MANAGEMENT ACUTE ABDOMEN

Briand Pollah
Digestive RSUD Jayapura
 Acute Abdomen

“Condition which requires immediate treatment” (FD

Moore, 1977): Surgery? When to perform?
“Clinical condition which arises from acute critical condition in the
abdominal cavity, and usually manifests as pain” . (Buku Ajar Ilmu
Bedah, 2016)
“ Signs and symptoms of abdominal pain and tenderness, a clinical
presentation that often requires emergency surgical therapy “
(Squires et al , Sabiston’sText book of Surgery , 2017)
 Why is it important?

• Patient with acute abdomen:

– Sudden onset
– Unknown etiology (not clear)
– Need immediate diagnosis & treatment (sense of crisis)

Prevent morbidity & mortality

Etiology
Degree Of Peritoneal Irritation
 Morbidity & Mortality

Obstruction -->fluid imbalance

Perforated viscus--> Peritonitis
Infection Sepsis -->Shock
Bleeding hypovolemic--> Shock
Ischaemia Perforation -->Peritonitis

DEATH
 History taking

• 60 - 80% of accurate diagnosis arises from

good & meticulous history taking
• Physical diagnosis confirms accurate diagnosis
• 10 - 15% of accurate diagnosis arise from
laboratory & radiological examinations
 History taking:

• May confirm :
– Suspected diagnosis
– Possible etiology
– Disease stages/ complications
– Differential diagnosis
 Patient Identity

• Ask the patient politely concerning his/her: name, age

• Record the gender:
– Male
– Female
• Ask the marital status of the patient (especially for female)
 Specific age groups

• In children
– Acute appendicitis
• In the elderly
– Perforated tumors
– Bowel obstruction due to tumors
• During pregnancy (reproductive age)
– Complicated Ectopic pregnancy
Site of Pain
 Onset of pain

• Sudden onset
 Onset of pain

• Gradual pain
 Upper abdominal pain
• Peptic or gastric ulcer
• Acute Cholecystitis, Acute Cholangitis
• Pancreatitis
• Early Appendicitis
• Hepatitis or liver abscess
• Extra abdominal:
– Inferior Pleuritis, lobar pneumonia,
pneumothorax
– Pericarditis, Myocardial infarction,
angina
• Pyelonephritis, renal colic
 Central abdominal pain

• • Early appendicitis
• • Bowel obstruction,
strangulated
• • Pancreatitis
• • Gastroenteritis
• • Mesenterial Emboli
/Thrombosis
• • Dissecting aortic aneurism
• • Mesenteric adenitis
• • Early sigmoid diverticulitis
 Lower abdominal pain

• ColonicGangrene/Obstruction
• Appendicitis
• Mesenteric adenitis
• Diverticulitis
• Ruptured tubo-ovarial abscess
• Tuboovarial Torsion
• Ectopic gestation
 Type :
Referred Pain
 Types:
Shifting/Migrating Pain
Types & Characters:
Type and severity of pain
Type and severity of pain
Type and severity of pain
 Other related symptoms:

• Ask the patient concerning related/concomitant

• symptoms of Gastro-intestinal function:
– Nausea
– Vomiting
– Loss of appetite
– Faintness
– Previous indigestion (habitual)
 Other related symptoms:

• Jaundice
• Bowel habit:
– constipation?
– Diarrhoea?
– Colour of the stool?
– Presence or absence of blood and mucus (slime)
 Other related symptoms:

• Urinary function:
– Micturition: amount of urine, lower abdominal discomfort,
colour of urine
• Gynaecological function ( female)
– Menstrual function
– Delayed or miss period
– Abnormal bleeding or discharge (colour, quantity)
 Previous history

• Similar pain
• Abdominal surgery
• Major illness: incl. fever, abdominal injury.
• Drugs
• Allergies
PHYSICAL EXAMINATION
 PHYSICAL EXAMINATION

• Preparation
– Check all the equipment required and have a good
light:
• Examination couch
• Stethoscope
• Explain the procedure and its goals to the patient.
• Wash your hands with antiseptic soap.
• Dry and warm your hands with tissues.
• General Exam & Vital Signs
 Abdominal Examination: Inspection

– Inspect the movement:

• Respiratory movement
• Visible bowel peristaltics
– Is there any scars on the skin of the abdomen?
– Is there any abdominal distention? • Flatus ? , Fluid ? ,
Fetus?
 Abdominal Examination: Inspection

• Is there any rashes and

discolouration?
– Cullen’s sign
– Gray Turner’s sign
– Ecchymosis of the abdominal
wall
• Is there any masses:
– Tumors? – Hernial sites?
– Masses with pulsation?
 Auscultation

• Using stethoscope, and place it gently on the abdomen, listen to

the bowel sounds and bruit at least for one minute:
– Absent?
– High pitched and hyperactive?
– Metallic sound?
– Vascular bruit?
 Abdominal Examination: Palpation

• Ask the patient to locate the site of maximum pain with the
tip of a finger.

• Using the palmar surface of your fingers, gently palpate

the abdomen, starting from a site farthest from the area of
maximum pain, move gradually towards it.
 Abdominal Examination: Palpation

• While palpating, look to the face expression of the patient, and

look for any signs of :
– Tenderness
– Rebound tenderness
– Muscle guarding
– Rigidity
– Murphy’s sig
 Abdominal Examination: Palpation

• While palpating, look to the face expression of the patient, and

look for any signs of :
– Swelling or masses
– Rovsing’s sign
– Expansile pulsation
– Hernial orifices
– Scrotum in male
Specific Signs
 Abdominal Examination : Percussion

• Place the palmar aspect of your left hand on the abdomen, and
gently percus its dorsal aspect with the tip of the middle finger of the
right hand, moving all around the abdominal region:
– Is it tymphanitic? – Is it Dull ?
– Is there any shifting dullness?
– Site of liver dullness ? and is it disappeared ?
 Signs of Life Threatening

• Fever, nausea, vomiting, tachicardia, tachipneu

• Abdominal pain
• Peritoneal signs
• Signs of dehydration
• Leucositosis
• Shock, Multiple organ dysfunctions
 Tips

• > 6 hours: surgical related diseases !!!

• Limited movement: peritonitis / ischaemia
• persistent pain on morphine : ischaemia
• Sense of Crisis
• Repeated exams : important
Laboratory Studies
 Radiologic Examinations
• Plain Radiographs ( Acute
Abdominal Series)
– Chest X-ray upright, Supine &
Upright/LLD
Abdominal X-Ray
• Abdominal Ultrasound
• Abdominal Computed
Tomography (CT)
• Scintigraphy (Radioisotope
Imaging)
• CT Angiography
 Procedures

• Colonoscopy and sigmoidoscopy

(Contraindicated in Fulminant Colitis)
• Diagnostic peritoneal lavage (DPL)
• Laparoscopy
Suspected Surgical Diseases
Management of Acute Abdominal Pain
 Principles of Management

• The key to diagnosis : the history and examination; testing is ancillary to this
and best done targeted.
• Those with clear evidence on history and examination of peritonitisand any
signs of perforation, shock, or organ failure (including gut death) need an
immediate operation, not more testing.
• Serial examinations are needed (without a clear cause for their pain and when
no signs of compensated shock or organ dysfunction exist).
• The emergency physicians and inpatient physicians should notify
• their surgical colleagues early when any concern of acute abdomen
• exists and before reaching diagnostic certainty, allowing for a
• coordinated plan of care. (Vertical Hospital Referral as necessary)
 Pre Operative Preparation

• Resuscitate the patient:

– intravenous fluids where indicated
– Administration of analgesia.
• Make a broad diagnosis on the basis of history, examination and
laboratory tests and imaging if indicated.
• If peritonitis is suspected, Acute abdominal series x ray
• Antibiotics as indicated
• Nil per mouth, NGT, Urine Output monitoring, & Intra vesical
Pressure Measurement
Algorithms: Generalized pain
Algorithms: Gradual Onset
 Algorithms: Localized Pain

Right Upper Quadrant Pain Left Upper Quadrant Pain

 SUMMARY
• Evaluation and management of acute abdominal pain
remain a challenging part of a surgeon’s practice.
• Inspite of emerging diagnostic tools & procedures, a careful history
and physical examination remain the most important part of the
evaluation.
• Even with these tools at hand, the surgeon must often make the
decision to perform a laparoscopy or laparotomy with a good deal of
uncertainty as to the expected finding
Trima Kasih