ADVISER : DR. SJAIFUL BACHRI, SP.B. DR. JOHAN L, SP.B

WRITER : NOK RACHMATIAH (406102017)

REFERAT PRESENTATION OF

ACUTE ABDOMEN

ACUTE ABDOMEN

Definition : A pathophysiologic process that has a

sudden onset and may require surgical intervention

A condition that requires immediate decision 1. Does this patient need surgery? 2. if necessary when the operation should

be done ? 3. Is it emergent, urgent, or can wait?

DEFINITION

Signs and symptoms of intra-abdominal disease usually best treated by surgery

A clinical situation due to intra-abdominal emergencies, suddenly onset, with pain as chief complaints

WHY DOES ACUTE ABDOMEN IS SPECIAL ?

Patient with acute abdominal pain : Suddenly onset Unknown causes Requires immediate diagnose and

treatment

Prevention 0f mortality or high

morbidity

One of the most common causes for hospitalization

Require immediate decision in diagnosis and treatment

Needs highly attention from the doctor.

May or may not require immediate operation

WHY NEEDS IMMEDIATELY TREATMENT ?

Every minute is precious, the late of

therapy ® highly risk

Every hour is precious, the late of therapy

® increasing the morbidity and mortality.

The late more than 12 hour ® increasing

the morbidity and mortality.

THE DEFINE OF ABDOMEN BASED ON REGION AND QUADRANT

DEFINITION OF PAIN

It is unpleasant sensation of varying intensity.

Stimulant of pain : 1. Mechanical trauma to the tissue.2. Excess heat or cold 3. Chemical damage4. Radiation damage 5. Inadequate blood flow

SOURCE OF ABDOMINAL PAIN

Abdominal 1. Abdominal wall 2. Intra peritoneal

organ 3. Retro peritoneal

organ 4. Pelvic organ

Extra abdominal 1. Intra thoracic organ 2. Systemic factor

THE TYPES OF ABDOMINAL PAIN

Visceral pain : is primitive and related to embryologic development.

Receptor : visceral peritoneum Stimulus : patient experienced pain by

traction, distention, and spasm. Mediation : autonomic nervous system Specificity : vague, poorly described,

and associated with nausea, vomiting

Localization : is poor and the patient placing the entire hand over the involved region.

Somatic pain : is entirely different from visceral pain

Receptor : pain stimuli start in the parietal peritoneum which is innervated by peripheral nerves

Stimulus : patient experienced pain by touch, pressure, heat, inflammation.

Mediation : central nervous system Specificity : precisely described as

sharp, knifelike, cutting

Localization : the pain is localized with great accuracy by the patient, who can often point the site with one finger.

THE LOCATION OF ABDOMINAL PAIN

Visceral pain : based on embryologic development Embryologic development

Location Organ

Fore gut Around epigastrium • Stomach • Duodenum• Hepatobilier system •Pancreas

Mid gut Around umbilicus • Small intestine • Colon until the middle of transversum colon

Hind gut Around lower abdominal

• From the middle of transversum colon until sigmoid colon.• Bladder

T6-T9

T6-T9

T8-T12

T8

T10

L2

S4

Somatic pain : more in line with anatomic location Location of pain Organ

Right upper abdomen

Gall bladder, liver, duodenum, pancreas, colon, lung, heart

Epigastrium Stomach, pancreas, duodenum, lung, colon

Left upper abdomen

Spleen, colon, kidney, pancreas, lung

Right lower abdomen

Appendix, adnexa, caecum, ileum, ureter,

Left lower abdomen

Colon, adnexa, ureter.

Suprapubik Bladder, uterus, small intestine

Periumbilical Small intestine

Back / hips Pancreas, aorta, kidney

Shoulder Diaphragm

MODE OF ONSET

Sudden onset :

The patient can describe exactly when the pain started

MODE OF ONSET

Gradual onset :

The patient usually responds vaguely to question about time of onset

REFERRED PAIN

Pain felt in an area of body distant from site of pathology

The more severe the pain the more likely it is to be referred

Due to existence of a shared central neural pathways for afferent nerves

Characteristic quality of many abdominal processes

THE ORIGINS OF REFERRED PAIN

Right shoulder : R. diaphragm Liver Gall bladder Pneumoperitoneum Left shoulder : L. diaphragm Spleen Pancreas Stomach

Back : Aorta Pancreas Duodenum Right scapula : Gall bladder Hepatobillier Left scapula : Spleen Tail of pancreas

THE ORIGIN OF REFERRED PAIN

Groin / genitalia Kidney Uterus Aorta Illiac vessels

THE VARIETY OF COLICKY PAIN

ANAMNESIS

60 – 80 % the accuracy of diagnosis obtained from good and thorough anamnesis

Physical examination : strengthen the

accuracy of diagnosis

10 – 15 % the accuracy of diagnosis

obtained from laboratory and imaging

examination.

SEVEN GOLDEN QUESTION OF ACUTE ABDOMEN

Onset of pain Location of pain Character of pain The pain spreading or referred pain Source of relief Source of aggravation Sign and symptom of gastrointestinal or

systemic that accompany abdominal pain such as : nausea, anorexia, vomiting, fever, etc.

PHYSICAL EXAM FOR ABDOMINAL PAIN PRESENTATION

General appearance : Mild, moderate, severe illness Mobile versus still Obvious pain or discomfort Skin color (pail, jaundice, anemia), and

awareness (conscious, decreased) Vital sign :Blood pressure, respiration rate, pulse,

and temperature

Inspection : Abdominal distention, bruises, scars, visible

peristalsis Auscultation : Normal bowel sound Increasing or decreasing bowel sound The absent of bowel sound Palpation : Often the most helpful part of exam Tenderness and pain Start away from painful area first Guarding, rebound, masses

Sign : Rovsing’s sign Obturator sign Psoas sign

Rectal examination

SUPPORTING EXAMINATION

Laboratory testing Base line testing Selective testing Pregnancy test in women of child bearing ageRadiology Plain or contrast film USG Laparoscopy CT-scan /MRI

Three position plain film 1. upright chest2. upright abdomen 3. flat abdomen

COMMON DIAGNOSES BY QUADRANT

ACUTE APPENDICITIS

Appendicitis is most common cause of acute surgical abdomen

Chief complain : abdominal pain at right lower quadrant

Which started from the stomach or around umbilicus right lower abdomen

Tenderness (+) at Mc Burney point Rovsing Sign & Blumberg Sign LeukositosisDifferential diagnose ectopic pregnancy rupture

pregnancy test (+)

Acute appendicitis

Perforated

Intraperitoneal puss

Peritonitis guarding muscle Peristaltic ⇩

Indication for operating management

HERNIA

Cases of acute abdomen : Hernia Incaserata Hernia Strangulate

H. Incaserata : Phinced intestine non reducible The passage of intestine disorder (nausea + vomiting, ≠

defecated, bowel sound ⇈)

H. Strangulate H.Incarserata symptoms + vascular disorder Necrotic intestine painfully ischemic pain

ILEUS OBSTRUCTION

Main symptom :

1. Crampy pain

2. Obstipation

3. Distention4. Vomiting

PERITONITIS Intra abdominal inflammation The patient feels continues pain Limited movement Examination may demonstrate with

guarding, tenderness The pain localized over in one quadrant

organ (local peritonitis ) The pain localized at all abdominal

quadrant (diffuse peritonitis ). leucocytosis

THE GRADE OF PERITONEUM IRRITATION

By abnormal fluid at intra peritoneum (lowenfels, 1975)

bloo

d

Urin

e

Bile

Pus

Panc

reas

flui

d

Insid

e of

inte

stin

e

Stom

ach

fluid

Mild irritation severe