Acute Abdomen

By group 4
Tutor: dr. Susilo Dinata
 Group Four
Name NIM Job Desk
Fransisca Alvionita 405070041 Crew
Malik Djamaludin 405070053 Crew
Nico Lie 405070085 Crew
Cynthia A. Loway 405070094 Crew
Monica Handayani 405070102 Crew
Clare Novialin 405070113 Scriber
Christina Hadi W. 405070120 Secretary
Fenny Fenorica 405070122 Leader
Kasmianto Abadi 405070131 Crew
Findha Yuliana N. 405070152 Crew
Rayhan Nugraha 405070166 Crew
Charles Prakarsa 405070167 Crew
 Scenario
How Low Can You Endure The Pain, Mr.
Bond?

Mr. Bond, a 22-year=old man is referred by

his GP to the hospital with pain in the right
lower quadrant. He says that within the last
month he felt epigastric pain or sometimes the
pain was located in the periumbilical region. He
also felt nauseated for the past two weeks and
since then he has vomited several times. Last
night the pain has begun to shift to its current
location.
Exam:
VS: BP 100/70mmHg, pulse 90 bpm,
temperature 380C.
Tenderness and guarding over the right lower
 Learning Objectives
• Able to explain about anatomy of anatomy (regio
4&9, Lower GIT, nerve system)
• Able to explain about physiology appendix
vermiformis
• Able to explain about mechanism of appendicitis pain
• Able to explain about abdominal pain & causes (in
children & adult)
• Able to explain about patophysiology of appendicitis
• Able to explain about examination to diagnose
• Able to explain about complication of appendicitis
• Able to explain about therapy (pharmacology & non-
pharmacology) of appendicitis
• Able to explain about preventive of appendicitis
ANATOMY
Anathomy Abdomen
Anathomy abdomen
LGIT ANATOMY
Position of the Appendix
Vermiformis
 Anatomy
• Embryologically, the appendix is a continuation of
the cecum, arising from its inferior tip.
• The narrow lumen of the appendix is lined by
colonic epithelium.
• There are a few submucosal lymphoid follicles
present at birth; these gradually increase in
number to a peak of approximately 200 follicles
between the ages of 12 and 20. After age 30,
there is an abrupt reduction to less than half that
number, and, subsequently, to a trace or a total
absence of lymphoid tissue after age 60.
Blood supply of the Appendix
Vermiformis
 Sensorik nerve of abdominal organ
Structure nerve location

Center of diagfragma N.Phrenicus C3-5

lateral of diaphragma, Plexus Celiacus Th6-9

gaster,pancreas, gall bladder,
small intestine
Appendics, colon proximal and Plexus Mesentricus(N. Th10-11
hips Vagus and
N.splanchnicus major)
colon distal, rectum, ren, ureter, N.Splanknicus caudal Th11-L1
and testis
Buli-buli,rectosigmoid Plexus hipogastricus S2-S4
 Mechanism of pain
Appendicitis pain from viscera is often
localized simultaneously in two body
surface area because of pain through
visceral pain and tenderness over the
right parietal.
There are 2 mechanism of appendicitis
pain:
• Visceral pain (appendix) symphatic
nerve  medulla spinalis (Th X-XI) 
periumbilical region  cramp
• parietal peritoneum inflamed appendix
attached to the abdominal wall  sharp
pain in peritoneal irritation in the RLQ
ACUTE ABDOMINAL
PAIN
• Visceral pain comes from the abdominal
viscera, which are innervated by autonomic
nerve fibers and respond mainly to the
sensations of distention and muscular
contraction—not to cutting, tearing, or local
irritation. Visceral pain is typically vague, dull,
and nauseating. It is poorly localized and tends
to be referred to areas corresponding to the
embryonic origin of the affected structure.
– Foregut structures (stomach, duodenum, liver,
and pancreas) cause upper abdominal pain.
– Midgut structures (small bowel, proximal
colon, and appendix) cause periumbilical pain.
– Hindgut structures (distal colon and GU tract)
cause lower abdominal pain.
• Somatic pain comes from the
parietal peritoneum, which is
innervated by somatic nerves, which
respond to irritation from infectious,
chemical, or other inflammatory
processes. Somatic pain is sharp and
well localized.
• Referred pain is pain perceived
distant from its source and results
from convergence of nerve fibers at
the spinal cord. Common examples
of referred pain are scapular pain
due to biliary colic, groin pain due to
renal colic, and shoulder pain due to
blood or infection irritating the
diaphragm.
 Projection Pain
• Cause by sensoric nerves stimualtion
because injured or nerves
inflammation
• Ex: phantom pain after amputation,
or localized peripheral pain in herpes
zoster
 Continue Pain
• Caused by peritoneum stimulation in
the parietal peritoneum and occur in
continuous time
• Peritonitis  localized pressure pain,
defense muscular to protect
inflammation area and avoid
movement or localized pressure
 Cholic Pain
• Caused by smooth muscle spasm in hollow
organs and usually cause by passage obstruction
in that organs (intestine obstruction, kidney
stone, bile stone, increase of intraluminer)
• Appear by hypoxia, feels come and go, nausea to
emesis, and very nervous
• Have specific TRIAS  reccurent abdominal pain
followed by nausea or emesis and force
movement
 Ischemic Pain
• Very intensive, permanent, and not
reduce. This is sign of necrosis phase
is inisiated. Further more, general
intoxification will appear
 Approach to the patient
• History is THE MOST IMPORTANT part of
the diagnostic process
– Location, quality, severity, radiation,
exacerbating or alleviating factors, associated
symptoms
• Visceral v. peritoneal
– A good through medical history
– A good through social history, including
alcohol, drugs, domestic abuse, stressors, etc.
– Family history is important (IBD, cancers, etc)
– MEDICATION INVENTORY
 Approach to the patient
• Physical exam
– Vitals, general appearance
– A good thorough medical exam
• Jaundice, signs of chronic liver disease
– Abdominal exam
• Look, listen, feel
• Know a few tricks
– DRE
– Pelvic exam
– MSK exam
 Approach to the patient
• Labs
– CBC, lytes, BUN, Cr, coags
– Amylase and lipase, LFTs
– UA
– bHCG
– Lactate
– Tox screen
– H. pylori serology
– FOBT
 Approach to the patient
• Imaging
– Plain films (KUB, UGI)
– CT
– Ultrasound
– MRI
– Angiography
• Endoscopy
– EGD
– Colonoscopy
– ERCP/EUS
 Surgical abdomen
• This is the first thing to be
considered in acute abdominal pain
– Early identification is a must as
prognosis worsens rapidly with delay in
treatment
• Important to get surgeons involved
early if this is even mildly suspected
• This is a clinical diagnosis
 Surgical abdomen
• Presentation is usually bad
– Fevers, tachycardia, hypotension
– VERY tender abdomen, possibly rigid
• Presentation can vary with other
demographic and medical factors
– Advanced age
– Immunosuppression
 Surgical abdomen
• Peritonitis
– Often signals an intraabdominal
catastrophe
• Perforation, big abscess, severe bleeding
– Patient usually appears ill
– Exam findings
• Rebound, rigidity, tender to percussion or
light palpation, pain with shaking bed
 Surgical abdomen
• Work-up
– Start with stat labs
– Surgical abdominal series (plain films)
– Consider stat CT if readily available
• Sometimes patients go straight to
surgery as initial step
• Again, get surgeons involved early
for guidance and early intervention
APPENDICITIS
 Appendicitis
• Appendicitis is inflammation of the appendix.
Appendicitis is a painful swelling and infection of the
appendix.

Epidemiology
• Appendicitis occurs in 7% of the US population, with
an incidence of 1.1 cases per 1000 people per year.
Some familial predisposition exists.
• The incidence of appendicitis is approximately 1.4
times greater in men than in women. Anyone can get
appendicitis, but it is more common among people 10
to 30 years old.
• Males and females are equally affected, except
between puberty and age 25, when males
predominate in a 3:2 ratio.
 Appendicitis: Number and Age-Adjusted Rates of Ambulatory Care Visits and
Hospital Discharges With First-Listed and All-Listed Diagnoses of by Age, Race, and
Sex in the United States, 2004

SOURCE: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care
Survey (NHAMCS) (3-year average, 2003-2005), and Healthcare Cost and Utilization Project Nationwide
Inpatient Sample (HCUP NIS)
 ETIOLOGY
“OBSTRUCTION OF THE APPENDICIAL
LUMEN BY MECHANICAL FACTORS”
• FECALITH
• INFLAMMATION
fecalith

• FOREIGN BODY
• NEOPLASM
• PARASITES
• LYMPHOID
HYPERPLASIA (30 %)
 Pathophysiology
mucus accumulates in the lumen &
pressure within the organ begins to
increase

Stage of
virulent bacteria convert the
accumulating mucus into pus
Acute Focal
Appendicitis

continued secretion combined with • poorly localized visceral pain

the relative inelasticity of the serosa tending to be periumbilical or
leads to a further rise in pressure epigastric in location, it’s
within the lumen because the appendix and the
small bowel have the same nerve
supply
obstruction of the lymphatic • anorexia
drainage ensues, leading to edema • nausea
of the appendix, beginning • vomiting
diapedesis of the bacteria, and the
appearance of mucosal ulcers. next slide…
 Pathophysiology
Continued secretion causes a
further rise in intraluminal pressure

Stage of Acute
Produces venous obstruction and
further edema and ischemia in the
Suppurative
appendix Appendicitis

Bacterial invasion spreads through

the wall of the appendix • The inflamed serosa of the
appendix contacts the parietal
peritoneum.
next slide… • Somatic pain, arising from the
peritoneum as a result of contact
with the inflamed appendix, is
perceived as the classic shift and
localization of pain in the right
lower quadrant.
 Pathophysiology
Continuation of this pathologic
process

venous thrombosis and then to

compromise of the arterial blood
First Stage of
supply Complicated
Appendicitis

The area of the appendix with the

poorest blood supply, the
midportion of the antimesenteric
border, undergoes gangrene with
the appearance of ellipsoidal
infarcts

The development of gangrenous

appendicitis
next slide…
 Pathophysiology
Continued secretion from viable
portions of the appendiceal mucosa
and continued high intraluminal
pressure

Second Stage of
Complicated
Perforation through a gangrenous
Appendicitis
infarct, spilling accumulated pus

Perforative appendicitis
 caused by stretching of
the appendix during the
early inflammatory
process
After 2 to 12 hours
When the inflammatory
process has extended to
involve the serosal layer of
the appendix and the
peritoneum
• an elevation in
temperature
• white blood cell count greater
than 10,000/mm3, with 75% or
more polymorphonuclear cells
• abrupt onset, with pain referred to the
epigastric or periumbilical area
• one or two episodes of nausea
• the pain gradually increases from
vague to colic
• the pain becomes localized to the
lower right quadrant
Palpation
• a deep tenderness in the lower right
quadrant, which is confined to a small area
approximately the size of the
fingertip,located at approximately the site of
the inflamed appendix
• Rebound tenderness
Gangrenous Apendicitis
 Symptoms
• The abdominal pain usually
– wake up at night
– before other symptoms
– begins near the belly button and then moves lower and to the right
– is new and unlike any pain felt before
– gets worse in a matter of hours
– gets worse when moving around, taking deep breaths, coughing, or
sneezing
• Other symptoms of appendicitis may include
– loss of appetite
– Nausea
– Vomiting
– constipation or diarrhea
– inability to pass gas
– a low-grade fever that follows other symptoms
– abdominal swelling
– the feeling that passing stool will relieve discomfort
• Symptoms vary and can mimic other sources of abdominal pain,
including
– intestinal obstruction
– inflammatory bowel disease
– pelvic inflammatory disease and other gynecological disorders
– intestinal adhesions
– constipation
 Clinical SIGNS
• Tenderness
(Maximal at the
Mc Burney’s p.)
• Rowsing Sign
• Cutaneous
hyperasthesia
• Iliopsoas Sign
• Obturator Sign
Rowsing Sign: “Pain
in the right lower
quadrant when
pressure is exerted
on the left lower
quadrant
Psoas Sign

“Pain on flexion of the thigh”

 Obturator Sign
“Pain on flexion and rotation of the
thigh”
ESSENTIALS OF DIAGNOSIS
• ABDOMINAL PAIN
• ANOREXIA, NAUSEA and VOMITING
• LOCALISED ABDOMINAL
TENDERNESS
• LOW-GRADE FEVER
• LEUCOCYTOSIS
 Exams and Tests
• If you have appendicitis, your pain will increase
when the doctor suddenly releases the pressure
after gently pressing on your lower right belly
area. If you have peritonitis, touching the belly
area may cause a spasm of the muscles.
• A rectal examination may reveal tenderness on
the right side of your rectum.
• Doctors can usually diagnose appendicitis by your
description of the symptoms, the physical exam,
and laboratory tests. In some cases, additional
tests may be needed. These may include:
– Abdominal CT scan
– Abdominal ultrasound
– Diagnostic laparoscopy

nb: in US,The drug, called NeutroSpec, was used

to help diagnose appendicitis in patients ages 5
and older who may have had the condition but
did not show the usual signs and symptoms.
 Differential Diagnoses
• Abdominal Abscess
• Mesenteric
Lymphadenitis
• Cholecystitis and Biliary
Colic
• Omental Torsion
• Constipation
• Ovarian Cysts
• Crohn Disease
• Ovarian Torsion
• Diverticular Disease
• Pediatrics,
Intussusception
• Ectopic Pregnancy
• Pelvic Inflammatory
Disease
• Endometriosis
• Renal Calculi
• Gastroenteritis
• Spider Envenomations,
Widow
• Gastroenteritis, Bacterial
• Urinary Tract Infection,
Female
• Inflammatory Bowel
Disease
• Urinary Tract Infection,
Male
• Meckel Diverticulum
• Mesenteric Ischemia
 MESENTERIC
LYMPHADENITIS
 Definition
• Lymph nodes are collections of cells that play a key
role in your body's ability to fight off illness. In
mesenteric lymphadenitis, the lymph nodes in a
membrane that attaches your intestine to your
abdominal wall (mesentery) become inflamed —
usually as a result of an intestinal infection.
• Mesenteric lymphadenitis occurs mainly in children
and teens and often mimics the signs and symptoms
of appendicitis. Unlike appendicitis, mesenteric
lymphadenitis is seldom serious and clears on its own
in a few days or weeks.
• Mesenteric lymphadenitis also can occur in healthy
children who have no symptoms.
 Symptoms
• Signs and symptoms of mesenteric
lymphadenitis may last a few days or
as long as a few weeks. They include:
– Abdominal pain, often centered on the
lower, right side, but the pain can
sometimes be more widespread
– Fever
• Depending on what's causing the
ailment, other signs and symptoms
may include:
– Diarrhea
– Nausea and vomiting
– Generally feeling unwell (malaise)
CROHN’S DISEASE
 Crohn Disease
• Chronic granulomatous inflammatory
disease of the GI tract.
• Can involve any part of GI tract from
mouth to anus
• Ileum is involved in majority of cases
• Confined to colon in 20%
• Terms:regional enteritis, terminal
ileitis, granulomatous ileocolitis
 Crohn Disease
• Etiology and pathogenesis are
unknown.
• Infectious, genetic, environmental
factors have been implicated.
• Autoimmune destruction of mucosal
cells as a result of cross-reactivity to
antigens from enteric bacteria.
 Crohn Disease
• Cytokines,including IL and TNF have
been implicated in perpetuating the
inflammatory response.
• Anti-TNF(remicade) drugs have
shown efficacy in treating Crohn
disease
 Crohn Disease
• Epidemiology: peak incidence is 15-
22 years old with a second peak 55-
66years
• 20-30% increase in women
• More common in European
• 4 times more common in Jews than
non-Jews
• More common in whites vs blacks
• 10-15% have family hx
 Crohn Disease
• Pathology: most important is the
involvement of all layers of the bowel and
extension into mesenteric lymph nodes
• Disease has skip areas between involved
areas
• Longitudinal deep ulcers and
cobblestoning of mucosa are characteristic
• These result in fissures, fistulas, and
abscesses
 Crohn Disease
• Clinical features: variable and
unpredictable
• Abd pain, anorexia, diarrhea, and
weight loss are present in most cases
• 1/3 of patients develop perianal
fissures or fistulas, abscesses, or
rectal prolapse
 Complications
• PERFORATION
• PERITONITIS
• ABSCESS
• ILEUS
Perforation of the Acute
Appendicitis
PERITONITIS
 Peritonitis
• Peritonitis is an inflammation (irritation) of
the peritoneum, the tissue that lines the
wall of the abdomen and covers the
abdominal organs.

Causes
• A collection of pus in the abdomen, called
an intra-abdominal abscess, may cause
peritonitis.
• The specific types of peritonitis:
– Peritonitis - spontaneous
– Peritonitis - secondary
– Peritonitis - dialysis associated
 Symptoms
• Abdominal distention
• Abdominal pain or tenderness
• Fever
• Fluid in the abdomen
• Inability to pass feces or gas
• Low urine output
• Nausea and vomiting
• Point tenderness
• Thirst

• Additional symptoms that may be associated with this

disease include:
– Cloudy dialysis fluid (if undergoing peritoneal dialysis)
– Nausea and vomiting
– Shaking chills
– Signs of shock
 Peritonitis - spontaneous
Causes
• Spontaneous peritonitis is usually
caused by ascites, a collection of fluid
in the peritoneal cavity. This usually
occurs from liver or kidney failure.
 Peritonitis - dialysis
associated
• Dialysis-associated peritonitis is
inflammation of the lining of the abdominal
cavity (peritoneum), which occurs in those
who receive peritoneal dialysis.

Causes
• Dialysis-associated peritonitis may be
caused by bacteria or fungi can cause the
infection.
• Approximately one infection occurs for
every 15 months of peritoneal dialysis.
 Peritonitis - secondary
• Secondary peritonitis is an inflammation of the peritoneum, the
tissue lining the abdominal cavity. Secondary means it is due to
another condition, most commonly the spread of an infection from
the digestive tract.

Causes
• Secondary peritonitis has several major causes. Bacteria may
enter the peritoneum through a hole (perforation) in the
gastrointestinal tract. Such a hole may be caused by a ruptured
appendix, stomach ulcer, perforated colon, or injury, such as a
gunshot or knife wound.
• Secondary peritonitis can also occur when bile or chemicals
released by the pancreas (pancreatic enzymes) leak into the lining
of the abdominal cavity.
• Inflammation of the peritoneal cavity caused by bacteria can
result in infection of the bloodstream (sepsis) and severe illness.
• Secondary peritonitis can also affect premature babies who have
necrotizing enterocolitis.
 Exams and Tests
• The doctor will perform a physical exam.
The abdomen is usually tender, and may
feel firm and "board-like." The patient may
extensively "guard" the area, using
protective movements such as curling up or
refusing to allow the area to be touched.
• Blood tests, x-rays, and CT scans may be
ordered.

Treatment
• The cause must be identified and treated
promptly. Treatment typically involves
surgery and antibiotics.
 Outlook (Prognosis)
• With treatment, patients usually do well.
Without treatment, the outcome is usually
poor.
Possible Complications
• Peritonitis can be life threatening and may
cause a number of different complications.
Complications depend on the specific type
of peritonitis.
 Prevention Peritonitis – spontaneous
• Patients with peritoneal catheters should be
treated with sterile techniques. In cases of
liver failure, antibiotics may help prevent
peritonitis from coming back.

Prevention Peritonitis - dialysis associated

• Careful sterile technique when performing
peritoneal dialysis may help reduce the risk
of inadvertently introducing bacteria during
the procedure. Some cases are not
preventable. Equipment design
improvements have made these infections
less common.
 TREATMENT
• Open appendectomy
Appendectomy can be performed as open surgery using one
abdominal incision that's about 2 to 4 inches (5 to 10
centimeters) long.
• Laparoscopic appendectomy
• Appendicitis surgery can be done as a laparoscopic operation,
which involves several small abdominal incisions. During a
laparoscopic appendectomy, the surgeon inserts special surgical
tools and a video camera into your abdomen to remove your
appendix.
But laparoscopic surgery isn't appropriate for everyone. If
your appendix has ruptured and infection has spread
beyond the appendix or if an abscess is present, you may
require an open appendectomy.
• Expect to spend one or two days in the hospital after your
appendectomy.
• Draining an abscess before appendix surgery
• Postoperative Details
• Administer intravenous antibiotics postoperatively.
The length of administration is based on the operative
findings and the recovery of the patient. In
complicated appendicitis, antibiotics may be required
for many days or weeks.
• Antiemetics and analgesics are administered to
patients experiencing nausea and wound pain.
• When appendicitis is not complicated, the diet may be
advanced quickly postoperatively and the patient is
discharged from the hospital once a diet is tolerated.
In patients with complicated appendicitis, a clear
liquid diet may be started when bowel function
returns.
ILEUS
 DEFINITION
• Intestinal obstruction is a blockage of your
small intestine or colon that prevents food and
fluid from passing through. Intestinal
obstruction can be caused by many conditions,
but it's most often the result of fibrous bands of
tissue in the intestine (adhesions), hernias or
tumors.
• Intestinal obstruction can result of
uncomfortable signs and symptoms(abdominal
pain and swelling, nausea, and vomiting). If left
untreated, intestinal obstruction can cause the
blocked parts of your intestine to die (become
necrotic). This tissue death can lead to
perforation of the intestine, severe infection
and shock.
 SYMPTOMS
• Crampy abdominal pain that comes and
goes (intermittent)
• Nausea
• Vomiting or diarrhea
• Inability to have a bowel movement or
pass gas
• Swelling of the abdomen (distention)
• Abdominal tenderness
• Fever
 CAUSES
Paralytic ileus
• Paralytic ileus can cause signs and symptoms of
intestinal obstruction. In paralytic ileus,
although there is no blockage, the intestines
don't function properly; movement of the
intestines is greatly reduced or absent. The
intestines are unable to move food and fluid
smoothly through the digestive system.
Paralytic ileus can affect any part of the
intestine. The most common cause of
paralytic ileus is abdominal surgery.
Postoperative paralytic ileus is not a form of
mechanical obstruction.
 CAUSES
Mechanical obstruction of the small intestine
Common causes of mechanical obstruction in the small
intestine include the following:
• Intestinal adhesions. These bands of fibrous tissue
in the abdominal cavity may be present at birth
(congenital). But, more often, they form after
abdominal surgery. Intestinal adhesions can bind
sections of your intestine, blocking the passage of
food and fluids.
• Hernias. Hernias occur when part of your intestine
protrudes into another part of your body. If a loop of
intestine becomes trapped due to a hernia, it will
cause intestinal obstruction.
• Tumors. A tumor within your small intestine may
block the passage of food and fluids, causing
obstruction.
 CAUSES
Mechanical obstruction of the colon
The most common causes of mechanical
colonic obstruction include the following:
• Cancer
• Diverticulitis — a condition in which
small, bulging pouches (diverticula) in
the digestive tract become inflamed or
infected
• Twisting of the colon (volvulus)
 RISK FACTORS
Conditions that increase your risk of intestinal
obstruction include:
•Abdominal or pelvic surgery
•Crohn's disease
•Cancer within your abdomen, especially if
you've had surgery to remove an abdominal
tumor or radiation therapy
•A history of constipation
•Malrotation, a condition present at birth
(congenital) in which your intestine doesn't
develop correctly
 DIAGNOSIS
• abdominal X-ray
• Ultrasound
• computerized tomography (CT)
scans.
These tests also help your doctor
determine if the obstruction is
paralytic ileus or if it's a mechanical
obstruction, and if it's a partial or a
complete obstruction.
 TREATMENT
• Use of prokinetic agents has had
moderate success. Rectal cisapride
(Propulsid), a serotonin agonist, has
reportedly been successful in
treating ileus, but the US Food and
Drug Administration (FDA) has
withdrawn this agent because of the
possibility it causes cardiac
dysrhythmias.
 Preventive Appendicitis
For prevention people are suggested
to consume more fibers and avoid
predispose flavor like spicy food
 PROGNOSIS APPENDICITIS
• Without surgery or antibiotics, mortality is >
50%.
• With early surgery, the mortality rate is < 1%,
and convalescence is normally rapid and
complete.
• With complications (rupture and development of
an abscess or peritonitis), the prognosis is worse:
Repeat operations and a long convalescence may
follow
• If your appendix is removed before it ruptures,
you will likely get well very soon after surgery. If
your appendix ruptures before surgery, you will
probably recover more slowly, and are more likely
to develop an abscess or other complications.
Acute abdomen In
children
 Ethiology
In first few years of life
• Congenital abnormalities
• Incarcerated inguinal hernia
• Intussuception
• Intestinal volvulus
• GI perforation
• NEC in preterm neonates

In older children
• Trauma
• Pancreatitis
• Meckel’s diverticulum
• Primary peritonitis
• Intestinal worm infestation
In adolescents
• Acute appendicitis
• Cholecystitis (acalculous)
• Testicular torsion
• Rupture of ovarian cyst

Non- surgical causes of abdominal pain

• Hyperthyroidisin
• Addison’s disease
• Diabetic ketoacidosis
• Hypercalcemia
• Lead poisoning
• Porphyria

Non-specific abdominal pain

• It is the most common cause of abdominal pain in late childhood
and early adolescence. It is a colicky pain with some localization
that becomes worse after meals. Bowel sounds may be increased
and a palpable mass of feces may be present in right or left iliac
fossa. The causes commonly are constipation, irritable bowel and
chronic spasm.

• The treatment consists of antispasmodics.

 DIFFERENTIAL
DIAGNOSE :
Pediatrics,Diabetic Ketoacidosis
Pediatrics, Gastroenteritis
Ovarian Cysts Pediatrics
Pediatrics Intussusception
Pediatrics, Pneumonia
Pediatrics, Sickle Cell Disease
Pediatrics, Urinary Tract Infections & Pyelonephritis
Sign & sympthom
 Treatment
• Some clinicians feel that providing
pain relief before a diagnosis is made
interferes with their ability to
evaluate. However, moderate doses
of IV analgesics (eg, fentanyl 50 to
100 μg, morphine 4 to 6 mg) do not
mask peritoneal signs and, by
diminishing anxiety and discomfort,
often make examination easier.
 Investigations in a child with acute
abdomen

• Abdominal X-Ray/Chest X-Ray

erect
• Ultrasound of both pelvis and
upper abdomen
• Peripheral smear
• Urine examination
 Additional investigations
• Serum Amylase/lipase – for
pancreatitis
• Blood cultures
• Beta HCG
• CT scan for abdomen
• Stool examination for worm
infestation
 Antibiotic therapy
• is an important aspect of the treatment of
ruptured appendicitis. Antibiotic therapy should
be directed against gram-negative and anaerobic
organisms such as Escherichia coli and
Bacteroides species. The administration of
antibiotics, nasogastric tubes, intravenous lines,
urethral catheters, antiemetic medicine,
antipyretic medicine, and analgesia should ideally
be part of the ED protocol for managing the
preoperative child. Proponents of preoperative
antibiotic recommend that all children with
appendicitis receive gentamicin and clindamycin
 Conclusion

• Based on sign and symptom in this

case,maybe Mr.Bond has chronic
exacerbation acute.
 Suggestion

• Considered to plan advance surgery

to reduce complication
• For prevention people are suggested
to consume more fibers and avoid
predispose flavor like spicy food
 References
• Alice S. Pakurar, John W. Bigbee. Digital Histology. USA:
John Wiley & Sons, Inc, 2004.
• Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL,
Jameson JL, et al, editors. Harrison’s principle of internal
medicine. 17th ed. USA: Mc. Graw Hill medical, 2008.
• Porth Carol, Gaspard Kathryn J. Essentials of
Pathophysiology. Lippincott Williams & Wilkins, 2003.
• www.vesalius.com
• www.youtube.com
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