The Acute Abdomen

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 of Symptoms & 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
• Nyeri
abdomen
oleh sebab
extra
peritoneal
• Kardiotorasik
• Urologi
• Vaskular
• Lain-lain
• Nyeri
abdomen Patologi
oleh sebab
intra
peritoneal
 The differential diagnosis of acute abdomen
• Acute appendicitis
• Acute peptic ulcer and its complications
• Acute cholecystitis
• Acute pancreatitis
• Acute intestinal ischemia (see section below)
• Acute diverticulitis
• Ectopic pregnancy with tubal rupture
• Ovarian torsion
• Acute peritonitis (including hollow viscus perforation)
• Acute ureteric colic
• Bowel volvulus
• Bowel obstruction
• Acute pyelonephritis
• Adrenal crisis
• Biliary colic
• Abdominal aortic aneurysm
• Familial Mediterranean fever
• Hemoperitoneum
• Ruptured spleen
• Kidney stone
• Sickle cell anaemia
• Carcinoid
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 ).
 DEFINITION OF PAIN

It is an unpleasant sensation of varying

intensity .

Pain fibers are stimulated any time a tissue is being

damaged . However , it is not felt very long after the
damage has been accomplished.
 STIMULANTS

1 Mechanical trauma to the tissue .

2 Excess heat or cold .
3 Chemical damage.
4 Radiation damage .
5 Inadequate blood flow.
 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

Pat. Experienced pain by

traction ,distention & spasm
The visceral peritoneum is insensitive to
touch & heat or any condition that promotes
an inflammatory reaction
visceral pain tidak terangsang walaupun ada
peradangan. visceral pain terangsalng kalau
terjadi retraksi (peregangan)
 3 - Mediation

Autonomic nervous System Interpreted at

the thalamic level of the brain

CerebralCortex T
halamus

Hypothalamus
Corpuscollosum

Pons
Cerebellum

M
edulla

Spinalcord
 4- Specificity

Vague , often dull , poorly described & associated with nausea & vomiting
 Visceral pain
5- Localization

Is poor & the pat. Placing the entire

hand over the involved region
 Somatic pain
dihantarkan ke otak melalui
perpheral nerve. Langsung
diantar ke korteks 1- Receptor

Pain stimuli start in the parietal peritoneum ,

which is innervated by peripheral nerves

P/ peritoneum
 Somatic pain

Pressure 2- Stimulus
Inflammation
Heat
Pat. experienced pain by

Touch
 Somatic pain

3- Mediation

Central nervous system

&
Interpreted at a specific
cortical location
 Somatic pain

4- Specificity
Cutting

Precisely described as

Sharp
 Somatic pain

5- Localization

The pain is localized with great accuracy

by the patient , who can often point to
the site with one finger
 Diagnostic Work-up
PF dinding perut:
• inspeksi
• auskultasi lab
- peristaltik yg normal?
- bruih?
- meninggi?
- menurun?
- sunyi tidak ada suara? pa
History-PE in
？
• Palpasi:
- nyeri tekan (tenderness) > X-rays
- guard (> kasih tekanan dinding perut ditempat normal ototnya
kontraksi
- trigiditi? > belum diraba, ditekan, semua dinding perut sudah
kontraksi
Echo
CT scans
 Analysis of pain
need

DATA COLLECTION

1 2 3

History Physical exam.

Lab.inv.

apply

your medical knowledge***

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 – peristaltic , bruits
• Palpation – tenderness, guarding, rigidity
 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 udara bebas

– Reactive bowel patterns

– Foreign bodies
 Ultrasound
• Rapid, safe, low cost
• Operator dependent
• Fluid, inflammation, air in walls, masses
• Liver, GB, CBD, Spleen, Pancreas, Appendix, Kidney,
Ovaries, Uterus
Ultrasound

Textbook of Sabiston, 16th ed.

 CT Scans
• Better than plain films and US for evaluation of
solid and hollow organs
• Intravenous contrast
• Oral contrast
• Per rectal contrast
• High use in appendicitis, diverticulitis, abscess,
pancreatitis
 When to Operate ?
• Peritonitis > penyebabnya apa?
– Excluding primary peritonitis
• Abdominal pain/tenderness + sepsis
• Acute intestinal ischemia
• Pneumoperitoneum: udara di rongga abdomen
• Make sure pancreatitis is excluded
 When NOT to Operate ?
• Cholangitis
• Appendiceal abscess
• Acute diverticulitis + abscess
• Acute pancreatitis or hepatitis
• Ruptured ovarian cysts
• Long standing perforated ulcers?
 Non Surgical Causes
• MI, Acute pericarditis
• PN, pulmonary infarction
• GE reflux, hepatitis
• DKA, Ac Adrenal Insufficiency
• Acute Porphyria
• Rectus muscle hematoma
• Pyelonephritis, Acute salpingitis
• Sickle cell crisis
Appendicitis
ACUTE APPENDICITIS

Dr. Kisman Harahap, SpB

Bag. Bedah FK Unri
RSUD Arifin Achmad Pekanbaru
infeksi > jebol > viseral sign
 Signs and Symptoms
• Umbilical then migrates towards the RLQ
• Tenderness, then rebound
– Rovsing
– Psoas
• Extension of leg-pt on left
– Obturator
• Rotation of flexed thigh-pt supine
• Rectal
• Perforation related symptoms
parietal tidak
ada muntah”
terjadi nyeri tekan
kalau sudah bocor
ROVSING’S SIGN
ILIOPSOAS SIGN

digerakkan nyeri
OBTURATOR’S SIGN
 di atas 7 > operasi

dibawah 5 : observasi
 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 (emergency department) for serial
exams; if no change and course remains
benign patient can D/C (discharge) with dx of
nonspecific abd pain
• Patients are given instructions to return if
worsening of symptoms, and they should be
seen by PCP(primary care physician) 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
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.
 Treatment
• Urgent appendectomy
• Antibiotics
– Only preoperative abx needed for uncomplicated
cases
– For complicated appendicitis 7-10 days
Laparoscopic Appendectomy
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

tersumbat

:tersumbat
 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
• Sudden onset of pain
– “Set your watch to it”
• Epigastric/shoulder -gaster
• RLQ-often DUodenum
• Lower quadrant-often diverticulum
• Often pre-existing history of ulcer or diverticular
disease
nyeri: 2 jam yang lalu
DIAGNOSIS
Physical Examination
• Auscultation : peristaltic <<<<
• Percussion: liver dullness (+)
• Palpation : tenderness, guarding and
rigidity(+)“Board-like abdomen”
Diagnosis

• Plain x-rays often demonstrate

• Upright CXR (chest X ray)
– 75% of perforated DU will have free air
– Sensitive to 5 cc
• CT scan
– Sensitive to <2 cc air
 Diagnosis
• CHEST X RAY-FREE AIR
udara dari usus keluar
Diagnosis
• CT –SCAN-FREE AIR
 Management

• Acute perforation of a viscous requires emergent

exploration
• Delayed presentations are more complex
– Can avoid operation if the perforation is contained
– May require delayed interventions
 Acute Abdomen-Summary

• History and physical more important than tests

• Making the decision to operate is much more important
than making the diagnosis
• Treatment is often (BUT NOT ALWAYS) surgical
• “Very old, very young, very odd…be very careful!”
de Domball