ACUTE ABDOMINAL PAIN

ACUTE ABDOMENOleh:Diah Anis Naomi, S.KedDicky Aditya Dwika, S.KedFadia Nadila, S.KedMaradewi Maksum, S.Ked1

2Undiagnosed pain that arises suddenly and is less than 7 days (usually less than 48 hours) duration.3Clinical Evaluation

History Mode of onsetDuration CharacterLocationIntensityChronologyFrequencyRadiation4LocationViceral painThe centrally perceived sensation is generally slow in onset, dull, poorly localized, and protracted. Visceral pain is most often felt in the midline because of the bilateral sensory supply to the spinal cord.Parietal pain

More acute, sharper, better-localized pain sensation.The cutaneous distribution of parietal pain corresponds to the T6L1 areas. Abdominal parietal pain is conventionally described as occurring in one of the four abdominal quadrants or in the epigastric or central abdominal area.5Referred pain

Denotes noxious (usually cutaneous) sensations perceived at a site distant from that of a strong primary stimulus. Spreading or shifting pain

Parallels the course of the underlying condition. The site of pain at onset should be distinguished from the site at presentation.6

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1111Mode of Onset and Progression of Pain

The mode of onset of pain reflects the nature and severity of the inciting process. Onset may be explosive (within seconds), rapidly progressive (within 12 hours), or gradual (over several hours). Example:Sudden onset: suggests an intra-abdominal catastrophe, such as a ruptured abdominal aortic aneurysm (AAA), a perforated viscus, or a ruptured ectopic pregnancy

Rapidly progressive pain that becomes intensely focused in a well-defined area within a period of a few minutes to an hour or two suggests a condition such as acute cholecystitis or pancreatitis.

Over several hours usually beginning as slight or vague discomfort and slowly progressing to steady and more localized pain including acute appendicitis, diverticulitis, pelvic inflammatory disease (PID), and intestinal obstruction.12Characteristic of Pain

13IntensityRelated to the magnitude of the underlying insult. It is important to distinguish between the intensity of the pain and the patient's reactionPain that is intense enough to awaken the patient from sleep usually indicates a significant underlying organic cause.14Other Symptoms Associated with Abdominal PainAnorexiaNausea and vomitingConstipation, or Diarrhea

Often accompanies abdominal pain, but since these are nonspecific symptoms, they do not have much diagnostic value.15Physical Examination

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21INVESTIGATIVES STUDIES

22LABORATORIUMUrin23LABORATORIUMDarah24LABORATORIUMRadiologis25DIFFERENTIAL DIAGNOSIS Kuadran kanan atas: 1. Cholecystitis acute 2. Perforasi tukak duodeni 3. Pancreatitis acute 4. Hepatitis acute 5. Acute congestive hepatomegaly 6. Pneumonia + pleuritis 7. Pyelonefritis acute 8. Abses hepar

Kuadran kiri atas: 1. Ruptur lienalis 2. Perforasi tukak lambung 3. Pancreatitis acute 4. Ruptur aneurisma aorta 5. Perforasi colon (tumor/corpus alineum) 6. Pneumonia + pleuritis 7. Pyelonefritis acute 8. Infark miokard akut

Paraumbilical: 1. Ileus obstruksi 2. Appendicitis 3. Pancreatitis acute 4. Trombosis A/V mesentrial 5. Hernia Inguinalis strangulata 6. Aneurisma aorta yang pecah 7. Diverculitis (ileum/colon)

Kuadran kanan bawah: 1. Appendicitis 2. Salpingitis acute 3. Graviditas axtra uterine yang pecah 4. Torsi ovarium tumor 5. Hernia Inguinalis incarcerata,strangulata 6. Diverticulitis Meckel 7. Ileus regionalis 8. Psoas abses 9. Batu ureter (kolik)

Kuadran kiri bawah: 1. Sigmoid diverculitis 2. Salpingitis acute 3. Graviditas axtra uterine yang pecah 4. Torsi ovarium tumor 5. Hernia Inguinalis incarcerata,strangulata 6. Perforasi colon descenden (tumor, corpus alineum) 7. Psoas abses 8. Batu ureter (kolik)

26RIGHT HYPOCONDRIACEPIGASTRICLEFT HYPOCONDRIACRight lower lobe pneumonia/embolismPancreatitisLeft lower lobe pneumonia/embolismCholecystitisGastritisLarge bowel obstructionBiliary colicPepti colicHepatitisMyocardial infarctionRIGHT LUMBARUMBILICALLEFT LUMBARRenal colicSmall bowel obstructionRenal colicAppendicitisIntestinal ischaemiaLarge bowel obstructionAortic aneurysmGastroenteritisCrohns diseaseRIGHT ILIACHYPOGASTRICLEFT ILIACAppendicitisCystitisSigmoid diverticulitisCrohns diseaseUrinary RetentionLeft tubo-ovarian pathologyRight tubo-ovarian pathologyDysmenorrheaEndometriosis27SURGICAL TREATMENT

28PRE-OPERATIVE MANAGEMENTAfter initial assessment, parenteral analgesics for pain relief should not be withheld. In moderate doses, analgesics neither obscure useful physical findings nor mask their subsequent development. Resuscitation of acutely ill patients should proceed based on their intravascular fluid deficits and systemic diseases. Medications should be restricted to only essential requirements. Particular care should be given to use of cardiac drugs and corticosteroids and to control of diabetes. Antibiotics are indicated for some infectious conditions or as prophylaxis during the perioperative period.A nasogastric tube should be inserted in patients likely to undergo surgery and for those with hematemesis or copious vomiting, suspected bowel obstruction, or severe paralytic ileus. A urinary catheter should be placed in patients with systemic hypoperfusion. In some elderly patients, it eliminates the cause of pain (acute bladder distention) or unmasks relevant abdominal signs.Informed consent29NON SURGICAL TREATMENTThere are numerous disorders that cause acute abdominal pain but do not call for surgical intervention.In addition to numerous extraperitoneal disorders nonsurgical causes of acute abdominal pain include a wide variety of intraperitoneal disorders, such asAcute gastroenteritis (from enteric bacterial, viral, parasitic, or fungal infection)Acute gastritisAcute duodenitisHepatitisSalpingitisovarian cystEndometritisEndometriosis TThreatened abortionSpontaneous bacterial peritonitisTuberculous peritonitis. 30THE ABDOMINAL SERIESSupine AbdomenErect Abdomen

3131Left Lateral Decubitus Abdomen

32Supine Erect

Small Bowel Obstructions33Gallstone ileus

34The gall bladder is filled with gas (arrow) in emphysematous cholecystitis.

Abdominal radiograph demonstrating incidental radioopaque gallstone (black arrow) and bladder calculus (white arrow).

35CholelithiasisUSG

36ACUTE APPENDICITIS

37THANK YOU! 38