Massa Ileocaecal Dengan Koagulopati Praoperatif: Laporan Kasus Ileocecal Mass With Preoperative Coagulopathy: A Case Report

Muhammad Kharis Mahdaviqia; Giri Yurista; Peter Ian Limas

doi:10.31004/koloni.v5i3.1245

Authors

Muhammad Kharis Mahdaviqia Universitas Tarumanagara
Giri Yurista Universitas Tarumanagara
Peter Ian Limas Universitas Tarumanagara

DOI:

https://doi.org/10.31004/koloni.v5i3.1245

Keywords:

apendisitis, ileocaecal, INR, koagulopati, laporan kasus

Abstract

Massa ileocaecal merupakan temuan klinis yang menantang karena keluhannya dapat menyerupai apendisitis komplikata, tuberkulosis intestinal, penyakit Crohn, maupun neoplasma kolon kanan. Laporan kasus ini bertujuan menggambarkan evaluasi klinis, alasan diagnosis awal apendisitis, temuan radiologi, koagulopati praoperatif dengan peningkatan INR, riwayat obat, dan rencana tata laksana. Artikel disusun sebagai laporan kasus deskriptif berdasarkan rekam medis pasien perempuan berusia 50 tahun yang dirawat pada Februari 2025. Pasien mengalami rasa tidak nyaman perut sejak beberapa bulan dan memberat menjadi nyeri kuadran kanan bawah, konstipasi, mual muntah, lemas, serta keringat dingin. Diagnosis awal mengarah ke apendisitis komplikata karena dominasi nyeri kanan bawah, leukositosis, keluhan gastrointestinal akut, serta temuan USG lesi hipoekoik regio kanan bawah. MSCT abdomen kontras kemudian menunjukkan penebalan sirkumferensial asimetris pada ileum terminal dan caecum, penyempitan lumen, fat stranding, enhancement, dan massa sekitar 4,9 x 6,7 x 8,1 cm tanpa ascites atau nodul hepar-lien. Laboratorium menunjukkan APTT 112 detik, PT 50,6 detik, dan INR 4,21 yang membaik menjadi INR 0,93 setelah optimasi, termasuk vitamin K. Riwayat obat sebelum rawat inap tidak terdokumentasi lengkap; selama perawatan pasien mendapat terapi suportif, antiemetik, gastroprotektor, antibiotik, koreksi elektrolit, dan optimasi medik. Peningkatan INR dapat disebabkan defisiensi vitamin K, gangguan fungsi hati, obat antikoagulan, antibiotik, atau koagulopati konsumtif, serta dapat meningkatkan risiko perdarahan dan menunda operasi. Kasus ini menegaskan perlunya integrasi anamnesis, rekonsiliasi obat, laboratorium, radiologi, dan histopatologi sebelum diagnosis definitif.

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