REFERAT PRESENTATION OF ACUTE ABDOMEN

ADVISER : DR. SJAIFUL BACHRI, SP.B. DR. JOHAN L, SP.B WRITER : NOK RACHMATIAH (406102017)

ACUTE ABDOMEN
Definition : A pathophysiologic process that has a sudden onset and may require surgical intervention

A condition that requires immediate decision

1. Does this patient need surgery? 2. if

necessary when the operation should be done ? 3. Is it emergent, urgent, or can wait?

DEFINITION

Signs and symptoms of intra-abdominal disease usually best treated by surgery A clinical situation due to intra-abdominal emergencies, suddenly onset, with pain as chief complaints

WHY DOES ACUTE ABDOMEN IS SPECIAL ?

Patient with acute abdominal pain : Suddenly onset Unknown causes Requires immediate diagnose and treatment

Prevention 0f

mortality or high morbidity

One of the most common causes for hospitalization Require immediate decision in diagnosis and treatment Needs highly attention from the doctor. May or may not require immediate operation

WHY NEEDS IMMEDIATELY TREATMENT ?

Every minute is precious, the late of therapy highly risk

Every hour is precious, the late of therapy increasing the morbidity and mortality.

The late more than 12 hour increasing the morbidity and mortality.

THE DEFINE OF ABDOMEN BASED ON REGION AND QUADRANT

DEFINITION OF PAIN
It is unpleasant sensation of varying intensity. Stimulant of pain : 1. Mechanical trauma to the tissue. 2. Excess heat or cold 3. Chemical damage 4. Radiation damage 5. Inadequate blood flow

SOURCE OF ABDOMINAL PAIN

Abdominal 1. Abdominal wall 2. Intra peritoneal organ 3. Retro peritoneal organ 4. Pelvic organ Extra abdominal 1. Intra thoracic organ 2. Systemic factor

THE TYPES OF ABDOMINAL PAIN

Visceral pain : is primitive and related to embryologic development. Receptor : visceral peritoneum Stimulus : patient experienced pain by traction, distention, and spasm. Mediation : autonomic nervous system Specificity : vague, poorly described, and associated with nausea, vomiting

Localization : is poor and the patient placing the entire hand over the involved region.

Somatic pain : is entirely different from visceral pain Receptor : pain stimuli start in the parietal peritoneum which is innervated by peripheral nerves Stimulus : patient experienced pain by touch, pressure, heat, inflammation. Mediation : central nervous system Specificity : precisely described as sharp, knifelike, cutting

Localization : the pain is localized with great accuracy by the patient, who can often point the site with one finger.

THE LOCATION OF ABDOMINAL PAIN

Visceral pain : based on embryologic development
Embryologic development Fore gut Location Around epigastrium Organ

Stomach Duodenum Hepatobilier system Pancreas

Small intestine Colon until the middle of transversum colon From the middle of transversum colon until sigmoid colon. Bladder

Mid gut

Around umbilicus

Hind gut

Around lower abdominal

T6-T9 T6-T9

T10

T8-T12

T8 L2

S4

Somatic pain : more in line with anatomic location

Location of pain Right upper abdomen Epigastrium Left upper abdomen Right lower abdomen Left lower abdomen Suprapubik Organ Gall bladder, liver, duodenum, pancreas, colon, lung, heart Stomach, pancreas, duodenum, lung, colon Spleen, colon, kidney, pancreas, lung Appendix, adnexa, caecum, ileum, ureter, Colon, adnexa, ureter. Bladder, uterus, small intestine

Periumbilical
Back / hips Shoulder

Small intestine
Pancreas, aorta, kidney Diaphragm

MODE OF ONSET
Sudden onset : The patient can describe exactly when the pain started

MODE OF ONSET
Gradual onset : The patient usually responds vaguely to question about time of onset

REFERRED PAIN
Pain felt in an area of body distant from site of pathology The more severe the pain the more likely it is to be referred Due to existence of a shared central neural pathways for afferent nerves Characteristic quality of many abdominal processes

THE ORIGINS OF REFERRED PAIN

Right shoulder : R. diaphragm Liver Gall bladder Pneumoperitoneum Left shoulder : L. diaphragm Spleen Pancreas Stomach Back : Aorta Pancreas Duodenum Right scapula : Gall bladder Hepatobillier Left scapula : Spleen Tail of pancreas

THE ORIGIN OF REFERRED PAIN

Groin / genitalia Kidney Uterus Aorta Illiac vessels

THE VARIETY OF COLICKY PAIN

ANAMNESIS

60 80 % the accuracy of diagnosis obtained from good and thorough anamnesis Physical examination : strengthen the accuracy

of diagnosis

10 15 % the accuracy of diagnosis obtained

from laboratory and imaging examination.

SEVEN GOLDEN QUESTION OF ACUTE ABDOMEN

Onset of pain Location of pain Character of pain The pain spreading or referred pain Source of relief Source of aggravation Sign and symptom of gastrointestinal or systemic that accompany abdominal pain such as : nausea, anorexia, vomiting, fever, etc.

PHYSICAL EXAM FOR ABDOMINAL PAIN PRESENTATION

General appearance : Mild, moderate, severe illness Mobile versus still Obvious pain or discomfort Skin color (pail, jaundice, anemia), and awareness (conscious, decreased) Vital sign : Blood pressure, respiration rate, pulse, and temperature

Inspection : Abdominal distention, bruises, scars, visible peristalsis Auscultation : Normal bowel sound Increasing or decreasing bowel sound The absent of bowel sound Palpation : Often the most helpful part of exam Tenderness and pain Start away from painful area first Guarding, rebound, masses

Sign : Rovsings sign Obturator sign Psoas sign

Rectal examination

SUPPORTING EXAMINATION
Laboratory testing Base line testing Selective testing Pregnancy test in women of child bearing age Radiology Plain or contrast film USG Laparoscopy CT-scan /MRI

Three position plain film 1. upright chest 2. upright abdomen 3. flat abdomen

COMMON DIAGNOSES BY QUADRANT

ACUTE APPENDICITIS
Appendicitis is most common cause of acute surgical abdomen Chief complain : abdominal pain at right lower quadrant Which started from the stomach or around umbilicus right lower abdomen Tenderness (+) at Mc Burney point Rovsing Sign & Blumberg Sign Leukositosis Differential diagnose ectopic pregnancy rupture pregnancy test (+)

Acute appendicitis

Perforated

Intraperitoneal puss Peritonitis guarding muscle Peristaltic

Indication for operating management

HERNIA

Cases of acute abdomen :

Hernia Incaserata Hernia Strangulate

H. Incaserata : Phinced intestine non reducible The passage of intestine disorder (nausea + vomiting, defecated, bowel sound ) H. Strangulate H.Incarserata symptoms + vascular disorder Necrotic intestine painfully ischemic pain

ILEUS OBSTRUCTION
Main symptom : 1. Crampy pain 2. Obstipation 3. Distention 4. Vomiting

PERITONITIS
Intra abdominal inflammation The patient feels continues pain Limited movement Examination may demonstrate with guarding, tenderness The pain localized over in one quadrant organ (local peritonitis ) The pain localized at all abdominal quadrant (diffuse peritonitis ). leucocytosis

THE GRADE OF PERITONEUM IRRITATION

By abnormal fluid at intra peritoneum (lowenfels, 1975)

Pancreas fluid

Inside of intestine

Mild irritation

Pus

Stomach fluid severe

blood

Urine

Bile