04/11/23

Acute AbdomenAcute Abdomen

Nurhayat Usman, dr Sp.B-KBD

Acute Abdomen (acute abdominal pain) “Condition which requires immediate treatment” (FD

Moore, 1977): Surgery? When to perform?

(Buku Ajar Ilmu Bedah, 1997): “Clinical condition which arises from acute critical condition in the abdominal cavity, and usually manifests as pain.

Acute abdominal pain: Chief complaint: acute pain (Nyhus, Vitello, Condon, 1995)

Why is it important ? Patient with acute abdomen:

Sudden onset Unknown etiology (not clear) Need immediate diagnosis & treatment

Prevent morbidity & mortality

Morbidity & Mortality

Obstruction Fluid imbalance

Perforated viscus Peritonitis

Infection Sepsis Shock

Bleeding Hypovolemic Shock

Ischaemia Perforation Peritonitis

Acute abdominal pain

Most can be diagnosed clinically

Require accurate and focused history taking

Need meticulous & rationale physical examination

Appropriate special investigations

TheDiagnosticProcess

HISTORY

Patient perception of symptoms

Patient description of symptoms

Physician perception

Physician interpretation of symptoms

LABORATORY SYNTHESIS PHYSICALFINDINGS RECORDING EXAM

DECISION

History Taking 60 - 80% of accurate diagnosis arises from good &

meticulous history taking

Physical diagnosis confirms accurate diagnosis

10 - 15% of accurate diagnosis arise from laboratory & radiological examinations

History Taking

May confirm : Suspected diagnosis Possible etiology Disease stages/ complications Differential diagnosis

History Taking

Introduction

• Greet the patient, and develop a warm and helpful environment

• Introduce yourself to the patient

Patient Identity

Ask the patient politely concerning his/her : name age

Record the gender : Male Female

Ask the marital status of the patient (especially for female)

Acute abdominal pain in specific groups In children

Acute appendicitis

In the elderly Perforated tumors Bowel obstruction due to tumors

During pregnancy Complicated Ectopic pregnancy

Chief complaint: Ask the patient regarding why the patient comes to you.

PAINPAIN Site at present

Onset

Radiation

Type

Aggravating /relieving factors

Severity

Duration

Site at onset

Progression

Site of pain

Upper abdominal pain Peptic or gastric ulcer Acute Cholecystitis, Acute Cholangitis Pancreatitis Early Appendicitis Hepatitis or liver abscess Extra abdominal:

Inferior Pleuritis, lobar pneumonia, pneumothorax Pericarditis, Myocardial infarction, angina

Pyelonephritis, renal colic

Central abdominal pain Early appendicitis Bowel obstruction, strangulated Pancreatitis Gastroenteritis Mesenterial Emboli /Thrombosis Dissecting aortic aneurism Mesenteric adenitis Early sigmoid diverticulitis

Lower abdominal pain Colonic Gangrene/Obstruction Appendicitis Mesenteric adenitis Diverticulitis Ruptured tubo-ovarial abscess Tuboovarial Torsion Ectopic gestation

Onset of pain

Sudden onset

Onset of pain

Gradual pain

Visceral pain &Parietal pain

Type of pain

Type and severity of pain

A. Toothache C. Colicky pain of inflammed hollow organs

A

C

Type and severity of pain

Intermittent colicky pain of obstructed hollow organ at early stage.

Type and severity of pain

Progressive & Continous colicky pain due to strangulated bowel obstruction (ischemic stage)

Other related symptoms:Ask the patient concerning related/concomitant symptoms of

Gastro-intestinal function: Nausea Vomiting Loss of appetite Faintness Previous indigestion (habitual)

Other related symptoms:

Jaundice Bowel habit:

Constipation? Diarrhoea? Colour of the stool? Presence or absence of blood and mucus

(slime)

Other related symptoms:

Urinary function: Micturition: amount of urine, lower abdominal

discomfort, colour of urine

Gynaecological function ( female) Menstrual function Delayed or miss period Abnormal bleeding or discharge (colour, quantity)

Previous history

Similar pain Abdominal surgery Major illness: incl. fever, abdominal

injury. Drugs Allergies

PHYSICAL EXAMINATION Preparation

Check all the equipment required and have a good light:

Examination couchStethoscopeExplain the procedure and its goals to the

patient.Wash your hands with antiseptic soap.Dry and warm your hands with tissues.

Implementation: A General Examination

General appearance : Consciousness Mood : Distressed? Anxious? Immobile Move cautiously Colour : Pallor? Flushing? Jaundice? Cyanosis?

Implementation: Examine the vital signs:

Temperature Pulse rate Blood Pressure Respiratory rate

Implementation:

Perform other systems examination, including cardio-pulmonary system.

Ask the patient politely to expose his/her abdomen.

Abdominal Examination: Inspection

Inspect the movement:Respiratory movementVisible bowel peristaltics

Is there any scars on the skin of the abdomen?

Is there any abdominal distention?Flatus ? , Fluid ? , Fetus?

Abdominal Examination: Inspection

Is there any rashes and discolouration? Cullen’s sign Gray Turner’s sign Ecchymosis of the abdominal wall

Is there any masses: Tumors? Hernial sites? Masses with pulsation?

Cullen Sign Gray-Turner Sign

Abdominal Examination: Palpation

Ask the patient to locate the site of maximum pain with the tip of a finger.

Using the palmar surface of your fingers, gently palpate the abdomen, starting from a site farthest from the area of maximum pain, move gradually towards it.

While palpating, look to the face expression of the patient, and look for any signs of :

Tenderness Rebound tenderness Muscle guarding Rigidity Murphy’s sign

While palpating, look to the face expression of the patient, and look for any signs of :

Swelling or masses Rovsing’s sign Expansile pulsation Hernial orifices Scrotum in male

Expansile pulsation

Specific signs

Rovsing’s sign Obturator sign Psoas sign

Abdominal Examination : Percussion

Place the palmar aspect of your left hand on the abdomen, and gently percus its dorsal aspect with the tip of the middle finger of the right hand, moving all around the abdominal region: Is it tymphanitic ? Is it dull ? Is there any shifting dullness? Site of liver dullness ? and is it disappeared ?

Auscultation Using stethoscope, and place it gently on the

abdomen, listen to the bowel sounds and bruit at least for one minute: Absent ? High pitched and hyperactive ? Metallic sound ? Vascular bruit ?

Digital Rectal Examination

Put on surgical hand gloves and ask the patient to expose his/her buttock and anus, and place the patient in lithotomy position.Apply lubricating jelly on to the right index finger.

Digital Rectal Examination Gently insert your right index finger into the anus, move toward

the anal canal slowly, and evaluate the followings: Anal margin: piles? Mucosal surface of the anal canal and the ampulla

(collaps?) Sites of any pain elicited Masses or swelling: consistency, location, surface, fixity to

the surroundings. Bowel contents: consistency of faeces? Mucus? Blood?

Perform bimanual palpation in female patient to examine the uterus, pelvic cavity and adnexa.

Write up Write up all significant findings in the medical

record. Conclude your diagnosis and differential diagnosis, and order any necessary special investigations

Extraperitonealcauses of acute abdomen Cardiothorax Urology Vascular E.t.c

Acute peritonitis

Patology

Degree of peritoneal irritation

(Lowenfels, 1975)bl

ood

Urin

e

bile

pus

Panc

reat

ic ju

ice

Bowe

l bon

tent

Gas

tric

juice

Mild Severe

Signs of Intrabdominal Sepsis

Fever, nausea, vomiting, tachicardia, tachipneu Abdominal pain Peritoneal signs Signs of dehydration Leucositosis Shock, Multiple organ failure

Tips > 6 hours: surgically related diseases !!!

Limited movement: peritonitis / ischaemia

Persistent pain on morphine : ischaemia

Sense of Crisis

Repeated exams : Very important

Perforated duodenal ulcer

Perforasi Ulkus VentrikuliPerforasi Ulkus Ventrikuli

GI bleeding

Pancreatitis

Acute appendicitis

Intusucseption

Sigmoid volvulus

Mesenteric thrombosis

Iskemi Usus, Thrombosis MesenterialIskemi Usus, Thrombosis Mesenterial

Mechanical Intestinal Obstruction

Obstetrics & gynecological causes

Obstetrics Ectopic gestation Abdominal pregnancy Rupture of the uterus Mola Destruen

gynecology Ruptured ovarial cyst Ovarial Torsion, Myoma Ruptured abscess Perforated Uterus

Ruptured

organ

Content

PusMaterials :• sebum• meconeum

Blood

Acute

abdomen

torsion

Strangulation

distentionischaemia

Abdominal pain inObgyn

A Good Diagnosticianis not Born, but is Developed