referat of acute abdomen
TRANSCRIPT
ADVISER : DR. SJAIFUL BACHRI, SP.B. DR. JOHAN L, SP.B
WRITER : NOK RACHMATIAH (406102017)
REFERAT PRESENTATION OF
ACUTE ABDOMEN
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 damage4. 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
Location Organ
Fore gut Around epigastrium • Stomach • Duodenum• Hepatobilier system •Pancreas
Mid gut Around umbilicus • Small intestine • Colon until the middle of transversum colon
Hind gut Around lower abdominal
• From the middle of transversum colon until sigmoid colon.• Bladder
T6-T9
T6-T9
T8-T12
T8
T10
L2
S4
Somatic pain : more in line with anatomic location Location of pain Organ
Right upper abdomen
Gall bladder, liver, duodenum, pancreas, colon, lung, heart
Epigastrium Stomach, pancreas, duodenum, lung, colon
Left upper abdomen
Spleen, colon, kidney, pancreas, lung
Right lower abdomen
Appendix, adnexa, caecum, ileum, ureter,
Left lower abdomen
Colon, adnexa, ureter.
Suprapubik Bladder, uterus, small intestine
Periumbilical Small intestine
Back / hips Pancreas, aorta, kidney
Shoulder 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 : Rovsing’s sign Obturator sign Psoas sign
Rectal examination
SUPPORTING EXAMINATION
Laboratory testing Base line testing Selective testing Pregnancy test in women of child bearing ageRadiology Plain or contrast film USG Laparoscopy CT-scan /MRI
Three position plain film 1. upright chest2. 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 LeukositosisDifferential 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. Distention4. 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)
bloo
d
Urin
e
Bile
Pus
Panc
reas
flui
d
Insid
e of
inte
stin
e
Stom
ach
fluid
Mild irritation severe