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 PRUNE BELLY
WALL SYNDR.
OBESITY
ABDOMINAL
DISTENTION
GASES
ABDOMINAL
FLUIDS
CONTENT
ABD. MASS
PRUNE BELLY SYNDROME
= EAGLE BARRET SYNDROME
= TRIAD SYNDROME

- DEFICIENT ABDOMINAL MUSCLE

- URINARY TRACT ABNORMALITY
UROPATHY NON OBSTRUCTIVE
- CRYPTORCHIDISM
 OUT PERFORATION

PNEUMOPERITONEUM
GASES BOWEL

OBSTRUCTION

IN MALABSORPTION
AEROPHAGIA
BOWEL OBSTRUCTION :

1. MECHANICAL/PARALYTIC
2. INCOMPLETE/COMPLETE
3. CONGENITAL/ACQUIRED
 SIMPLE
MECHANICAL
STRANGULATION

OBSTRUCTION VASCULAR
COMPROMISE

PARALYTIC
= ILEUS
=INTESTINAL PSEUDOOBSTRUCTION
 SPASMOLYTIC
HYPOKALEMIA
ACUTE
PNEUMONIA

ILEUS

MUSCLE & NEURON

CHRONIC
(CHRONIC INTESTINAL PSEUDO
OBSTRUCTION)
 OBSTRUCTION

ACCUMULATION OF
BOWEL CONTENTS

OVERGROWTH
GUT CIRCULATION
MICROORG.

MUCOSAL DAMAGE

ENTEROCOLITIS

SEPSIS
 ABD. CAVITY

ABD.MASS
PELVIC

RETROPERITONEAL
-KIDNEYS : -WILM’S TUMOR
-NEUROBLASTOMA
-CYSTE
-PANCREAS
 PANCREATIC CYST

TRUE PSEUDO

DELINEATED BY EPITHELIAL WALL DELINEATED BY FIBROUS WALL

PANCRATITIS FAIL TO RESOLVE

RESECTION
DRAINAGE
 OVARIAL CYST

HEMATOCOLPOS

TUBOOVARIAN ABSCESS
PELVIC
TERATOMA

FETUS
 WORMS > 100
IN
FECAL IMPACTION
TUMOR
FOREIGN BODY
ABD. CAV. GUT APP. ABSCESS

OUT
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 Non neoplastic

=Benigna adenoma =Juvenile

=Malignant carcinoma =Inflammatory
=Hyperplastic
 POLYPS OF THE GUT

JUVENILE FAMILIAL

HAMARTOMA ADENOMA

PREMALIGNANT
 INTESTINAL JUVENILE POLYPS

NON SYNDROMIC SYNDROMIC

SOLITARY EXTRAINTESTINAL FEATURES

(-) (+)

AMPUTATED
JPS = BRRS
= CS
 INTESTINAL JUVENILE POLYPS

NONSYNDROMIC JUVENILE POLYPOSIS SYNDROME

( JPS )

NON MALIGNANT 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 NONINVASIVE

ENDOSCOPY MATRIX METALLOPROTEINASES IN URINE

 MMP VEGF
(MATRIX METALLOPROTEINASE) (VASCULAR ENDOTHELIAL GROWTH FACTOR)

ANGIOGENESIS

PHYSIOLOGICAL PATHOLOGICAL

-DEVELOPMENT
-TUMOR GROWTH
-TISSUE REPAIR
-METASTASIS
-REPRODUCTION
 GROWTH

ANGIOGENESIS

MMP(+) IN URINE
 Table 1 Lower Gastrointestinal surveillance strategies

Recomendations by Howe et Recommendations by Dunlop

From age 15 or ealier if From age 15-18 or earlier

symptoms: if symptoms
Do full blood examination and Interval 1-2 years
endoscopy

If normal,repeat 3 yearly Gene carriers or affected continue

If polyps are found,remove surveillance until age 70
and screen annually until
polyps free ,then 3 yearly
Table 2 Upper gastrointestinal surveillance strategies

Recommendation by Recommendation by Recommendation by

Howe et al Dunlop Sayed et al

Contemporaneously with From age 25 Frequency :SMAD4+

colonoscopy patients :1-3 yearly

Biliary and/or pancreatic Frequency :1-2yearly Mutation negative or

duct bruishings contemporaneously BMPR1A+ patients :
recommended if elevated with colonoscopy 5 yearly
amylase or abnormal
liver function test
 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 – ß LIPOPROTEINEMIA
 PATHOGENESIS

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

HEPATIC STEATOSIS

INFLAMATION NON INFLAMATION

ALCOHOLIC (BENIGNA STEATOSIS)

NON ALCOHOLIC
STEATOHEPATITIS
(NASH)
8-20 %
NO INCREASED
MORTALITY

PROGRESIVE FIBROSIS FIBROSIS (-)

(10-50 % OF NASH)

NO INCREASED MORTALITY
CIRRHOSIS (10% OF NASH)
 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 OUT

OBSTRUCTION ASCITES
 INTAKE
PORTAL HYPERTENSION
LOSS - PCM SYNTHESIS
-HEART FAILURE - NEPHROTIC SYND. - HEPATIC CIRRHOSIS
-CIRRHOSIS

HYDROSTATIC PRESS.

ONCOTIC PRESS.

ASCITES

PERMEABILITY LYMPH
-DHF
OBSTRUCTION
-PERITONITIS TBC
-PERITONEAL TUMOR