GROUP 8 CASE 4

MondaySeptember 19th 2011

Dr. Linda Tutor

Ahmad Farid Haryanto Leader

Johan Yap Secretary

Marcelly Raymando Satyo Scriber

Kevin Barnabas Malingkas Member

Meida Astriani Member

Anggi Zerlina Darwin Member

Megawati Lohanatha Member

Anggelina Angkola Member

Angelia Member

Maria N.E. Bagul Member

Nancy Member

Amelia Febriana Hanjaja Member

GRO

UP 8

PROBLEM 4A (Adult)

A 25-year-old female has periumbilical pain that began 8 hours ago; since then she has vomited once with a small, loose bowel movement. Her last meal was 12 hour ago, and she doesn’t feel hungry. She denies dysuria and urinary frequency; her last period was a week ago. On examination, she moderately uncomfortable and her temperature is 38,30C; other vital signs are normal. Breath sounds are clear; she has no rashes. Abdominal examination reveals few bowel sounds, rectus muscle rigidity and tenderness to palpation, particularly periumbilically. Pelvic examination shows no vaginal discharge, but there is some abdominal tenderness with gentle bimanual palpation. She feels pain on digital rectal examination.

LEARNING OBJECTIVE

• Students can explain acute abdomen, make the diagnosis and exclude the differential diagnosis

oAppedicitisoPeritonitiso Intestinal Obsctruction / Ileuso SalpingitisoUTI

What we need to know

• Anatomy of Lower GI.Tract System– Jejunum– Ileum– Colon (Appedix)– Rectum

• Abdominal Quadrant and It’s Content

ACUTE ABDOMEN

ACUTE ABDOMEN

• The acute abdomen can be defined generally as an

intra-abdominal process causing severe pain and

often requiring surgical intervention. It is a condition

that requires a fairly immediate judgement or

decision as to management.

http://www.ece.ncsu.edu/

Major Sign and Symptoms

• Abdominal pain • Guarding (contraction of abdominal muscles and

discomfort when the doctor presses on the abdomen)

• Rigidity (hardness) of abdominal muscles • Rebound tenderness (an increase in severe pain

and discomfort when the doctor abruptly stops pressing on a localized region of the abdomen)

• Leukocytosis (increase in white blood cell count)

Types of Abdominal PainTypes of Abdominal Pain

SOMATIC PAINSOMATIC PAIN VICERAL PAINVICERAL PAIN

1 2

• Colic pain • Ischemic pain• Peritonitis

Somatic Pain Visceral Pain

Receptor Pain stimuli start in the parietal peritoneum, which is innervated by peripheral nerves

Visceral peritoneum

Stimulus Touch, pressure, heat, inflammation

Traction, distention, & spasm

Mediation CNS & interpreted at a specific cortical location

Autonomic Nervous System interpreted at the thalamic level of the brain

Specifity Precisely described as sharp, knifelike, cutting

Vague, often dull, poorly described

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

Poor and the patien is placing the entire hand over the involved region

Characteristic of Abdominal pain

– Referred painperceived at a site distant from the source of stimulus.example : irritation of diaphragm can produce pain in the shoulder.

– Migration painshifting from one place to another which can give insight into the diagnosisexample : pain that moves from the epigastrium to the periumbilical and moves again to the RLQ.

– Cholic painContinue pain which is response from parietal peritoneumcontinuely with guarding.Appears because of smooth muscle spasm from hollow visceralintermitent.

– Ischemic painIs a alarm sign of necrosis. Sharp and persistent

DIAGNOSIS OF ACUTE ABDOMEN• Anamnesis• Labolatory Testing• Physical Examination• Diagnostic Imaging

Anamnesis

– Past historyappendectomy, cholecystectomy, and so forth

– Medicationcorticosteroid, anticoagulants, cocaine

– Age– Patients position– Menstrual history

PHYSICAL EXAMINATION

• Patient overall appearancepale,iritable,activity

• Evaluation of the vital signsTemperature, Heart rate, Respiratory rate, Blood pressure

• Inspection• Auscultation• Palpation• Percussion

DIAGNOSTIC IMAGING

Radiographic studies • Abdominal ultrasound• Computerized tomography (CT) of the

abdomen• Magnetic resonance imaging (MRI)• Barium x-rays• Capsule enteroscopy

APPENDICITIS

Epidemiology

• Peak incidence : ages 10 – 30 years• Most common acute surgical condition of

abdomen• Males and females are equally affected,

except between puberty and age 25, when males predominate in a 3:2 ratio.

Risk Factor

• Most cases of appendicitis occur between the ages of 10 and 30 years.

• Having a family history of appendicitis may increase a child's risk for the illness

• Having cystic fibrosis also seems to put a child at higher risk.

ETIOLOGY

• Obstuction, by:– Fecal mass– Enlarged lymphoid follices, associated with a

variety of inflammatory and infectious disorders including Crohn disease, gastroenteritis, amebiasis, respiratory infections, measles, and mononucleosis

– Worms (pinworms, Ascaris, and Taenia)– Viral infections ( measles )– Tumors

Patophysiology

Inflammation

Obstructs the appendix

Obstruction of mucus outflow

Pressure in appendix increases

Appendix contracts

Multiplying bacteria, inflammation and

pressure continue to increase

Restricting blood flow to the organ

Severe abdominal pain

Mucus, stool, or parasites

The blood supply to the appendix is cut

off

Reduced blood flow

Necrosis

Perforation

Appendicular abcsess

Peritonitis

If

• SIGN and SYMPTOMS– The abdominal pain usually

• begins near the belly button and then moves lower and to the right ( from epigastric to RLQ )

• gets worse in a matter of hours

• gets worse when moving around, taking deep breaths, coughing, or sneezing

– Other symptoms of appendicitis may include

• loss of appetite• nausea• vomiting• constipation or diarrhea• inability to pass gas• a low-grade fever that

follows other symptoms• abdominal swelling• the feeling that passing

stool will relieve discomfort

DIAGNOSIS

1. Anamnesis2. Physical examination

• Low grade fever• Pain at Mc Burney’s point• Rebound tenderness • Guarding• Psoas sign (+)

3. Labolatory Testing• WBC count > 10,500

cells/mm3 Neutrophilia greater than 75%

• CRP test

4. Diagnostic Imaging•Abdominal x-ray •CT scan of the abdomen:

Very good test for diagnosing appendicitis•Ultrasound of the abdomen •MRI scan of the abdomen

May be helpful in diagnosing acute appendicitis in the pregnant female.

Management

• Choice of therapy– Surgery– Medications

• If the diagnosis is too late, perforation may occur already and the mortality may increase if it happens

MEDICATION

• Antibiotics– Metronidazole (Flagyl)– Gentamicin (Gentacidin,

Garamycin)– Cefotetan (Cefotan)– Cefoxitin (Mefoxin)– Meropenem (Merrem)– Piperacillin and tazobactam

sodium (Zosyn)– Ampicillin and sulbactam

(Unasyn)

• Analgesics– Morphine sulfate

(Astramorph, Duramorph, MS Contin, MSIR, Oramorph)

SURGERY• Surgery to remove the appendix is called an

appendectomy• The two types of appendectomy include:

– Open appendectomy: • An incision is made in the right lower abdomen and the

appendix is removed through the incision.

– Laparoscopic appendectomy: • A small incision is made in the umbilicus and the surgeon

uses a flexible fiberoptic scope to remove the appendix through the small incision.

• The laparoscope cannot be used if the surgeon suspects that the appendix has ruptured

ComplicationIntraperitoneal complications

Early Appendix stump blowout-spillage of

colonic contents into the peritoneal cavity.

Generalised peritonitis-perforated or gangrenous appendix , virulent organisms, late presentation or diagnosis

Abscesses-local, pelvic, subhepatic, subphrenic

Retained fecolith causing chronic local infection

Haematoma due to slippage of a vascular ligature or a mesenteric or omental tear

Early or late (even many years later)Intestinal obstriction due to adhesion

LateInfertility due to tubal occlusion

following pelvic infection

Abdominal wall complications• Early

– Superficial wound infection– Deep wound infection– Dehiscence

• Late– Incisional hernia

PROGNOSIS

• The prognosis is excellent. • With uncomplicated appendicitis, most people recover with

no long-term complications.

PERITONITISPeritonitis is an inflammation (irritation) of the peritoneum, the tissue that lines the wall of the abdomen and covers the

abdominal organs.

2 Major Types• Primary: Caused by the spread of an infection

from the blood & lymph nodes to the peritoneum. Very rare < 1%

• Usually occurs in people who have an accumulation of fluid in their abdomens (ascites).

• The fluid that accumulates creates a good environment for the growth of bacteria.

• Secondary: Caused by the entry of bacteria or enzymes into the peritoneum from the gastrointestinal or biliary tract.

• This can be caused due to an ulcer eating its way through stomach wall or intestine when there is a rupture of the appendix or a ruptured diverticulum.

• Also, it can occur due to an intestine to burst or injury to an internal organ which bleeds into the internal cavity.

Intra-abdominal infections result in 2 major clinical manifestations

• Early or diffuse infection results in localized or generalized peritonitis.

• Late and localized infections produces an intra-abdominal abscess.

Signs and Symptoms

The signs and symptoms of peritonitis include:• Swelling rigidity and tenderness in the abdomen

with pain ranging from dull aches to severe, sharp pain

• Fever and chills• Loss of appetite• Thirst• Nausea and vomiting• Limited urine output• Inability to pass gas or stool

Diagnosis

The following procedures also may be performed:• Blood tests -- to see if there is bacteria present in

your blood• Samples of fluid from the abdomen -- identify the

bacteria causing the infection• CT scan -- identifies fluid in the abdomen, or an

infected organ• X-rays -- detect air in the abdomen, which

indicates that an organ may be torn or perforated

Evaluation :

• The usual sounds made by the active intestine and heard during examination with a stethoscope will be absent, because the intestine usually stops functioning.

• The abdom may be rigid and boardlike• Accumulations of fluid will be notable in primary

due to ascites.

Examination • Leukocytosis

• Marked acidosis are common laboratory findings.

• Plain abdominal films may show dilation of large and small bowel with edema of

the bowel wall.

• Free air under the diaphragm is associated with a perforated viscus.

• CT and/or ultrasonography can identify the presence of free fluid or an abscess.

• When ascites is present, diagnostic paracentesis with cell count (>250

neutrophils/L is usual in peritonitis), protein and lactate dehydrogenase levels,

and culture is essential.

• In elderly and immunosuppressed patients, signs of peritoneal irritation may be

more difficult to detect.

THERAPY• The therapy goal in curing peritonitis, is to

rehydrate, correction of electrolytes abnormalities, preventing further infections, and to correct the underlying problem(s)

• It has high mortality rate for patient that have suffered more than 48 hours ( up to 40 % )

Complications

• Sepsis -- an infection throughout the blood and body that can cause shock and multiple organ failure

• Abnormal clotting of the blood (generally due to significant spread of infection)

• Formation of fibrous tissue in the peritoneum• Adult respiratory distress syndrome -- a

severe infection of the lungs

Prognosis

• With treatment, patients usually do well. Without

treatment, the outcome is usually poor.

• Peritonitis can be life threatening and may cause a

number of different complications. Complications

depend on the specific type of peritonitis.

Perforation

Definition Gastrointestinal perforation is a hole that develops through the

entire wall of the stomach, small intestine, large bowel, or gallbladder. This condition is a medical emergency.

Etiology Gastrointestinal perforation can be caused by a variety of illnesses,

including appendicitis, diverticulitis, ulcer disease, gallstones or gallbladder infection, and less commonly, inflammatory bowel disease, including Crohn's disease and ulcerative colitis.

It may also be caused by abdominal surgery.

PerforationSymptoms Perforation of the intestine leads to leakage of intestinal

contents into the abdominal cavity. This causes inflammation called peritonitis.

Symptoms may include: Abdominal pain - severe Chills Fever Nausea Vomiting

Examinations• X-rays of the chest or abdomen

may show air in the abdominal cavity (not in the stomach or intestines), suggesting a perforation.

• CT scan of the abdomen often shows the location of the perforation.

• The white blood cell (WBC) count is often higher than normal.

TreatmentsTreatment usually involves

surgery to repair the hole (perforation). Occasionally, a small part of the intestine must be removed. A temporary colostomy or ileostomy may be needed.

In rare cases, antibiotics alone can be used to treat patients whose perforations have closed. This can be confirmed by a physical exam, blood tests, CT scan, and x-rays.

Prognosis Surgery is usually successful, but

depends on the severity of the perforation and the length of time to treatment.

Complications Bleeding Infection ( including a widespread

infection called sepsis, which can lead to death )

Intra-abdominal abscess

Preventions Prevention depends on the cause.

Diseases that may lead to intestinal perforation should be treated appropriately.

Adynamic ileusMechanical ileus

Ileus

ILEUS

• DEFINITION is a term for a difficulty of intestine passage. – Ileus is divided into two:

• Ileus obstructive• Ileus paralytic.

– Ileus obstructive is caused by an obstruction. – Ileus is paralytic is caused by nerve problems.

The Difference between Paralytic Ileus and Obstructive Ileus

Paralytic Ileus

• Bowel sounds minimal

• Air Fluid level provides

line up

• Not accompanied by a

paroxysmal colicky

abdominal pain

Obstructive Ileus

• Bowel sounds hyperactive

• Air fluid level provides a

stepladder

• Accompanied by a

paroxysmal colicky

abdominal pain

Adynamic ileus Paralysis of intestinal motility

Causes A. Abdominal trauma B. Abdominal surgery (i.e. laparatomy) C. Serum electrolyte abnormality Hypokalemia,

Hyponatremia, Hypomagnesemia, Hypermagensemia D. Infectious, Inflammatory or irritation (bile, blood)

1.Intrathoracic Pneumonia, Myocardial Infarction2.Intrapelvic Pelvic Inflammatory Disease3.Intraabdominal Appendicitis, Diverticulitis,

Cholecystitis, Pancreatitis, Perforated Duodenal Ulcer E. Intestinal Ischemia Mesenteric embolism, ischemia or

thrombosis F. Skeletal injury Rib fracture, Vertebral fracture G. Medications Narcotics, Phenothiazines, Diltiazem or

Verapamil, Clozapine, Anticholinergic

Symptoms A. Abdominal distention

B. Nausea and Vomiting are variably present

C. Generalized abdominal discomfort

Colicky pain of Mechanical Ileus is usually absent

A. Flatus and Diarrhea may still be passed

Signs A. Quiet bowel sounds

B. Abdominal distention

Differential Diagnosis A. Mechanical Ileus

B. Bowel Pseudoobstruction

Radiology: Refractory ileus course A. Indicated to evaluate for Mechanical Ileus B. Upper GI series and small bowel follow through

1. May be diagnostic and therepeutic 2. Use gastrograffin instead of barium 3. Barium may further obstruct bowel lumen 4. Gastrograffin may stimulate bowel motility

C. Decompress stomach with Nasogastric TubeD. Instill gastrograffin via Nasogastric Tube

Management A. Initial

1. Limit or eliminate oral intake 2. Intravascular fluid replacement 3. Correct electrolyte abnormalities (e.g. Hypokalemia) 4. Consider Nasogastric Tube placement

B. Refractory Management 1. Consider Prokinatics 2. Consider lower bowel stimulation (e.g. Enema)

Mechanical ileus

Types A. Simple mechanical obstruction

1. Bowel lumen is obstructed 2. No vascular compromise

B. Closed loop obstruction 1. Both ends of a bowel loop are obstructed 2. Results in strangulated obstruction if untreated 3. Rapid rise in intraluminal pressure

C. Strangulated obstruction1. Bowel lumen and vascular supply is

compromised

Causes A. Most Common Causes

1. Postoperative Adhesions (accounts for 50% of cases)

2. Hernia (25% of cases, especially younger patients)

3. Neoplasms (10% of cases, esp. older patients)

a. Colon Cancer (most common) b. Ovarian Cancer c. Pancreatic cancer d. Gastric Cancer

Symptoms • Frequent and recurrent Generalized Abdominal Pain • Duration: Seconds to minutes

– Character: Spasms of crampy abdominal pain – Frequency

a. Intermittent pain initially b. Every few minutes in proximal obstruction c. Constant pain suggests ischemia or perforation

Symptoms more severe in proximal obstruction 1. Proximal obstruction

a. Severe, colicky abdominal pain b. Constant pain suggests ischemia or perforation c. Develops over hours and occurs every few minutes d. Bilious Emesis e. Mild abdominal distention

2. Distal obstruction a. Develops over days and becomes progressively worse b. Emesis may occur and is brown and feculent c. Significant abdominal distention

Signs• Bowel sounds

– Initial: High pitched, hyperactive bowel sounds

– Later: hypoactive or absent bowel sounds • Tender abdominal mass Closed loop Bowel

Obstruction may be palpable • Abdominal distention and tympany on

percussion Indicates distal obstruction • Rectal examination for blood

Management: Conservative Therapy A. Fluid replacement B. Bowel decompression

1. Nasogastric Tube2. Long intestinal tube offers no advantage

C. Antibiotic 1. Indications

a. Surgery planned b. Bowel ischemia or infarction c. Bowel perforation

2. Cover Gram Negatives and Anaerobesa. Second-generation Cephalosporin

Indications for surgery 1. Inadequate relief with Nasogastric tube

placement 2. Persistant symptoms >48 hours despite

treatment (strangulation)3. Neoplasms

Complications A. Intestinal Ischemia or infarction B. Bowel necrosis, perforation and bacterial

peritonitis C. Hypovolemia

Differential Diagnosis

Pancreatitis

Pancreatitis• Pancreatic inflammatory disease may be

classified as– Acute Pancreatitis– Chronic Pancreatitis

Acute Pancreatitis• Etiology

– Alcohol– Gallstones– metabolic factors ( hypercalcemia, renal failure )– Drugs ( NSAIDs )– Abdominal trauma/surgery

• The pathologic divide into– Edematous pancreatitis

usually mild and self limited– Necrotic pancreatitis

Acute Pancreatitis• Pathophysiology

Acute Necrotic pancreatitis

Edema and vascular damage

Viral infection, endotoxin, eksotoxin,

Digest cellular membrane

Autodigestion proteolytic enzyme (esp. trypsin)

Acute Pancreatitis• Clinical feature

– Abdominal pain located in periumbilical and often radiates to the back

– Nausea and vomiting– Chemical peritonitis– Pain is more intense when the patient is

supine– Low-grade fever

Acute Pancreatitis• Local Complication

– Pancreatic abscess– Pancreatic ascites– Rupture pancreas

• Systemic Complication– Hypovolemia– Pleural effusion– Sudden death– Peptic ulcer– Renal artery

thrombosis

Acute Pancreatitis• Treatment

– Analgesic for pain– Intravenous fluids and colloids to maintain

normal intravascular volume– nasogastric suction– Prophylactic antibiotics

Chronic Pancreatitis

• Chronic pancreatitis may present as episodes of acute inflammation in a previously injured pancreas or as chronic damage with persistent pain or malabsorption.

SALPHINGITIS

Definition

• Inflammation of the fallopian tube. When the ovaries are involved, it is termed Pelvic Inflammatory Disease (PID)

• As a result of the infection spreading to the top of the uterus

• Because at most gonorrhea infections, puerperal infection, postabortum

• Can also be caused by the actions (kerokan, laparotomy, insertion of IUD)

Sign and symptoms

• Pain is usually bilateral• Pelvic pressure • Back pain radiating down one or both legs• Nausea and headache• Distended abdomen and hypoactive bowel

sounds• Extreme tenderness with bimanual exam• Purulent cervical discharge

TREATMENTFor uncomplicated infection due to N. gonorrhoeae, options include:

• Ceftriaxone 125 mg IM• Cefixime 400 mg po • Ciprofloxacin 500 mg po

Because C. trachomatis often accompanies N. gonorrhoeae, the following may be used:

• Doxycycline 100 mg po bid for 7 days• Azithromycin 1 g po in a single dose • Ofloxacin 300 mg bid for 7 days

Conclusions and Suggestions

• This patient had an acute abdomen that most likely caused by appendicitis.

• We suggest him to take further examination (labolatory and imaging test) to exclude the other differential diagnosis.