Penegakkan Diagnosis Ileus Obstruktif Pada Laki-Laki Usia 50 Tahun Dibuat oleh: Hanifah Tri Utami,Modifikasi terakhir pada Sun 20 of May, 2012 [22:02 UTC] Abstrak Ileus merupakan suatu kondisi dimana terdapat gangguan pasase (jalannya makanan) di usus. Ileus ini terutama dibagi dua berdasarkan penyebabnya, yaitu ileus obstruktif dan ileus paralitik. Ileus obstruktif adalah kerusakan atau hilangnya pasase isi usus yang disebabkan oleh sumbatan mekanik sedangkan ileus paralitik adalah hilangnya peristaltik usus sementara akibat suplai saraf otonom mengalami paralisis dan peristaltik usus terhenti sehingga tidak mampu mendorong isi sepanjang usus. Ileus Obstruktif merupakan kegawatan dalam bedah abdominalis yang sering dijumpai, merupakan 60-70% dari seluruh kasus akut abdomen yang bukan apendisitis akut. Penyebab yang paling sering dari obstruksi ileus adalah adhesi/streng. Pasien pada kasus ini didiagnosis ileus obstruktif dan dilakukan terapi bedah laparotomi eksplorasi dan ditemukan adhesi atau streng antar ileum yang menjadi penyebab munculnya ileus obstruktif. Keyword: ileus obstruktif, ileus paralitik, perbedaan Kasus Seorang laki-laki, usia 50 tahun, datang ke IGD diantar keluarganya dengan keluhan utama tidak bisa buang angin sejak 3 hari sebelum periksa dan disertai nyeri perut hilang timbul, mual, muntah berwarna kehijauan, tidak bisa buang air besar dan buang angin. Pada pemeriksaan fisik tampak keadaan umum lemah, namun kesadaran compos mentis, tanda vital hipertensi, dinding abdomen tampak lebih tinggi dari dinding thorax, nyeri tekan pada perut kanan bawah, namun peristaltik masih normal. Hasil pemeriksaan darah pada saat masuk dapat dilihat pada bagian laboratorium. Pemeriksaan colok dubur dalam batas normal. Pemeriksaan laboratorium kimia darah ditemukan hipoklorida dan darah rutin eosinopenia, limfositopenia, dan monositosis. Diagnosis Ileus obstruktif Terapi Pasien dirawat-inapkan dan dilakukan laparotomi eksplorasi dan ditemukan adanya adesi ileum sehingga dilakukan tindakan adhesiolisis. Terapi non operatif diberikan injeksi intravena antara lain ceftriakson 1 gram setiap hari, ketorolac 10 mg setiap 8 jam, ranitidin 50 mg setiap 12 jam, metronidazol 500 mg dalam 100 mL larutan infus dan diberikan setiap 8 jam. Dilakukan pemasangan nasogastric tube

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serta larutan infuse ringer laktat 32 tetes permenit. Diskusi Nyeri perut kolik yang muncul pada pasien ini dapat menjadi petunjuk bahwa asal kelainan adalah dari organ yang berongga atau mempunyai saluran. Kita dapat memikirkan usus dan ureter sebagai penyebab nyeri perut kolik terbanyak. Adanya keluhan tambahan muntah berwarna kehijauan dan keluhan gangguan saluran cerna yaitu berupa tidak bisa buang air besar dan buang angin mengindikasikan terjadinya gangguan pada pasase usus atau disebut juga ileus. Secara garis besar berdasarkan penyebabnya, ileus dibagi dua, yaitu ileus obstruktif dan ileus paralitik. Penting bagi seorang dokter untuk mengetahui perbedaan kedua ileus tersebut untuk menegakkan diagnosis sehubungan dengan terapi yang akan diberikan. Berikut penjelasan yang menggambarkan kedua ileus tersebut. Ileus obstruktif Ileus obstruktif adalah suatu penyumbatan mekanis pada usus dimana merupakan penyumbatan yang sama sekali menutup atau menganggu jalannya isi usus. Ileus obstruktif dapat disebabkan oleh: 1. Adhesi (perlekatan usus halus) merupakan penyebab tersering ileus obstruktif, sekitar 50-70% dari semua kasus. Adhesi bisa disebabkan oleh riwayat operasi intraabdominal sebelumnya atau proses inflamasi intraabdominal. Obstruksi yang disebabkan oleh adhesi berkembang sekitar 5% dari pasien yang mengalami operasi abdomen dalam hidupnya. Perlengketan kongenital juga dapat menimbulkan ileus obstruktif di dalam masa anak-anak. 2. Hernia inkarserata eksternal (inguinal, femoral, umbilikal, insisional, atau parastomal) merupakan yang terbanyak kedua sebagai penyebab ileus obstruktif, dan merupakan penyebab tersering pada pasien yang tidak mempunyai riwayat operasi abdomen. Hernia interna (paraduodenal, kecacatan mesentericus, dan hernia foramen Winslow) juga bisa menyebabkan hernia. 3. Neoplasma. 4. Intususepsi usus halus menimbulkan obstruksi dan iskhemia terhadap bagian usus yang mengalami intususepsi. 5. Penyakit Crohn 6. Volvulus sering disebabkan oleh adhesi atau kelainan kongenital, seperti malrotasi usus. 7. Batu empedu yang masuk ke ileus 8. Striktur yang sekunder yang berhubungan dengan iskhemia, inflamasi, terapi radiasi, atau trauma operasi. 9. Penekanan eksternal oleh tumor, abses, hematoma, intususepsi, atau penumpukan cairan. 10. Benda asing, seperti bezoar. 11. Divertikulum Meckel Terdapat 4 tanda kardinal gejala ileus obstruktif: 1. Nyeri abdomen 2. Muntah

3. Distensi 4. Kegagalan buang air besar atau gas(konstipasi). Gejala ileus obstruktif tersebut bervariasi tergantung kepada: 1. Lokasi obstruksi 2. Lamanya obstruksi 3. Penyebabnya 4. Ada atau tidaknya iskemia usus Gejala selanjutnya yang bisa muncul termasuk dehidrasi, oliguria, syok hipovolemik, pireksia, septikemia, penurunan respirasi dan peritonitis. Terhadap setiap penyakit yang dicurigai ileus obstruktif, semua kemungkinan hernia harus diperiksa. Diagnosis ileus obstruktif tidak sulit; salah satu yang hampir selalu harus ditegakkan atas dasar klinik dengan anamnesis dan pemeriksaan fisik, kepercayaan atas pemeriksaan radiologi dan pemeriksaan laboraorium harus dilihat sebagai konfirmasi dan bukan menunda mulainya terapi yang segera. Diagnosa ileus obstruksi diperoleh dari : Anamnesis. Pada anamnesis ileus obstruktif usus halus biasanya sering dapat ditemukan penyebabnya, misalnya berupa adhesi dalam perut karena pernah dioperasi sebelumnya atau terdapat hernia. Pada ileus obstruksi usus halus kolik dirasakan di sekitar umbilkus, sedangkan pada ileus obstruksi usus besar kolik dirasakan di sekitar suprapubik. Muntah pada ileus obstruksi usus halus berwarna kehijaun dan pada ileus obstruktif usus besar onset muntah lama. Pemeriksaan Fisik 1. Inspeksi. Dapat ditemukan tanda-tanda generalisata dehidrasi, yang mencakup kehilangan turgor kulit maupun mulut dan lidah kering. Pada abdomen harus dilihat adanya distensi, parut abdomen, hernia dan massa abdomen. Terkadang dapat dilihat gerakan peristaltik usus yang bisa berkorelasi dengan mulainya nyeri kolik yang disertai mual dan muntah. Penderita tampak gelisah dan menggeliat sewaktu serangan kolik. 2. Palpasi. Pada palpasi bertujuan mencari adanya tanda iritasi peritoneum apapun atau nyeri tekan, yang mencakup defance musculair involunter atau rebound dan pembengkakan atau massa yang abnormal. 3. Auskultasi. Pada ileus obstruktif pada auskultasi terdengar kehadiran episodik gemerincing logam bernada tinggi dan gelora (rush) diantara masa tenang. Tetapi setelah beberapa hari dalam perjalanan penyakit dan usus di atas telah berdilatasi, maka aktivitas peristaltik (sehingga juga bising usus) bisa tidak ada atau menurun parah. Tidak adanya nyeri usus bisa juga ditemukan dalam ileus paralitikus atau ileus obstruksi strangulata. 4. Bagian akhir yang diharuskan dari pemeriksaan adalah pemeriksaan rektum dan pelvis. Ia bisa membangkitkan penemuan massa atau tumor serta tidak adanya feses di dalam3

kubah rektum menggambarkan ileus obstruktif usus halus. Jika darah makroskopik atau feses postif banyak ditemukan di dalam rektum, maka sangat mungkin bahwa ileus obstruktif didasarkan atas lesi intrinsik di dalam usus. Apabila isi rektum menyemprot; penyakit Hirschprung. Radiologi. Pemeriksaan sinar-X bisa sangat bermanfaat dalam mengkonfirmasi diagnosis ileus obstruktif serta foto abdomen tegak dan berbaring harus yang pertama dibuat. Adanya gelung usus terdistensi dengan batas udara-cairan dalam pola tangga pada film tegak sangat menggambarkan ileus obstruksi sebagai diagnosis. Dalam ileus obstruktif usus besar dengan katup ileocaecalis kompeten, maka distensi gas dalam kolon merupakan satu-satunya gambaran penting. Penggunaan kontras dikontraindikasikan adanya perforasi-peritonitis. Barium enema diindikasikan untuk invaginasi, dan endoskopi disarankan pada kecurigaan volvulus. Laboratorium. Leukositosis, dengan pergeseran ke kiri, biasanya terjadi bila terdapat strangulasi, tetapi hitung darah putih yang normal tidak menyampingkan strangulasi. Peningkatan amilase serum kadang-kadang ditemukan pada semua bentuk ileus obstruktif, khususnya jenis strangulasi. Terapi ileus obstruksi biasanya melibatkan intervensi bedah. Penentuan waktu kritis serta tergantung atas jenis dan lama proses ileus obstruktif. Operasi dilakukan secepat yang layak dilakukan dengan memperhatikan keadaan keseluruhan pasien. Tujuan utama penatalaksanaan adalah dekompresi bagian yang mengalami obstruksi untuk mencegah perforasi. Tindakan operasi biasanya selalu diperlukan. Menghilangkan penyebab ileus obstruksi adalah tujuan kedua. Kadang-kadang suatu penyumbatan sembuh dengan sendirinya tanpa pengobatan, terutama jika disebabkan oleh perlengketan. Dekompresi pipa bagi traktus gastrointestinal diindikasikan untuk dua alasan: 1. Untuk dekompresi lambung sehingga memperkecil kesempatan aspirasi isi usus. 2. Membatasi masuknya udara yang ditelan ke dalam saluran pencernaan, sehingga mengurangi distensi usus yang bisa menyebabkan peningkatan tekanan intralumen dan kemungkinan ancaman vaskular. Pasien dipuasakan, kemudian dilakukan juga resusitasi cairan dan elektrolit untuk perbaikan keadaan umum. Setelah keadaan optimum tercapai barulah dilakukan laparatomi. Pemberian antibiotika spektrum lebar di dalam gelung usus yang terkena obstruksi strangulasi terbukti meningkatkan kelangsungan

hidup. Tetapi, karena tidak selalu mudah membedakan antara ileus obstruksi strangulata dan sederhana, maka antibiotika harus diberikan pada semua pasien ileus obstruksi. Operasi dapat dilakukan bila sudah tercapai rehidrasi dan organ-organ vital berfungsi secara memuaskan. Tetapi yang paling sering dilakukan adalah pembedahan sesegera mungkin. Tindakan bedah dilakukan bila: 1. Strangulasi 2. Obstruksi lengkap 3. Hernia inkarserata 4. Tidak ada perbaikan dengan pengobatan konservatif (dengan pemasangan NGT, infus, oksigen dan kateter). Tindakan yang terlibat dalam terapi bedahnya masuk kedalam beberapa kategori mencakup: 1. Lisis pita lekat atau reposisi hernia 2. Pintas usus 3. Reseksi dengan anastomosis 4. Diversi stoma dengan atau tanap resksi. Pengobatan pasca bedah sangat penting terutama dalam hal cairan dan elektrolit. Kita harus mencegah terjadinya gagal ginjal dan harus memberikan kalori yang cukup. Perlu diingat bahwa pasca bedah usus pasien masih dalam keadaan paralitik. Ileus paralitik. Ileus paralitik atau adinamic ileus merupakan keadaan dimana usus gagal atau tida mampu melakukan kontraksi peristaltik untuk menyalurkan isinya. Ileus paralitk bukanlah merupakan suatu penyakit primer usus melainkan akibat dari berbagai penyakit primer, tindakan operasi yang berhubungan dengan rongga perut, toksin dan obat-obatan yang dapat mempengaruhi kontraksi otot polos usus. Gerakan peristaltik merupakan suatau aktivitas otot polos usus yang terkoordinasi dengan baik, dipengaruhi oleh berbagai faktor seperti keadaan otot polos usus, hormon-hormon intestinal, sistem saraf simpatik dan parasimpatik, keseimbagan elektrolit dan sebagainya. Ileus paralitik hampir selalau dijumpai pada pasien pasca operasi abdomen. Keadaan ini biasanya hanya berlangsung 24-72 jam. Beratnya ileus parlitik pasca operasi bergantung pada lamanya operasi, seringnya manipulasi usus dan lamanya usus berkontak dengan udara luar. Pencemaran peritoneum oleh asam lambung, isi kolon, enzim pankreas, darah dan urin akan menimbulkan paralisis usus. Kelainan retoperitneal seperti hematomaretroperitoneal, terlebih lagi bila disertai fraktur vertebra sering menimbulkan ileus paralitk yang berat. Demikian pula kelainan pada rongga dada sepert empiema dan infark miocard dapat disertai paralisis usus. Gangguan elektrolit terutama hipokalemia merupakan penyebab yang cukup sering. Etiologi Ileus Paralitik 1. Neurogenik. Pasca operasi, kerusakan5

medulla spinalis, keracunan timbale, kolik ureter, iritasi persarafan splanknikus, pankreatitis. 2. Metabolik. Gangguan keseimbangan elektrolit (terutama hipokalemia), uremia, komplikasi DM, penyakit sistemik seperti SLE, sklerosis multiple. 3. Obat-obatan. Narkotik, antikolinergik, katekolamin, fenotiasin, antihistamin. 4. Infeksi. Pneumonia, empiema, urosepsis, peritonitis, infeksi sistemik lainnya 5. Iskemia usus Gejala yang muncul dapat berupa gangguan pada siklus buang air besar, perut kembung (distensi), muntah, badan meriang (panas). Hasil pemeriksaan fisik pada pasien ileus paralitik: distensi abdomen, meteoristik, bising usus menurun atau bahkan menghilang, keadaan umum sakit bisa ringan atau bahkan berat. Pada pemeriksaan colok dubur didapatkan rektum tidak kolaps dan tidak didapatkan kontraksi dari usus. Pada pemeriksaan foto abdomen tampak gambaran herring bone atau gambaran tulang ikan. Penatalaksanaan secara non medis adalah KIE (Komunikasi, Informasi dan Edukasi) tentang penyakit ini, tirah baring, puasa, pasien mendapat nutrisi parenteral sampai BU (+)/ Flatus (+), pasang NGT / Naso Gastric tube (selang lambung), dan kateterisasi urin. Kesimpulan Ileus adalah gangguan pasase isi usus yang merupakan tanda adanya obstruksi usus akut yang segera memerlukan pertolongan dokter. Ileus obstruktif adalah kerusakan atau hilangnya pasase isi usus yang disebabkan oleh sumbatan mekanik. Ileus paralitik adalah hilangnya peristaltik usus sementara. Keduanya berbeda dalam hal gejala terutama nyeri perut yang ditimbulkan, pemeriksaan abdomen khususnya kelainan peristaltik usus, pemeriksaan rectal toucher, dan pemeriksaan radiologi x-ray abdomen. Perbedaan ini dapat mempermudah untuk menegakkan diagnosis jenis ileus sehingga dapat diberikan terapi yang tepat. Referensi 1. Ghazali, R. 2007. Radiologi Diagnostik. Yogyakarta : Pustaka Cendikia Press. 2. Heller, J. 2008. Medical Encyclopedia: Small Bowel Resection-series: Normal Anatomy. National Library of Medicine. 3. Levine, B.A., and Aust, J.B. Kelainan Bedah Usus Halus. Dalam Buku Ajar Bedah Sabistons essentials surgery. Editor: Sabiston, D.C. Alih bahasa: Andrianto, P., dan I.S., Timan. Editor bahasa: Oswari, J. Jakarta: EGC, 1992. 4. Mukherjee, S. 2008. eMedicine: Ileus. The Medscape Journal. 5. Price, S.A. Patofisiologi: Konsep klinis proses-proses penyakit. Editor: Price, S.A., McCarty, L., Wilson. Editor terjemahan: Wijaya, Caroline. Jakarta: EGC, 1994. Penulis Hanifah Tri Utami, Bagian Ilmu Penyakit Bedah, RS

Temanggung, Jawa Tengah 2012.

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Sekitar separuh empedu dikeluarkan diantara jam-jam makan dan dialirkan melalui duktus sistikus ke dalam kandung empedu. Sisanya langsung mengalir ke dalam saluran empedu utama, menuju ke usus halus. Jika kita makan, kandung empedu akan berkontraksi dan mengosongkan empedu ke dalam usus untuk membantu pencernaan lemak dan vitaminvitamin tertentu. Empedu terdiri dari: - garam-garam empedu - elektrolit - pigmen empedu (misalnya bilirubin) - kolesterol - lemak. Fungsi empedu adalah untuk membuang limbah tubuh tertentu (terutama pigmen hasil pemecahan sel darah merah dan kelebihan kolesterol) serta membantu pencernaan dan penyerapan lemak. Garam empedu menyebabkan meningkatnya kelarutan kolesterol, lemak dan vitamin yang larut dalam lemak, sehingga membantu penyerapannya dari usus. Hemoglobin yang berasal dari penghancuran sel darah merah dirubah menjadi bilirubin (pigmen utama dalam empedu) dan dibuang ke dalam empedu. Berbagai protein yang memegang peranan penting dalam fungsi empedu juga disekresi dalam empedu