CASE PERSONAL  

I. IDENTITY OF PATIENTName : An.AAge : 9 yearsSex : MaleReligion : IslamJob : StudentAddress : Pegagan lor, Kapetakan-Cirebon

II. ANAMNESIS (AUTOANAMNESIS AND ALLOANAMNESIS)

The main complaint: stomach pains

Additional complaint: nausea, vomiting, diarrhea,

History of present illness:A 9-year-olds came to the hospital emergency room on Monday Arjawinangun date 07/02/2012, the patient complained of abdominal pain since the day of Friday afternoon 29/6/201, stomach feels bloated suddenly after coming home from school, and urine of patients admitted from the day the amount of diarrhea Friday morning until Sunday morning.Patients do not eat spicy food before and did not snack at random.In addition, patients also experienced a high fever since Thursday morning, patients were nausea and vomiting when eating and drinking.The patient vomited in a day more than 5 x and vomit green to victimization.Before entering the hospital, the patient can not flatus since Saturday 06/30/2012.The patient had never previously treated. Defecate smoothly currently still a little liquid, waste water small current.

 Past Medical History:

-           Paien never experienced pain like it is today-           The patient had no history of previous trauma-           The patient had no history of previous illness magh-           Patients had no previous history of urinary stones-           Patients no history of previous oprasi-           Patients also do not have a previous hernia riwat 

Family History of Disease:-           There was no family history of disease

III. PHYSICAL EXAMINATION 

Status GeneralisGeneral condition : Look sick is moderateConsiousness : Compost mentisVital signs : Blood Pressure : 90/60 mmHg

                            Pulse rate : 96 x / minute                             Respiration rate : 26 x / minute                            Temperature : 36.8 º C

Head : Normocephal.Eyes : - Conjunctiva anemis : (- / -)

- Sclera jaundice : (- / -)- Light reflex director : (+ / +)

Neck : palpable enlargement of lymph nodules (-), palpable enlargement of the thyroid (-)

ThoraxCast : Inspection : ictus Cordis (-)

                          Palpation : Cordis palpable ictusPercution : limits in normalAuskultation : Heart sound I-II, Additional heart sound (-)

Pulmo : Inspection : movement of right and left hemithorax are symmetrical at static and dynamic state

Palpation : vocal and tactile fremitus right and left hemithorax are symmetric

                            Percution : resonant at whole hemithorax, word of CVA pain (-)                            Auskultation : vesicular + / + N, crackles - / -, wheezing - / -     

Abdomen : Inspection : flat, cicatrix (-), hiperemis (-)Palpation : tender (+) in all quadrants, defans muscular (+)

                            Percussion : hypertymphany at other regions of the abdomen

                            Auscultation : bowel sound (-), tenderness (+) in all quadrants

Extremities : Upper : Jaundice - / -, Edema - / -, Cyanosis - / - Below : Jaundice - / -, Edema - / -, Cyanosis - / -

                       IV. EXAMINATION SUPPORT 

Blood Laboratory:- WBC: 19.0 X 10 ³ UL

- GRA: 17.1 X 10 ³ UL- GRA%: 89.9%- LYM%: 392 000%

Imaging examination:Plain photo abdomen:- Normal Preperitoneal- Psoas normal linea- Contours of both kidneys is not clear- Excessive air seemed to fill small caliber bowell boweldengan further enlarged and

thickened wall of the air seemed to fill at least part of the more distal- Appear multiple fluid level in the water and LLD ereck photo- No visible free water on the second image on the photo subdiafragma erect and LLD

ImpressioObstructive - ileus where the high- There does not appear peritonitis or pneumoperitonium

 VI . DIFFERENTIAL DIAGNOSIS

-                  Cleaner layout obstructive ileus-                  Acute appendicitis-                  Hernia incarcerate-                  Gastroenteritis-                  Acute cholecystitis-                  Acute Cystitis

VII. WORKING DIAGNOSIS-                  Cleaner layout obstructive ileus

 VIII.  MANAGEMENT

       Medical:IVFD RL 20 GTTLapixim 2x1 Antrain 2x12x1 amp IV ketorolac2x1 amp IV ranitidineCebaktam 2x 1

Operative:Laparotomy

 IX.     Prognosis

- Quo ad Vitam: ad dubia bonam- Quo functionam ad: ad dubia night

                   

 CHAPTER I  

Acute abdomen is a condition that occurs suddenly arise where the main symptoms are abdominal pain and can be life threatening and its reduction surgery is usually required.This incidence of acute abdomen is often found in medical environments.

General management of patients with acute abdominal pain do not be an easy matter because it is a challenge for a physician to diagnose the cause of acute abdomen.Decision for surgery should be enforced as any delays can cause complications that result m eningginya morbidity and mortality.

The accuracy of diagnosis and mitigation depends on the ability to determine a good analysis of the data anamnesis, physical examination and investigations are obtained. Thorough knowledge of anatomy and physiology of the abdomen and its contents play an important role in getting rid of the many possibilities that could be the cause of acute abdominal pain.

When the patient entered the severe abdominal pain, the doctor must have a mindset to make differential diagnosis. The importance of narrowing the differential diagnosis to be a top choice because of the need for making the determination of when a patient needs surgery.A major Cuan on the abdominal pain is very severe abdominal pain, which appears in a previously healthy patients and lasted at least for 24 hours and sometimes require surgery.   

CHAPTER II

REVIEW REFERENCES

 ACUTE ABDOMINAL 2.1.              Definitions

Acute abdomen are generally defined as intraabdominal processes that occur that cause great pain and arise suddenly, which can rapidly deteriorate and life-threatening and require surgery.

A situation that requires quick decisions or judgments for their management. The term acute abdominal pain show a state of sudden and severe abdominal lasting less than 24 hours. This is a situation that requires rapid and specific diagnosis. Its management usually require surgery.  2.2.              EtiologyCircumstances-circumstances that can cause acute abdomen can be divided into 6 major categories of:

1. Inflammatory Inflammatory category can be divided into two parts, namely bacterial and chemical. Common examples of bacterial such as acute appendicitis, diverticulitis, and some cases inflammtory Pelvic Disease.Examples of chemicals include perforation, peptic ulcer disease which causes stomach acid content of peritoneal reaction.

2. Mechanical Examples of such circumstances cause me kanik obstruction.C ontohnya inkarserata hernia, adhesions, intussusepsi, intestinal malrotation with volvulus, congenital atresia or stenosis of the intestine.Common causes of mechanical bowel obstruction is a Ca Colon.

3. Neoplasms4. Vascular

Vascular disorders that cause acute abdominal thrombosis or embolism example is A. mesenteric. When blood flow stops, tissue necrosis occur, with bowel gangrene that occurs in the intestine.

5. Congenital DefectsA congenital defect may involve surgery anytime soon since the time of birth (eg, duodenal atresia, omphalocele or hernia diaphragmatica) until many years later as in chronic intestinal malrotation.

6. Trauma Causes of traumatic acute abdomen varies from stab wounds and blunt abdominal gunshot wound to the circumstances leading to rupture of the spleen. History of trauma should be clear. 1

 

2.3.              DiagnosisPain, anorexia, nausea, vomiting and fever rupakan me a typical manifestation of

acute abdominal disorders.Vital signs on physical examination tenderness multitude

'defense musculair' and changes in intestinal peristalsis.However, the critical distinction between an acute abdomen and not the non-acute, but the abdominal surgery cramoplasty and abdomen.Identification of abdominal surgery depends upon the use of three basic diagnostic components: anamnesis, physical examination and ancillary tests.

 2.3.1. Anamnesis

Onset Since when is being felt? How long does the pain last?

Painful Does the pain occur suddenly or gradually?   Where is the initial location of pain, and where the current location of

pain? Does the pain change location? Whether the pain spreads to other locations? What kind of pain that is felt? What can reduce the pain? What worsens the pain?

Throw up When it starts throwing up? How the relationship between vomiting and pain? How often the patient vomiting?

▪        What is spit?

Past medical history

▪        Have experienced similar pain? 

Defecation Is there a change in bowel habit?

▪        When Chapter last & what kind?

History of Menstruation Other symptoms of

Appetite, swallowing disorders, weight loss, increased waist circumference, fever

Symptoms of Acute Abdomen

Painful

▪        Location of pain,▪        The onset and progression of pain,▪        This type of pain▪        Characteristics▪        That reduce and exacerbate

 

Location of pain: abdominal pain upper▪        Gastric or duodenal ulcer▪        Cholecystitis, cholangitis▪        Pancreatitis▪        Appendicitis (early)▪        Hepatitis or Liver Abscesses▪        Extra abdomen:

o         Pleurisy, Pneumonia lobaris inferior, Pneumothoraxo         Pericarditis, Myocardial infarction, anginao         Pyelonephritis, renal Colik

  

Abdominal pain was:

▪        Disturbances (early)▪        Small bowel obstruction or gangrene▪        Pancreatitis▪        Gastroenteritis▪        Mesenteric embolism / thrombosis▪        Aortic dissection        Adenitis mesenteric        Sigmoid diverticulitis (early)

Abdomen pain below:

▪        Colon obstruction or gangrene▪        Interference▪        Adenitis mesenterik▪        Diverticulitis▪        Pyosalphinx a ruptured abscess▪        Tortio tubo-ovarian▪        Ectopic Pregnancy

 The onset and progression of pain generalized extreme pain dangerous hollow organ perforation, ruptured aneurysm, ectopic pregnancy or an abscess.

▪        accompanied by systemic symptoms: tachycardia, sweating, tachypnea, and shock.

mild pain so severe that develops within 1-2 hours to:▪        Acute cholecystitis,▪        Acute pancreatitis,▪        Intestinal strangulation,▪        Mesenteric infarction,▪        Colik kidney or ureter,▪        Small bowel obstruction where the high

                  

      

 Pain is gradual:

▪        Acute appendicitis▪        Hernia inkarserata

▪        Pancreatitis▪        Small bowel obstruction where the low▪        Large bowel obstruction▪        Uncomplicated peptic ulcer,▪        Genitourinary system and gynecological disorders.

  

This type of painVisceral pain

visceral pain stimulation of the organ or structure in the abdominal cavity. Pull / stretch / contraction of excessive muscle pain ischemia Can not accurately indicate the location of pain

       Foregut: stomach, duodenum, hepatobilier system, pancreas pain in the pit of the stomach or epigastrium        Midgut: the small intestine and colon to the mid transverse Colon pain around the umbilicus.        Hindgut: the mid-transverse colon to the Colon Sigmoid Colon pain in lower abdomen

Somatic pain

Stimulation of the parts supplied by the peripheral nerve. Pain like being stabbed or slashed and patients can pinpoint its location with a finger.

Pain moved

Evolve according to the pathology. Pain in the beginning, its location can be different from the location of pain at the time of

patient treatment.

 Referred pain / referral

A segment of innervation serves> 1 area Pain in areas away from the location of organs that have stimulus

 Organ or structure Nerve Level

Innervation▪ The center of the diaphragm N. phrenic C 3-5▪ Edge of the diaphragm, stomach, Plexus seliakus Th 6-9

Pancreas, gallbladder, small intestine▪ Appendix, Colon proximal, pelvic organ Plexus mesenterikus 10-11 years▪ Distal colon, rectum, kidney, ureter, testis

N. caudal splanchnic Th 11 - L1

▪ Bladder, rektosigmoid Hypogastric plexus S2 - S4

Types of pain:Characteristics of painContinuous painstimulation of the parietal peritoneum perceived as constantly ongoing inflammatory reactions such as Colic Pain visceral pain due to spasm of the smooth muscle of hollow organs and organ barriers to the passage in TSBTrias colic: kumatan abdominal pain, nausea, vomiting, involuntary movement.

 

Circumstances which aggravate and mitigate the Comfortable position

lying motionless on the peritonitis walking with bent Appendicitis, patient is lying down with legs bent that stimulate inflammation M. psoas

(Appendicitis, Psoas Abscesses)

Pain that increases during breathing: pain Pleuritis, Peritonitis, peritoneal Abscesses, abdominal distension due to intestinal obstruction, cholecystitis Characteristics of vomiting

not accompanied by bile: Stenosis of the pylorus. repeatedly mingled with gall: beginning proximal small bowel obstruction.

the distal small bowel obstruction and bowel obstruction, vomiting that occurs preceded by prolonged nausea, vomiting eventually accompanied faeces.

The vomiting

very severe and persistent: strangulation of the small intestine or acute pancreatitis. occur at the peak of pain: renal colic or intestinal colic. In the acute vomiting usually occur after abdominal pain, while in gastroenteritis, vomiting, pain arising started.

 Constipation

large bowel obstruction can be bowel and flatulen at all, obstruction in the small intestine can not cause constipation.

 Diarrhea

Diarrhea accompanied by blood ulcerative colitis, Crohn's disease, basilar or amoeba dysentery.

CHAPTER abdominal pain accompanied with mucus and blood intussusepsi. Jaundice tract abnormalities in hepatobilier Hematokezia or hematemesis gastroduodenal lesions hematuria urethral colic, cystitis Pielitis dysuria, the presence of stones, acute hydronephrosis, pelvic Abscesses on urinary

vesicles, which irritate the appendix Abscesses right ureter. KET menstruation and Endometriosis. Leukorrhea PID and dysmenorrhea

 General observation

colicky pain lots of move parietal pain (appendicitis, peritonitis) silent

 

SYSTEMIC SYMPTOMSFeverAbdomen

Inspection

       abdominal distension.        distended abdomen with a scar adhesion op intestine.        peristalsis which appears in the abdominal wall bowel obstruction.

Auscultation

       accompanied by increased bowel sounds colic or intestinal obstruction in the early phase of pancreatitis pd.        decreased bowel sounds bowel obstruction or advanced stages of diffuse peritonitis.

Palpation        abdominal tenderness irritation / inflammation of the peritoneum below        off pain irritation / inflammation of the peritoneum        deffence muscular stimulation varies, the type of irritant

Laboratory

Low Hb hidden bleeding. leukocytosis infection. hypovolemic shock. examination of electrolytes, urea and creatinine Blood Gas Analysis hypotension, generalized peritonitis, pancreatitis, and sepsis to

anticipate the occurrence of acidosis Increased serum amylase pancreatitis hepatobilier abnormalities of liver function tests (serum bilirubin, alkaline

phosphatase, SGOT, SGPT, albumin and globulin)

 X-ray

air shadow in the abdominal cavity. free air under the diaphragm hollow organ perforation water fluid level intestinal obstruction Obliteration of the shadow M. psoas bleeding from the kidney injury, Pyomiositis

M.psoas, Abscesses M.psoas, or retroperitoneal Abscesses. Opaque shadow along the urinary tract canalikuli and urinary tract stones. Acute appendicitis: inflammation of the appendix Appendix vermikularis or that occur in

acute bacterial infections Appendix lumen obstruction was a factor precipitating factors Constipation increase pressure intracaecal functional blockage of the appendix and

the increasing growth of normal flora bacteria Colon Mild fever 37.5 -38.50 C, when the high temperature is likely that the perforation

occurred. Bloating in patients with perforation Protrusion on the lower right abdominal mass or Abscesses form peripendikuler tenderness and pain off at McBurney's point Rovsing sign (+)

Blumberg sign (+) Digital rectal To find the location of the appendix tested psoas and obturator test

 

Physical examination

Mild fever 37.5 -38.5 0 C, when the high temperature is likely that the perforation occurred.

Bloating in patients with perforation Protrusion on the lower right abdominal mass or Abscesses form peripendikuler tenderness and pain off at McBurney's point Rovsing sign (+) Blumberg sign (+) Digital rectal To find the location of the appendix tested psoas and obturator test number of leukocytes binding to help make a diagnosis Ultrasound can improve the accuracy of diagnosis

 Approximately 10% of patients with acute abdominal pain was very old and very young.P

Asien over age 65 have twice the incidence of surgical disease (30%) as a cause of pain in the abdomen compared to patients under the age of 65 years.In the adult age group, women more often suffer from abdominal pain than men, but men who display symptoms of disease incidence have surgery higher.Genitourinarius system common cause of abdominal pain in women. In order of presentation of the more rare, because genitourinarius common in women include pelvic inflammatory disease, urinary tract infections, dysmenorrhea, and the ectopic pregnancy.

The pain is clearly a major complaint in patients of acute abdomen, it is important to know the origin, location, propagation, and the nature of the pain. There are three types of onset of abdominal pain: ekplosif (suddenly), quickly and slowly.

Patients who were suddenly seized with agonizing pain explosive, eg hollow viscus rupture into the cavity free peritonealis or 'vascular accident' sustained.Derived from renal colic and biliary tract can be start suddenly, but rarely cause pain so severe, so that helpless patients.Patients with pain and a quick start quick bad mem akuta may suffer pancreatitis, trom bosis mesenterica or intestinal strangulation.Patients with pain may slowly begin to suffer inflammation of the peritoneum (peritonitis), as seen in appendicitis or diverticulitis.

Severity of pain is characterized as torture, severe, dull or like colic. Excruciating pain not respond to narcotics illustrates a vascular lesion such as an acute abdominal aneurysm ruptures minalis or bowel infarction.Small bowel infarction patients suffering from pain beyond typical physical description and the proportion of laboratories. Severe pain easily controlled by medication but is typical of peritonitis caused by a ruptured viscus or pankreatiti s akuta.Dull pain, equivocal difficult localized, describes a process of inflammation and is an early sign of appendicitis.Colicky pain and cramps marked as encouragement ('rush') describes gastroenteritis. Pain due to mechanical obstruction of the small intestine is also colic, but it has a rhythmic pattern with a pain-free intervals alternating with severe colic. Peristaltic encouragement could be heard during severe colicky peristaltic impulse that accompanies gastroenteritis was not necessary coordination with colicky pain.

Clinical picture is very important, related to the location of the distribution of pain in the affected organs.The place of abdominal pain reflects the type of nerve stimulation and embryology of the organ of origin. Perception of abdominal pain, visceral pain is the beginning and then become somatic.Peritoneum and abdominal viscera viscera are innervated by sensory nerves from T5 - L3. The flow of nerves leading to the viscera is very little the pain was so vague that it is difficult to determine the location of the pain.

The sensation of pain that is difficult to be localized in the abdomen is mediated through the autonomic nervous system associated with intra-abdominal viscera viscera is called pain. The cause of visceral pain is tension in the muscle fibers caused by a strain of the wall, muscle spasm or strain of the organ capsule. Strong peristaltic contractions occur to prevent obstruction. The pain associated with obstruction it feels great and cramping can occur but are intermittent, with the interval without pain called colic. Ischemic cause of muscle pain due to visceral gut peristalsis and loss of ability to be paused's tension.The cause of ischemic visceral pain most often occurs due to intestinal strangulation in a hernia or volvulus. A rare cause of acute mesenteric thrombosis ohnya cont.

Peritoneum parietale restricts abdominal diaphragm surfaces have sensory innervation of the somatic nervous dar T6-L1.When the parietal peritoneum e irritated, somatic pain arises.Somatic pain is localized and there is spasm in the muscles and are innervated from the original source of the pain. Examples of pain and muscle spasm in RLQ is usually associated with inflammation caused by appendicitis in the RLQ parietal peritoneum. Sign of abdominal pain in peptic ulcer perforation is comprehensive due to the diffusion of the acid in the peritoneal space causing severe irritation of the parietal peritoneum at all.

Referred pain is pain that occurs in other places of origin of the pain which are supplied from the same neural segment.Visceral pain is divided into three locations in the abdomen.Localization of the pain suggests organ affected. Epigastric pain associated with organ supplied by the T6-T8, stomach, duodenum, pancreas, liver and biliary tract and the parietal peritoneum is associated.Perimubilical pain associated with the innervation of the T9-T10 and including the small intestine, appendix, and the upper ureter.Hipogastric pain associated with the innervation of the T11-T12, Colon, bladder, lower ureters and the uterus.  Charts which supply the sensory innervation of visceral organs 6

Organ Neural pathways Sensory levelLiver, spleen, and the center of the diaphragm

N. phrenicus C3-C5

Peripheral diaphragm, stomach, pancreas, gall bladder and small intestine

Celiac plexus and N splanchnicus

T6 - T9

Appendix, colon, and organs in the pelvis

Mesenterica plexus and N. splanchnicus

T10 - T11

Sigmoideum colon, rectum, kidney, ureter and testicular

N. splanchnicus the lowest T11-L1

Bladder and rectosigmoid Plexus hipogastrika S2-S4 Pain 'flank' and the angle costrovertebralis pain associated with kidney or ureter stones or

with pyeloneph ritis.Kidney pain can also be accompanied by pain in the ipsilateral testis.

Diaphragm irritation can cause pain in the distribution of C4. So that the process of inflammation of the liver or spleen, or a collection of fluid per forata subdiaphragma ulcer can turn into shoulder pain. 

2.3.2.        Physical examinationWhen patients present with abdominal pain, then the proper and thorough history is an

important basis for diagnosis., But the decision on whether surgery or not, made on the basis of physical examination should be done carefully and systematically. \

6 Physical examination measures included:(1) inspection, (2) auscultation, (3) percussion(4) palpation, (S) examination of the rectum / genital  (6) examination of specific signs

  Inspection

-           The position of the patient.In the severe colic patient can not lie down quietly.Patients with peritonitis lying quietly with his knees bent even though there is great pain.-           Patients with facial expressions-           Frequency and respiratory movements-           Tensions m.rectus abdominis-           "Darmsteifung" (peristaltic movement seen in the abdomen)

AuscultationOn auscultation should be noted peristaltiknya sound. Peristalsis can be increased,

berkuran g or disappear altogether in the presence or suspected acute abdomen.Peristalsis is said to be lost if there is no sound after peritoneal we listened for a few-minutes. Did not mean there is no peristaltic paralytic ileus caused by diffuse peritoneal irritation.While hiperperistaltik usually found in three forms:a. The constant presence of borborygmi and hard enough, and can vary in intensity, but no particular pattern. Was found in acute gastroenteritis or intestinal disorders caused by the disruption of food. This peristaltic rhythm is not certain and the variations in intensity occur without changes in discomfort in the abdomen.b. Less common but much more important is the sound caused by rhythmic contractions of intestinum.It is found in the acute mechanical obstruction. In this situation, abdominal colic, silent between the two periods into which borborygmi sound then gradually increased in intensity: this borborygmi rises to the top of the loudest sound (crescendo), to then gradually disappeared until only a very weak sound.Patients aware of the incidence of seizures with pain that waxes and wanes along with the activity of Peris taltik.If someone has pern ah hear the rhythmic peristaltic crescendo on acute mechanical obstruction, he will not be able to either diagnose it.

c. Partiil a chronic obstruction in the lower small intestine and also in the healing phase of a diffuse peritonitis, high sound like the echo can be heard because of the periodic contractions: da ri intestine being stretched by the fluid in the cavity of the gut.Here there is no regular rhythm on peristaliknya. Can be with or without symptoms of abdominal cramps.A noise is heard in episgastrium be an important sign of chronic intestinal ischemia.Bruit (noise) on the left or right of the midline of the abdomen may indicate a blockage of the vasa da mean renal blood.The discovery of a noise is very important in assessments of abdominal pain pence vague and repetitive.

Percussion Percussion is done subtly useful for determining the area of pain. This also often reveal the presence of the unexpected overcast condition that is with the pain; this indicates the existence of an unknown mass shifts intestinum. Any sign of shifting dullness (deaf switch) can be a feature of the regulation intra-abdominal anger after a trauma to the abdomen.It should be carefully investigated the extent of the liver and vesica urinary deaf.

Palpation First of all, the patient asked to cough. If there is an acute inflammation of the

peritoneum, the cough is usually going to cause pain great is limited to areas of inflammation.Examination of the ca ra cause pain with cough is very useful; patient in asking for shows with her fingertips right place where pain arises earlier.In this way a place can be localized inflammation without holding previous palpation. So the examiner can avoid so as not to touch this area to other parts of the abdominal examination were done.The discovery of a spasm, and distinguish between intentional kejan g (by her own) with spontaneous seizures.It should be noted that not hurt. First of all examiners must be in good hands warm. Musculus rectus abdominis second seizure may be palpable in this way. A place that feels pain with cough were examined after the examination was finished we all do.

I check my abdominal spasm.Entire sections of the left hand, placed on the abdomen in the quadrants of the most distant from the pain and tenderness: this should be done as gently as possible in a long time to ensure that patients not really in pain.To Then the patient was told to breathe in, while the fingers of his left examiner musculus rectus abdominis intersect with, pressed gently with the examiner's right hand.At the time when there expirasi voluntary spasm of the musculus rectus will always be felt under his hand: is the involuntary spasm or spasm which really will not be palpable. Muscle will be felt stiff, dense, tense as a building board. No need here push hands too deep in the abdomen so that the stiffness is palpable, and the examiner should not cause pain.

 

Abdominal palpation the wrong way.Large stiffness in both musculus rectus showed a diffuse peritoneal irritation.Whereas

segmental spasm in a m. Rectus (spasmus limited to one quadrant) found in the early peritonitis.But because there is no room to spread rnembatasi peritoneal fluid to one side of the abdomen, then the stiffness along which extensive in one of the musculus rectus paralysis flass id musculus rectus entirely on the other can not occur as a result of peritonitis or peritoneal irritation.Extensive unilateral rigidity (extensively) origin of the re reflex.It is sometimes found in the acute renal pain but its mechanism is poorly understood.

Palpation of the two recti muscles simultaneously useful in assessing the breadth and nature of abdominal tension.

Determination of the pain hit. Appropriate area with tenderness in the abdomen, can be determined with certainty by palpation a smooth way with a finger.Acute appendicitis or acute cho lecystitis normally demarcated on the organ that unless there was te complications of diffuse peritonitis.This examination can only be done right with careful and gentle palpation with one finger.Do not check the entire surface with our hands: for in this way we can not determine the extent and precise localization. Examination with light percussion of the abdomen can be done to determine the localization of tenderness.

Determination of the pain hit. Appropriate area with tenderness in the abdomen, can be determined with certainty by palpation a smooth way with a finger

 Abdominal palpation should be followed by examination in the alley ping, and the lower

angle costovertebralis cavum thoracis.Use was the only one finger to check these areas carefully.Strong palpation with one finger on the bottom spatium intercostale will sometimes cause pain that is sometimes easy to be confused with abnormalities in the diaphragm. On examination pain in the costovertebral region, the examiner uses one finger touched tuk un Columna vertebral area between the twelfth and the costa.The pain in this area ren pathognomonis to the inflammatory process, whereas a sense of tenderness over the lateral in-costa costa or on the edge of the waist may be a sign of a variety of circumstances.

In examining the angle tenderness on the finger probe costovertebralis appropriately be placed in the 12th costa and vertebral muscles. 

The discovery of a mass. Examiner has determined where ri nye press earlier without causing pain to the sufferer.Also been determined is the spasm of the muscles of the abdominal wall and how wide. After this try to do more in the abdominal palpation. If there is stiffness of the muscles of the abdominal wall, palpation will not be able to do. But although there is no stiffness we still difficult to palpate the tools or mass in the abdomen when there is pain in patients. However, with a very gentle palpation without hurting the patient so that the resulting stiffness is deliberate, an experienced clinician can find explicitly the limits of such tender mass vesica strained fellea appendicitis or an abscess.

We need to invent a palpation the acute abdomen for a second time been giving morphine or in the operating room after dinarkose.If you always abide by this rule the masses that had been known to often be overlooked. Also, this method allows the assessment of a much more te pat on the properties of known mass.

Pulsus fingered.The nature and frequency of the pulse is a sign of the pen ting of the severity of acute abdominal disease.Pulsus a slow, regular full and would not rule out the possibility of a severe peritoneal infection, but showed that patients responded well. His pulse was elevated medium, fast, irregular, were the characteristics of progressive abdominal in ile.This is one sign that had worried about, although minimal abdominal findings.Pulsus very fast and usually there is little information on peritonitis.

After the abdominal examination is done, the inguinofemoral and externa genitalia organs to be carefully examined, so do not ignore the incarcerata hernia strangulation.

During this inspection should also feel the femoral artery, because the absence or not symmetrical pulsation of this artery (right and left), in circumstances where there is severe abdominal pain can be one sign of abdominal aortic aneurysm dissectans.Pelvic examination and rectum 9.1

This was done pa ling end, but should never be forgotten.Abnormalities in the Douglas cavity more easily we are touched with lithotomi position than the lateral position. Palpas i on the rectum and Douglas cavity we should do it systematically; in this way the exact location of pain can be determined and this can be a meaningful description of the diagnosis.Also prostate and seminal vesicul a note because of inflammation in these tools to mpunyai symptoms such as acute abdomen.In women, uterine artery pulsation can be found growing which is a sign of pregnancy or crepitus in the broad ligament that occurs in gas bacillus cellulitis after a septic abortion.Correct diagnosis and sometimes salvation of souls sometimes people can depend on things such details.Examination of the pelvis and rectum that is repeated once more after the narcotics are held, if there is reason to show pelvic lesions.

 Examination - Special examination 6.9

a.Painful cough.b.Rebound tenderness (tenderness off). The pain caused by strong pressure on the abdomen at a distance from the infla masi we suspect, then we release the pressure suddenly.Tat when the abdominal wall back to its original position, the pain occurs in pressure and tem pat inflamasinya own place.Freelance tenderness in disclose to the other side, which is the side of the lesion, is a useful ancillary evidence that there is a limited acute peritoneal irritation in the area of pain.With the same meaningless pain and cough were more reliable because it is tender out there, although there is no pain cough.Out that there is tenderness everywhere showed diffuse irritation of peri toneal.No need to do checks on peritonitis in Fusa clear, because this action would aggravate the pain of the patient.In cases of doubt, especially sufferers of thick fat with muscle and a thick omentum, "rebound phenomen" very valuable to determine the extent of inflammatory processes.c. Iliopsoas test.Patients are asked memfleksikan articulatio coxae against the prisoners that we provide.If there is inflammation that is located close to m. Psoas, with an examination before the patient will feel pain.Disorders in low-grade can be determined by ordered panderita lying on the opposite side and busi mengexten thigh in a position exposed to a large extent. 

      

  

 Iliopsoas test

 d. Obturator test.Here the legs folded up 90 ° and then held endorotasi and exorotasi.Hipogastrium pain can be caused if there is inflammation of the mass that is located in contact with m.obturator internus. This may be positive if there is appendicitis or pelvic fluid or blood accumulation in the pelvis.

           

   

 

   Obturator test

Ding din fist percussion on the anterior thorax.The positive results found in a variety of circumstances including acute hepatitis.This sign is also positive if there is acute cholecystitis. Percussion with the palm of the hand (fist) on the anterior wall of the lower thorax.Intensity can be controlled with good punches and allow un tuk perform this maneuver with the softness of manner.Patients will feel a sharp flash of pain in circumstances where there is an acute inflammatory process in the diaphragm or the liver on the right side or around the spleen and stomach on the left side.

e. Contralateral tenderness. Sometimes difficult to distinguish pe intrathoracal disease that causes abdominal pain with rigidity or acute inflammatory processes in the upper abdominal quadrant.Pressure on opposite sides of a rather deep toward the affected side'll give rikan pain that this intraabdominal process, is that the process is on the diaphragm will not give pain.

f. Inspiratory arrest (Murphy). This characteristic of acute cholecystitis. Patients with a long breath at the time where we have put the pressure on the abdominal wall in an area roughly fellea vesica. If the liver is down then the vesica fellea will be felt by the fingers and the patient will feel a great pain with breathing due to stop soon. Can po h epatitis sitip on acute hepatic failure, due to acute heart kegagaian.g.Umbilical discoloration (cullen). Skin color is bluish umbilicus may be if there is a broad hemoperitoneurn. This is usually an indication of a ruptured ectopic pregnancy. But this sign is also positive in every situation in which the blood is ba many in the cavum peritonii.But the "Cullen" is negative does not mean the absence of intraperitoneal bleeding. 9

 

  

2.3.3. Examination Support2.3.3.1. Laboratory

A complete blood count and serum electrolytes routinely performed in patients suffering from abdominal pain to.Intra-abdominal inflammation may increase the elevation of leukocytes although it is not always true. Even more important than the initial blood count is a tendency towards a progressive increase in leukocyte count, which shows the progression Vitas process of inflammation or sepsis.Leftward shift in the peripheral blood smear is another strong indication for the state of inflammation compared with leukocyte count.

If the patient is dehydrated, a history of vomiting and diarrhea or if they are taking medications such as diuretics that can increase the amount of serum electrolytes, such as the concentration of serum sodium, potassium, blood urea nitrogen, creatinine, glucose, chloride, and carbon dioxide.In addition, laboratory tests can detect diabetes, kidney failure, or other systemic diseases. Examination of serum amylase and lipase may help to evaluate upper abdominal pain due to pancreatitis. Although the accompanying increase in serum amylase pancreatitis but can also accompany other diseases such as duodenal ulcer perforation and intestinal obstruction.Patients with right upper abdominal pain should be examined bilirubin, alkaline phosfatase, and serum transaminases due to the possibility of obstructive jaundice or acute hepatitis.

Examination of her urine and provide important clinical information useful.Urinalysis can detect possible urinary tract infection, hematuria, proteinuria, or hemoconcentration.Women of childbearing age suffer from acute abdominal or hypotension should check the concentration of serum or urine β human chorionic gonadotropin.  2.3.3.2 Examination of X-Ray               Films obtained in a series of abdominal akuta traditionally terlazim confirmation tests are required in these patients. Plain is still useful in some diseases.X-ray can detect pneumoperitoneum is better than other radiographic examinations. Examination of the thorax images upright can find out the presence of air 1 cm from the diaphragm into the peritoneal cavity. For some patients who can not stand examination of the abdomen with a lateral decubitus position can also find out pneumoperitoneum.

              Radiographs with the patient tilted to the left can detect 5-10 ml of air under the lateral abdominal wall. Free air in the peritoneal cavity showed a perforation of the digestive tract. Perforated duodenal ulcers usually cause air to enter the peritoneal cavity. Approximately 75% of patients with duodenal ulcer perforation radiographically showed a pneumoperitoneum.Perforation of the stomach and colon can cause extensive pneumoperitoneum. Number pneumoperitoneum also depends on the length of the perforation and leakage.Plain abdomen may show a broad picture of pneumoperitoneum. Movie picture shows the difference serous and mucous lining of the bowel wall that is located on the surface of the free air serosa. Hidropneumoperitoneum extensive water appears as a picture of fluid level. Supine position may indicate a collection of air between the abdominal wall that does not appear in the intestine.              Plain may also show abnormal calcification. Approximately 10% and 90% of gallstones contain calcium kidney stones that provide a sufficient radioopak.Appendicolith mengkalsifikasi and radiographically can be seen in 5% of patients with appendicitis. Calcific pancreatitis is characterized by chronic pancreatitis appears on the plain, and vascular calcification can assist the evaluation of abdominal aortic aneurysms, aneurysm areteri visceral, vascular and visceral atherosclerosis.              Plain abdominal supine and upright positions may indicate gastric obstruction; small bowel obstruction proximal, middle, and distal; and colon obstruction.  2. 3.3.3.Ultrasonography

Ultrasound examination is useful in patients with acute abdominal pain because it can provide a quick evaluation, safe, inexpensive on the liver, gallbladder, bile ducts, spleen, pancreas, appendix, kidney, ovary, and uterus.Transabdominal and intravaginal ultrasound can help to evaluate the ovaries, adnexa and uterus. Ultrasound can also detect the distribution of intra-abdominal fluid. Colour Doppler ultrasound evaluation of the blood vessels to help intra-abdominal and retroperitoneal.Aortic and visceral artery aneurysms, venous thrombosis, fistula arterioles venosus, and other vascular abnormalities with ultrasound can dievalua's.Unfortunately, in patients with acute abdominal air usually found in large quantities at a disturbing picture of abdominal sonographic abdominal organs but bone, fat does not interfere with air and CT-Scan image.Therefore, CT-Scan a major examination of the acute abdomen. 2.3.3.4.  CT-Scan

CT-Scan examination immediately to the abdomen is now commonly performed.This examination proved to be very useful for evaluating abdominal complaints in patients who have clear indications for laparotomy or oskopi hungry.CT-scan is very useful in identifying free intraperitoneal air is very small and the location of areas of inflammation that require immediate surgery (appendicitis, abscess tubovarian) or delay surgery (diverticulitis, pancreatitis, hepatic abscess).

2.4    .Differential Diagnosis

In Gastrointestinal Disorders:o         Nonspecific abdominal paino         Appendicitis

o         Small bowel obstruction and colono         Peptic ulcer perforationo         Hernia incarceratao         Intestinal perforationo         Meckel's diverticulumo         Boerhaave's syndromeo         Diverticulitiso         Inflammatory bowel disorderso         Mallory-Weiss syndromeo         Gastroenteritiso         Acute Gastritiso         Adenitis mesentericao         Parasitic infections

Abnormalities in liver, spleen and biliary tracto         Acute cholecystitiso         Acute cholangitiso         Hepatic abscesso         Ruptured liver tumoro         Spontaneous rupture of the spleeno         Myocardial splenicuso         Biliary colico         Acute hepatitis

Abnormalities of the pancreaso         Acute pancreatitis

Abnormalities of the urinary tracto         Ureter or renal colico         Acute pyelonephritiso         Acute Cystitiso         Myocardial Renalis

Gynaecologico         Ruptured ectopic pregnancyo         Ovary Tumoro         Ruptured ovarian follicular cystso         Acute salpingitiso         Dysmenorrheao         Endometriosis

Vascular abnormalitieso         Ruptured aneurysm of the aorta and visceralo         Acute colitis iskhemiko         Mesenterica thrombosis

Abnormalities of peritonealo         Intra-abdominal abscesso         Primary peritonitiso         Peritonitis tuberculosa

Retroperitoneal disorders Peritoneal hemorrhage

 

2.4.1 distinguishing signs on upper abdominal painAcute appendicitis

Acute cholecystitis

Peptic ulcer perforation

Acute Pancreatitis

Pneumonia and Pleurisy

Coronary occlusion

Age Usually <40 years

> 40 years 30-50 years

30-50 years

All ages > 40 years

Gender Men = Women

Women, obese

Rare in women

Especially in women

Men = Women

Man

Painful Epigastric; radiating to RLQ; in line with the distribution

Great; radiating to the back and shoulders; reduced with antispasmodics

60-70% have a history of ulcers; sudden onset; pain is continuous;

TBA sudden onset after eating a lot; severe and constant pain; radiating to the back

In the upper abdomen, not localized; commuted with respiratory muscle splinting

Puncture; spread to the shoulder and left arm

Throw up No, but it always happens with anorexia

A lot of vomiting

Not a lot of vomiting

Always Not available

Reflex

Appearance

No pain to peritonitis

Looked tired

Looks in

Looks in pain,

Was restless;

Dyspnea; cyanosis;

because pain

pain; not move her belly; looking shocked

looked shocked when necrosis

respiratory grunting

nervous at all; sweating; subnormal blood pressure

Temperature of

99 - 100F; can be higher after perforation

99-102 F subnormal

Subnormal at onset; subsequently varied

100-103 F Normal to subnormal

Malaise Localized in RLQ

Localized in the RUQ

Diffuse. many in the upper abdomen, kakau as a board, no sound peristaltic

Epigastric; rebound; decreased peristaltic sounds

Epigastric; not settled, no restrictions on the movement of abdominal breathing

The upper part of abdomen; but are subject to change and do not settle

Laboratory

Leukocytosis

Leukocytosis

Leukocytosis

Increased serum amylase

Very leukocytosis

Leukocytosis, the ECG is helpful

X-Ray There is no point

May indicate stones or gall bladder is not visible

Free air at 85% 4 hours after onset

"Sentinel Loop" small intestine

Thorax X-Ray done

There's no point.

   Distinguishing signs on the lower abdominal pain

  Appendicitis acuta

Ureteric obstruction

Salpingitis acuta

Ectopic Pregnancy

Diverticulitis

Age Usually <40 years

<40 years <40 years <40 years > 40 years

Gender Men = Women

Men = Women

Woman Woman Man

Painful Epigastric; move to RLQ; constant with exacerbations

Weight, such as punctured; starting from the lumbar area; spread to the scrotum; dysuria; frequency

Dull; pain remained at LQ; attacks of recurrent severe pain: back pain; dysuria

Sharp stabbing (usually not diagnosed until rupture occurs)

Cramps, pain LLP; diarrhea

Menstruation

- - No change or menorrhagia

No menstruation; 15-25% irregular

-

Temperature of

90-100 F before perforation

Normal 99-102 F Normal 99-101 F

Malaise Localized in RLQ; repeated

Costovetebral; not in the abdomen

Bilateral LQ; suprapubic; repeated

Unilateral LQ; repeated

LLQ; recurrent mass + / -, distension + / -

Rectal and pelvic examination

Discomfort on the right

- Discomfort in the movement of the cervix; spending purulent

Discomfort of being on the movement of the cervix; out blood (blackish brown)

-

Laboratory

Normal sediment; leukocytosis

Hematuria; leukocytosis -

Vaginal or cervical fluid culture positive for gonococcus; sediment slightly increased

Aschheim-Zondek be positive or not; puncture cul de sac contained blood

Leukocytosis

X-Ray Not useful 95% saw a stone; Pyelogram IV can help

Not helpful Not helpful Does not help though barium X rays can show diverticulosis

 

2.5    Management of Acute Abdomen2.5.1. Management in general 12

1. Fasting

2. Gastric decompression by NGT installation

3. Rehydration with infusion

4. Installation of Catheter

5. Laboratory examination:

- Routine Blood

- Amylase, Lipase

- Na, K

- U, Creatinine

- GDS

6. Roentgen

                  Photo 2 positions: - BNO BNO Upright and flat, or

                                               - LLD and BNO Flat

                  Photo 3 positions: Upright BNO, LLD, BNO Flat

2.5.2. Management of acute abdomen based on severity and clinical symptoms  

  Priority Mechanism Clinical picture Management

I. Pain, collapse, shock (Catastrophic) as ulcer perforation, ruptured ectopic pregnancy, acute pancreatitis, mesenterica thrombosis, ruptured aneurysms, and others.

Perforation, hemorrhage, thrombosis, necrosis

Sudden severe pain, shock or stages such as shock, feelings of discomfort in the abdomen, tense, severe systemic reactions, silent abdomen

Immediate resuscitation and supportive action, surgery immediately if there are indications

II. Pain (intermittent), colic such as acute intestinal obstruction,

Obstruction of a weak muscular organ (smooth

Recurrent cramping pain, vomiting, distention, abdominal

Enforce diagnosis if possible, correction of the balance of

obstruction of biliary colic, colic uereter.

muscle), strangulation may impending or existing

noisy, systemic reactions are mild to severe,-Ray can be used

systemic, immediate surgery if indicated

iii. Pain, discomfort, inflammation such as acute appendicitis, acute cholecystitis, acute diverticulitis, acute salpingitis

Irritation by bacterial, chemical, ischemic faktos

Pain is variable, usually increases, localized discomfort, then diffuse to rupture, muscle spasms, usually there is a mass, systemic reactions of moderate to severe.

Clinical diagnosis is usually possible, immediately on the appendicitis operation, time to prepare for all the therapy (fluids, antibiotics, surgery)

2.5.3.   Specific causes of acute abdominal disease by category of severity and the need for

  Operation Non OperatingCatastrophe (Priority I)

Rupture of a spontaneous weak organ or trauma (peptic ulcer disease, ectopic pregnancy) with severe bleeding.Rupture of solid organs, especially trauma (spleen, liver, kidneys)Acute vascular occlusions (mesenteric damage, obstruction stragulasi)Severe bleeding, peptic ulcer, varicose esophagus. 

Acute PancreatitisCoronary thrombosisDissecting aneurysm (with rapid diagnosis and circumstances that allow the operation can be done) 

Colic (Priority II)

Acute intestinal obstructionAppendicitis acuta (colic from fecolith the lumen)

Biliary colic, renal colic, gastroenteritis, fecal impaction

Inflammation (Priority III)

Acute appendicitisAcute cholecystitisAcute diverticulitis

Adenitis mesentericaRegional enteritisPelvic Inflammatory DiseaseRuptured ovarian follicle (Mttelschemrz)Urinary tract infectionPneumonia and pleurisy

2.6. Peritonitis2.6.1. Definitions

              Peritonitis is the inflammation that occurs in some or all of the peritoneum.Peritonitis is the most common cause of death in the acute abdomen.Infectious organisms that can reach the peritoneum through the following ways:

1. Through the injuries of the abdominal wall 2. Through the bloodstream.3. Of visceral abdominal (common causes)4. Through the diaphragm (very rare) or lymphatic spread (very rare).

Commonest organism was pneumococcus from the blood, which can lead to a state of primary peritonitis. The organism can achieve pe ritoneum of viscera through (1) Rupture of viscera (2) through the damaged wall viscera.In women there is an additional pathway through an infected fallopian tube. Sometimes - sometimes there is a local abscess originating from extra or intraperitoneal from the diseased organ, which eventually will break, so go to the peritoneal cavity and cause peritonitis. 2.6.2. Etiology

1. Perforation -           Appendix vermiformis-           Gastric or duodenal ulcer-           Typhoid or tuberculosis ulcers of the small intestine-           Diverticulum in the colon-           Of the gallbladder or bile duct

2. Gangrene-           Intussusepsi-           Volvulus

  

3. The spread of infection -           Pyosalpinx-           Infected uterus-           Pyonephrosis

4. Rupture of-           Liver abscess-           Splenic abscess

Another rare form of peritonitis may occur from the entry of the bile or urine into the peritoneal cavity. 2.6.3. Symptoms & SignsSymptoms of peritonitis varies depending on the section and extensive peritoneal affected, source of infection and onset. Symptoms include:

1. Severe pain in abdomen2. Throw up3. Nausea 4. Fever

On physical examination found: Inspection:

-           The person is sick, agitated, his face pale-           Position the patient does not move / be afraid to move because the pain-           Abdomen was tense-           Rapid and shallow breathing

Auscultation:-           Bowel sounds decreased / missing

Percussion:-           Percussion pain-           Tuberculosa peritonitis there is a phenomenon on the chess board

Palpation:-           Pain Press-           Pain off-           Stomach feels like a board-           Defense Musculair

Rectal toucher:-           Pain in the whole circle

 2.6.4. Examination Support

1. Laboratory-           Routine blood, leukocytosis was found-           Examination of peritoneal fluid (to see the erythrocytes, leukocytes and bacteria, when the cause is trauma)

2. X-Ray Inspection-           There is free water in the peritoneal cavity in an upright position and LLD BNO-           There is free water in the sub diaphragm in Thorax AP photo - Lateral

 2.6.5. Management of

1. Fasting2. NGT decompression with the installation of3. Rehydration with infusion4. Administration of oxygen5. Catheter6. Provision of broad spectrum antibiotics intravenously7. Operation

  

 

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Treatment. 11 th edition.Vol I. California: Mc Graw-Hill companies. pp. 503-16.7. Michael J. Zinner, Seymour I. Schwartz, Harold Ellis. Of 2001. Maingot's

Abdominal Operations. Tenth Edition.Vol I. Singapore: McGraw-Hill International. h lm 351-59

8. Tomnsend, Beauchamp, Evers, Mattox.2004. Sabiston Textbook of Surgery, The Biological Basis of Modern Surgical Practice. 17 th edition.Philad elphia: Elsevier Saunders Inc.. pp. 1219-30.

9. J. Dunphy Englebert, T W. Botsford Of 1998. Physical examination Peme Surgery.Issue 5. Philadelphia: W. B Saunders Company. pp. 172-81

10. Cope, Zachary. , 2005. Early Diagnosis of the Acute Abdomen. 21 issue. New York: Oxford University Press. pp. 233-41

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