Acute Abdomen

By :Raisa CesardaRifa Fauzia

Preseptor :dr. Liza Nursanty, SpB, Mkes, FINACS

Anatomy

DEFINITION

Acute Abdomen is clinics due to the gravity of the situation in the abdominal cavity which usually occurs suddenly with pain as the primary complaint

Identification of abdominal pain include: - Types of pain, - nature of pain, - onset of pain, -Location of pain,Abdominal pain

Type of painVisceral painParietal painReferred pain

Nature of painReferred painIf a segment of the neural inervate more than one region.

Projection PainPain is caused by the stimulation of the sensory nerve injury or inflammation of the nerves.

Continous PainPain due to stimulation of the parietal peritoneum will be felt continuously since continued, for example in the inflammatory reaction.

Colic PainVisceral pain spasm of smooth muscles of hollow organsIschemic PainSign of is threatened tissue necrosis.Move PainDevelopment of pathology.

Onset of pain

Sterotypes of pain onset and associated pathologySuddent onset (full pain in seconds)Perforated ulcerMesenteric infarctionRuptured abdominal aortic aneurysmRuptured ectopic pregnancyOvarian torsion or ruptured cystPulmonary embolismAcute myocardial infarction Rapid onset (initial sensation to full pain over minutes or hours)Strangulated herniaVolvulusIntussusceptionAcute pancreatitisBillliary colicDiverticulitisUreteral and renal colicGradual onset (hours)AppendicitisStrangulated herniaChronic pancreatitisPeptic ulcer diseaseInflammatory bowel diseaseMesenteric lymphadenitisCystitis and urinary retentionSalphingitis and prostatitis

Clinical Assesment

pain should include:OnsetSite of onsetSite at presentType of painRadiation of PainAggravating or relieving factorsprogression

Associated Bowel SymptomsNausea VomitConstipationDiareFeses : color, blood , mucusJaundice

Associated Urinary Symptomsurinary : amount, colour ( blood, pus), history stone

Associated gynecological symptommenstrual cycleabnormal bleeding, dicharge ( color, quantity)

OTHER HISTORYPost medical historyPost surgical historyFamily history : Malignancy or inflamatory bowel disease

Physical ExaminationGeneral Appearance- General Conditions - Mood: Anxious ,Communicable - Mobility - Color: pallor, Flushing, Jaundice, CyanosisVital Signs :TemperaturePulse rateBlood PressureRespiratory rate

Physical ExaminationCardiopulmonary examinationAbdomen examinationInspectionmovement: visible peristalsis - The scar on the abdomen - Abdominal distentionFlatusFluidFetus

Erythema or discolouration a. Peri-umbilical - Cullen signb. Flanks - Grey Turner signAny Visible masses Tumor, hernia, pulsation

Important Signs in Patiens with Abdominal PainSignFindingAssociationCullens signBluish periumbilical discolorationRetroperitoneal hemorrhage (hemmorrhagic pancreatitis, abdominal aortic aneurysm ruptureKehrs signSevere left shoulder painSplenic ruptureEptopic pregnancy ruptureMcBurneys signTenderness located 2/3 distance from anterior iliac spine to umbilicus on right sideAppendicitisMurphys signAbrupt interruption of inspiration on palpation of right upper quadrantAcute cholecystitisIliopsoas signHyperextension of right hip causing abdominal painAppendicitisObturators signInternal rotation of flexed right hip causing abdominal painAppendicitisGrey-Turners signDiscoloration of the flankRetroperitoneal hemorrhage (hemorrhagic pancreatitis, abdominal aortic aneurysm rupture)Chandelier signManipulation of cervix causes patient to lift buttocks off tablePelvic inflammatory diseaseRovsings signRight lower quadrant pain with palpation of the left lower quadrantAppendicitis

Palpation see the expression of the patient and look for signs of: Tenderness (Tenderness) Rebound (rebound tenderness) Defans dystrophy (Muscle guarding / Rigidity) Murphy's, Rovsing's signs Period, lump (hole hernia, scrotum) pulsation

Rovsings Sign in Acute Appendicitis Obturator Sign in Pelvic Appendicitis

Murphy's sign in Acute Cholecystitis

PercusionTymphaniticDullShifting dullnessAuscultationBowel sounds (+/-)Decreased / increasedMetallic soundsVascular bruit

Rectal Examination:- tenderness- induration- mass- frank blood

Vaginal Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour

LABORATORY EXAMINATION : - Complete blood count - Urinalisis and pregnancy tests - Blood chemistry

EXAMINATION OF RADIOLOGY : - Chest x-ray - Abdominal x-ray 3 positions: Upright, supine, lateral decubitus Left - ultrasonography - CT-Scan - MRI

Right upper quadrantAcute HepatitisType of pain : visceral painTanda Khusus :Anamnesis : - History poor food hygiene, past history drug or tatto, Use of drug hepatotoksik like allopurinol, amiodarone, amitriptyline, PE : - pain with jaundice (sklera ikterik, kulit kuning), hepatomegali.Lab : SGOT and SGPT increased

CholangitisPain at RUQCharcots triad (fever, pain RUQ, and jaundice), Reynolds pentad, mild hepatomegaly, tachicardia.Radiology : imaging (USG dan CT Scan)

Cholecystitis & CholelithiasisType of pain: local, constan. Pain radiate to flank and right scapulaAnamnesa : history eat fatty, history cholangitis.PE : fever, dan murphy sign positifRAdiology : USG

DiseaseEtiologyCharacteristik PainManifestation clinisLabRadiologitreatmentAcute Pankreatitis Biliary tract disease, alcohol, drugs, trauma, hyperparathyroidism, malnutrition, hyperlipidemia, ductus pankreas obstruction, duodenum obstruction, infection, ischemia, herediter.Pain at epigastrik regio radiate to back, persistent pain, compounded by lying position and relieving by trunkus flexi positionNausea, vomit, disensi abdomen, fever.Tenderness at epigastrik, Bowel sound (-) atau decreasedHct , WBC , serum amylase Plain abdominal film (radioopaque gallstone)CT scanMedicationsurgeryDuodenal ulcerH. pylori, NSAID, hipersecretion acidPain at epigastrik, pain like a burn, intermittent pain, pain will loss by food ar antasid, Nausea , vomit, flatulenceWBC Upper gastrointestinal radiographyendoscopyMedication antasid, antagonis H2 histamin, antibiotikDyspepsiaH. pyloriPain at epigastrik, radiate to back in lower scapulaSubsternal pressure, epigastric distress, Nausea , flatulenceEndoscopyEKG

DiseaseEtiologyCharateristic painManifestation clinisLaboratoriumRadiologiPengobatanAppendisitisLumen Obstruction cause fecalith, parasite, foreign body Pain at epigastrik or mid umbilical radiate to right lower quadrant abdomentAnorexia, nausea, vomit, tenderness at mc burney pointMild leukoctocisPlain abdominal x-ray, USG, CT- ScanAppendectomyMesenteric adenitisToxin and bacteriaPain at upper abdomen move to right lower quadrant abdomentnausea, vomit, generalized lyphadenopathy, Temperature increasedLeukocytosissurgeryKETEctopic pregnancyPain at right lowe abdomenBleeding at vagina, miss menstrual periodPregnancy test (+)USGLaparatomyUreterolithiasisPain radiate to labia, scrotum, penisHematuriaUrinalisisIVPSurgery

ALHAMDULILAH

(iii) Associated Bowel SymptomsCONSTIPATION a. Progressive intestinal obstruction from a neoplasm or inflammatory bowel disease b. Paralytic Ileus c. Post Operative d. Obstructed groin hernia (iii) Associated Bowel SymptomsCONSTIPATION a. Progressive intestinal obstruction from a neoplasm or inflammatory bowel disease b. Paralytic Ileus c. Post Operative d. Obstructed groin hernia

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