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Acute Abdomen
Preseptor:dr. Liza Nursanty, SpB, Mkes,
FINACS
Presentan :
Harum Binar .M 12100113016
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Acute abdomen difined generally as anintraabdominal process causing severe painand often requiring surgical intervention.
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4 quadrant
- Right Upper Quadrant
- Right Lower Quadrant
- Left Upper Quadrant
- Right Lower Quadrant
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1. Right hypocondrium
2. Epigastric
3. Left hypocondrium
4. Right Lumbar
5. Regio umbilical
6. Left lumbal
7. Right inguinal
8. Suprapubic
9. Left inguinal
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Acute abdominal pain is a common physicalcomplaint and prompted more than 7 millionemergency departement visits last year in the
united states.
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ASSESMENT
Well elicited history
Proper physical
examination
Investigations are usually carried out :
only to support the diagnosis.
or to narrow down the differential diagnoses.
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HistoryHistory of Present illnessFamily History
Past Medical history
History of drugs taken or Medicationeg. ingestion of certain toxic drugs or
Alcohol intake
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Free Peritoneal Air
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This plain abdominal radiograph of a 55-year-old woman presenting with
features of intestinal obstruction shows dilated loops of the small bowel
associated with thickened edematous valvulae conniventes and a strangulated
left inguinal hernia (arrow).
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http://www.ajronline.org/content/vol176/issue1/images/large/01_AA0350_04.jpeg8/10/2019 Acute Abdomen RPS
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(ii) Progression of PainProgression f rom :
Dull, aching, poorly localized character
To:
Sharp, constant & better localized pain
indicates involvement of Parietal peritoneum
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(iii) Associated Bowel SymptomsCONSTIPATION
a. Progressive intestinal obstruction from a
neoplasm or inflammatory bowel disease
b. Paralytic Ileus
c. Post Operatived. Obstructed groin hernia
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(iv) Associated Bowel SymptomsDIARRHOEA
Diarrhoea with pain is mainly medical.
The following are the exceptions :
a.Obstructed Richter's Hernia
b.Gall Stone ileusc.Superior mesenteric vascular occlusion
d.Intestinal Obstruction associated with
pelvic abscess
e.Spurious diarrhea in chronic faecalimpaction
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DRUG HISTORY
Corticosteroidsmask pain
Anticoagulantscan lead to an intramural
haematoma of the gut causing obstruction
Oral Contraceptives - rupture of hepaticadenomas
NSAIDs - erosive gastritis & peptic ulcers
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NAUSEA & VOMITING
i. Frequency of vomitingii. Character of vomiting:
projectile, non-projectile or self-induced
iii. Nature of vomiting:
a. Bilious vomiting of small bowelobstruction
b. Non-bilious vomiting in obstruction
proximal to ampulla of vater
c. Faeculent vomiting in distal small gutobstruction, large bowel obstruction ,
strangulation
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NAUSEA & VOMITINGPain first, followed by Vomiting is usuallysurgical.
The vomiting is due to reflex
pylorospasm
Nausea & vomiting first , followed by painis usually due to a medical condition
Vomiting is very prominent in
a.Mallory-Weiss syndrome.
b.Boerhaave syndrome(trans- mural
esophageal tear)
c.Acutegastritis
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ANOREXIAAnorexia or decreased appetite with pain is
usually seen in Acuteappendicitis
Urinary Symptoms with Pain
Ureteric colicCystitis
FEVER & CHILLS/RIGORSAmoebic Liver AbscessPygenic Liver Abscess
Perinephric Abscess
Intra-abdominal pus collection
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OTHER HISTORYPast Surgical history: previous operations-
leading to adhesions
Past Medical history: Sickle cell disease,
Diabetes or Cancer or Renal failure
Menstrual History in females(i) Missed period- ectopic pregnancy
(ii) Mid of period-ovulation pain (Mittel-
schmerz)
(iii) With heavy periods- endometriosisFamily history of colon cancer, any other
malignancy or inflammatory bowel disease
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Physical ExaminationGeneral Appearance
a.Anxious Patient lying motionless:
(i) Acuteappendicitis
(ii) Peritonitis
b.Rolling in bed & restless:(i) Ureteric Colic
(ii) Intestinal colic
c.Writhing in Pain:
Mesenteric Ischemiad. Bending Forward:
Chronic Pancreatitis
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Physical Examination (contd.)h. Low grade temp. is seen with
- Appendicitis
- Acutecholecystitis
i. High grade temp. is seen with
- Salpingitis- Abscess
j. Very High Grade Temp.with increasing
lethargy
seen in imminent septic shock- Peritonitis
- Acutecholangitis
- Pyonephrosis
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Systemic ExaminationErythema or discolouration
a. Peri-umbilical - Cullen sign
b. InguinalFox sign
c. Flanks - Grey Turner sign
Seen in Hemorrhagic pancreatitisor any other cause of haemoperitoneum
Any Visible masses
Any visible cough impulse at hernia site
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Systemic ExaminationPer abdomen:
Palpation
Be gentle
Start away from site of pathology then towards
Check for Hernia sitesTenderness
Rebound tenderness
Guarding- involuntary spasm of muscles
during palpationRigidity- when abdominal muscles are tense &
board-like. Indicates peritonitis.
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Systemic ExaminationLocal Right Iliac Fossa tenderness :
a. Acuteappendicitis
b. AcuteSalpingitis in females
c. Amoebiasis of Caecum
Low grade, poorly localized tenderness :Intestinal Obstruction
Tenderness out of proportion to examination:
a. Mesenteric Ischemia
b. AcutePancreatitisFlank Tenderness:
a. Perinephric Abscess
b. Retrocaecal Appendicitis
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Systemic ExaminationRovsings Sign in AcuteAppendicitis
Obturator Sign in Pelvic Appendicitis
Psoas Sign
- Retrocaecal appendicitis
- Crohns Disease- Perinephric Abscess
Murphy's sign in AcuteCholecystitis
Thumping tenderness over lower ribs in
inflammation of- Diaphragm
- Liver or spleen
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Systemic ExaminationPulsatile Abdominal Mass with Hypotension
Leaking AAA
Cutaneous Hyperaesthesia indicates
involvement of Parietal Peritoneum
Per Rectal Examination:- tenderness
- induration
- mass (Blummers shelf)
- frank blood
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Systemic ExaminationPer Vaginal Examination
- Bleeding
- Discharge
- Cervical motion tenderness
- Adnexal masses or tenderness- Uterine Size or Contour
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INVESTIGATIONS
Complete Blood Count with differentialC-reactive protein estimation
Electrolyte ,Blood Urea , Creatinine
Urine dipstick
Amylase or LipaseLiver Function Test
INVESTIGATIONS
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INVESTIGATIONSRadiology
Upright X ray chest for
- Basal Pneumonia- Ruptured Oesophagus
- Elevated Hemi diaphragm
- Free Gas under diaphragm
Abdominal X ray film- Air-Fluid Levels
- Stones
- Ascites
- Eggshell calcification in AAA
- Air in Biliary tree.
- Obliteration of Psoas Shadow in retro- peritoneal
disease
- Right lower quadrant sentinel loop in acute
appendicitis
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INVESTIGATIONS
Other Investigations-USG
-CT abdomenfor AAA, Pancreatic disease, or
ureteric colic (non- Contrast)
-IVU-Mesenteric Angiography for
-Ischaemia, Haemorrhage
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