Professional Documents
Culture Documents
dr KISMAN HARAHAP SP B
Bagian Bedah FK UNRI/SMF Bedah
RSUD Arifin Achmad
PEKANBARU
Outline
• Definitions
• What causes an “acute abdomen”
• To examine the physiologic background of abdominal
pain As An aid to accurate interpretation
ofSymptoms & Signs .
• Differential Diagnosis
– History and physical
– Labs
– Diagnostic imaging
• Special emphasis
– Appendicitis
– Bowel infarction
– Perforated viscous
Acute Abdomen
• Symptoms and signs of
acute intra- abdominal
disease processes,
usually treated best by
surgical operation
• The term acute abdomen refers to a sudden,
severe abdominal pain of unclear etiology that
is less than 24 hours in duration. It is in many
cases a medical emergency, requiring urgent
and specific diagnosis. Several causes need
surgical treatment.
• = Surgical abdomen
Acute Abdomen-Symptoms
• Symptoms linked to visceral distention or
ischemia
• Inflammation of the peritoneum
– Parietal component provides localization
– End result of a process involving viscera
• Early diagnosis means understanding the
patterns that lead up to peritoneal irritation
Anatomic background
Parietal peritoneum
clothes the anterior & posterior
abdominal walls the under surface
of the diaphragm & the cavity of
the pelvis.( supplied segmentally
by the spinal nerves ) .
Visceral peritoneum
is the continuation of the parietal
peritoneum, which leaves the
posterior wall of the abdominal
cavity to invest certain viscera
therein . ( has no nerve supply ).
T6-T9
foregut
1 2 3 T6-T9
4 5 6 T10
7 9
8
T8-T12
T8
midgut
L2
S4 hindgut
Lokasi Nyeri
Akut
pada abdomen
Anatomi luar
Abdomen
• Anterior: 9 regio
– epigastrium
– hipokondrium ki/ka
– umbilikal
– lumbar ki/ka
– hipogastrium/suprapubis
– inguinal ki/ka
• Pembagian lain: 4 regio
– kuadran ki/ka atas
– kuadran ki/ka bawah
Lokasi normal
viscera
abdomen
Patologi
Nyeri
abdomen
oleh sebab
extra
peritoneal
• Kardiotorasik
• Urologi
• Vaskular
• Lain-lain
Lokasi Nyeri
Akut
pada abdomen
DEFINITION OF PAIN
Abdominal Extra-abdominal
Systemic dysfunction
Functional abdominal
Diabetes ,tabes dorsalis
Abdominal wall porphyria
+ pain organs
Intra-thoracic
Pelvic organs
Retro-peritoneal organs
Intra-peritoneal organs
Types
of abdominal pain
1
2
Visceral pain is primitive
Somatic pain is entirely
and therefore related to
different from visceral
embryologic development . pain
Visceral pain
1- Receptor
( Visceral peritoneum )
Visceral pain
2 - Stimulus
Hypothalamus
Corpus collosum
Pons
Cerebellum
Medulla
Spinal cord
Visceral pain
4- Specificity
1- Receptor
P/ peritoneum
Somatic pain
2- Stimulus
Pressure
Touch
Heat
Inflammation
Somatic pain
3- Mediation
4- Specificity
Precisely described as
Sharp
Cutting
Knifelike
Somatic pain
5- Localization
lab
pa
History-PE in
? X-rays
Echo
CT scans
Diagnostic Work-up
History-PE
X-rays
Lab
Echo
CT scans
Exploratory laparotomay
Analysis of pain
need
DATA COLLECTION
1 2 3
apply
Sudden onset
[The patient can tell you exactly when the pain started ]
The pain that start suddenly has a mechanical basis
Some thing has been
Twisted
Occluded
Ruptured
Cont’ Mode of onset
Gradual Onset
Gradual Onset
Three Types
(3) Renal
((2) system
1 )Small = ( retroperitoneal
Intestine
Biliary System foregut)) )
= (( midgut
Foregut pain is experienced in the epigastrium
Pain is felt in
Pain the flank
is experienced & radiates
in the periumbilical to the
region groin
Important features of colic pain
Peritonitis
Generalized
Localized
2 Inflammation
Intra-abdominal inflammation is peritonitis
Peritonitis causes somatic pain
Contamination
BY
Foreign body
Chemicals
Bacteria
Trauma
Important features of somatic
pain
I. Pat. Laying quite in bed . ( movement is limited )
cause
Tissue Hypoxia
Necrosis With metabolic
changes
After 6-12 h
Severity of acute abdominal pain
Th
e a
ss
oc
iat
ed
ps
yc
ho
log
ic
fac
Patient perc tor
eption s
aus e
g c
d e r lyin
un
o f the
e v e rity
S
Factors influencing clinical
manifestation
(1)
Extent of the pathologic process
(2)
Time of Assessment
Depending on the time of assessment ,
the characteristics will reflect what is
present at that time – not previously &
not subsequently .
Factors influencing clinical
manifestation
(3)
Emotional factors
Objective criteria are more reliable than
subjective factors .When there is a discrepancy
between the severity of pain & objective
findings ,caution should be exercised .
Factors influencing clinical
manifestation
(4)
The Patient’s Intelligence
A clinical history is only as reliable as its source .
If the pat. is
Or
Very
Psychotic
Senile
Veryyoung
Intellectually
illimpaired
The information obtained must be interpreted
carefully . Objective & subjective findings should
be compatible .
Factors influencing clinical
manifestation
(5)
Level of consciousness
Some neurologic problems make the
interpretation of acute abdominal pain difficult .
Paraplegia
Unconsciousness
Sympathetic denervation
• Timing
– Matched to clinical condition
• Emerges over time and then concentrates (acute appy)
• Sudden onset (perforated viscous)
• Referred pain
– Linked to anatomic distribution
• Required reading
– Copes “ Early diagnosis of the Acute abdomen”
History of Present Illness
• O nset
• P recipitating/ relieving
• Q uality
• R adiation
• S everity
• T iming
Physical Examination
• Overall appearance
– Walking and recumbent
• Vital signs
– Temperature
• High/low/low-grade
– Tachycardia
– Hypotension
• Inspection: scars, hernias, masses
• Auscultation
• Palpation
Physical Examination
• Percussion:
– Tenderness
• No sudden moves
• Take your time
• Rigidity and guarding
• “Board-like abdomen”
– Tympanitic
– Dull
Lab Tests
• WBC + differential
• Basic chemistry panel
–K
– Bicarbonate
• Amylase
• Liver function tests
• Urinalysis
• Pregnancy test
Diagnostic Imaging
Plain Films
• Upright CXR
– “Free” air
• KUB (kidney/ureter/bladder)
– Calcifications
– Air/ Fluid levels
– Reactive bowel patterns
– Foreign bodies
Lateral Decubitus Film
Ultrasound
• Rapid, safe, low cost
• Operator dependent
• Fluid, inflammation, air in walls, masses
• Liver, GB, CBD, Spleen, Pancreas, Appendix,
Kidney, Ovaries, Uterus
Ultrasound
Symptoms
Source: Berry J Jr, M alt RA. Appendicitis near its centenary. Ann
Surg 1984;200:567.
Distinguishing Appendiceal
Perforation
Appendicitis Appendicitis
With Perforation w/o Perforation
N=70 N=176
Duration of symptoms (hrs, 48.5 hrs 18.0 hrs
median)
Fever as presenting 34.3 11.4
complaint (% of cases)
Nausea or vomiting (% of 60.0 70.5
cases)
Anorexia (% of cases) 52.9 64.2
Urinary symptoms (% of 10.0 10.8
cases)
Rebound tenderness (% of 64.3 71.6
cases)
Rectal tenderness (% of 41.4 41.5
cases)
Impression of a mass (% of 21.4 6.2
cases)
Source: Berry J Jr, Malt RA. Appendicitis near its centenary. Ann
Surg 1984;200:567.
Differential Diagnosis
• Both
Womensexes
– Gastroenteritis
PID
– Pyelonephritis
Ovarian torsion
– Diverticulitis
Ectopic pregnancy
– Crohn’s
Ovarian disease
cyst
– Meckel’s diverticulum
– Pancreatitis
Disposition
• Abdominal pain patients can be put in 4
groups
• Group 1: classic presentation for Acute
appendicitis- prompt surgical intervention
• Group 2: suspicious, but not diagnosed
appendicitis- benefit from imaging and 4-6h
observation with surgical consult if serial exam
changes or imaging studies confirm
Disposition
• Group 3: remote possibility of appendicitis-
observe in ED for serial exams; if no change
and course remains benign patient can D/C
with dx of nonspecific abd pain
• Patients are given instructions to return if
worsening of symptoms, and they should be
seen by PCP in 12-24 h
• Also advised to avoid strong analgesia
Disposition
• Group 4: high risk population(including
elderly, pediatric, pregnant and
immunocomprimised)- require high index of
suspicion and low threshold for imaging and
surgical consultation
Perforation of Appendix
When Does Perforation Happen?
• Statistics
– 25% risk of perforation after 24 hours
• What does it mean?
– Change in type of surgery
– Risk of abscess
– Peritonitis
• Increased mortality
Treatment
• Urgent appendectomy
• Antibiotics
– Only preoperative abx needed for uncomplicated
cases
– For complicated appendicitis 7-10 days
Laparoscopic Appendectomy
Postoperative Complications
• Infection: < 5 % to 60 %
• Wound Closure
– Primary
– Delayed primary
– Secondary
• Bowel obstruction
• Infertility-no longer suspected
Mortalitas pada appendektomi
# Tanpa komplikasi < 0,05 – 1%
# Mulai ada komplikasi 0,05%
# Dengan perforasi 0,05%
Open Appendectomy
Infarcted/Ischemic Bowel
Mesenteric Infarction/Ischemia
• Always consider in patient with atypical presentation
of abdominal pain-
– Older patients
– Hx of arrhythmias or previous emboli
– Pain out of proportion to exam
– Evidence of visceral complaints without peritonitis
– Systemic complications
– Acidosis
Infarction by Endoscopy
Anatomy of the SMA
Occlusion of the SMA
• Source
– Embolic (>50%)
– Venous, Atherosclerotic (thrombotic), NOMI
• Chronic
– Mesenteric/intestinal angina
– 30-60 minutes post eating
– Voluntary anorexia/wt loss
• Acute (>60% mortality)
– “Abdominal apoplexy”
– Variable symptoms at first with progression
– System collapse
Arteriogram of Normal SMA
Occluded SMA
Treatment of Acute SMA Occlusion
• High index of suspicion
• Arteriogram
• Medical therapy
– Papavarin
– Heparin
• Surgical intervention
Perforated Viscous
Perforated Viscous