JEJUNOILEAL BY PASS
5. OCCUPATIONAL EXPOSURE :
HYDROCARBON
6. METABOLISM : A LIPOPROTEINEMIA

PATHOGENESIS

1.PERIPHERAL
MOBILIZ. OF
FATTY ACID

2. HEPATIC SYNTHESIS
OF FATTY ACID

4. IMPAIRED SYNTHESIS
& EXCRETION VLDL (
VERY LOW DENSITY
LIPOPROTEIN) FROM
THE LIVER
3. HEPATIC CATABOLISM OF
FATTY ACID

FATTY LIVER
HEPATIC STEATOSIS
INFLAMATION
ALCOHOLIC

NON INFLAMATION
(BENIGNA STEATOSIS)
NON ALCOHOLIC
STEATOHEPATITIS
(NASH)
8-20 %

PROGRESIVE FIBROSIS
(10-50 % OF NASH)

CIRRHOSIS (10% OF NASH)

NO INCREASED
MORTALITY

FIBROSIS (-)

NO INCREASED MORTALITY

HEPATIC STEATOSIS

NASH

ALC. HEPATITIS

ALT > AST

AST > ALT

2:1

2:1
ALT = SGPT

ALANINE AMINO TRANSFERASE= SERUM GLUTAMATE PYRUVATE TRANSAMINASSE

AST=SGOT
ASPARTAT AMINO TRANSFERASE = SERUM GLUTAMIC OXALOACETAT
TRANSAMINASE

FLUIDS
BOWEL
IN

OBSTRUCTION

OUT

ASCITES

INTAKE

PORTAL HYPERTENSION
-HEART FAILURE

- PCM

LOSS
- NEPHROTIC SYND.

SYNTHESIS
- HEPATIC CIRRHOSIS

-CIRRHOSIS

HYDROSTATIC PRESS.
ONCOTIC PRESS.

ASCITES
PERMEABILITY
-DHF
-PERITONITIS TBC
-PERITONEAL TUMOR

LYMPH
OBSTRUCTION