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Acute Abdomen

Nurhayat Usman, dr Sp.B-KBD 4/29/2013

Acute Abdomen (acute abdominal pain)


Condition which requires immediate treatment (FD

Moore, 1977): Surgery? When to perform?


(Buku Ajar Ilmu Bedah, 1997): Clinical condition

which arises from acute critical condition in the abdominal cavity, and usually manifests as pain.
Acute abdominal pain: Chief complaint: acute pain

(Nyhus, Vitello, Condon, 1995)

Why is it important ?
Patient with acute abdomen:

Sudden onset Unknown etiology (not clear) Need immediate diagnosis & treatment

Prevent morbidity & mortality

Morbidity & Mortality


Obstruction Fluid imbalance

Perforated viscus
Infection Bleeding Sepsis

Peritonitis
Shock

Hypovolemic Shock Peritonitis

Ischaemia Perforation

Acute abdominal pain


Most can be diagnosed clinically Require accurate and focused history taking Need meticulous & rationale physical examination Appropriate special investigations

The Diagnostic Process

HISTORY Patient perception of symptoms Patient description of symptoms Physician perception Physician interpretation of symptoms

LABORATORY FINDINGS

SYNTHESIS RECORDING

PHYSICAL EXAM

DECISION

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

History Taking
Introduction
Greet the patient, and develop a warm and helpful environment Introduce yourself to the patient

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)

Acute abdominal pain in specific groups


In children

Acute appendicitis

In the elderly

Perforated tumors Bowel obstruction due to tumors

During pregnancy

Complicated Ectopic pregnancy

Chief complaint:

Ask the patient regarding why the patient comes to you.


Onset Radiation Type Site at onset

PAIN
Duration

Site at present

Progression

Severity
Aggravating /relieving factors

Site of 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


Colonic Gangrene/Obstruction Appendicitis

Mesenteric adenitis
Diverticulitis Ruptured tubo-ovarial abscess Tuboovarial Torsion Ectopic gestation

Onset of pain
Sudden onset

Onset of pain
Gradual pain

Type of pain

Visceral pain & Parietal pain

Type and severity of pain


A

A. Toothache C. Colicky pain of inflammed hollow organs

Type and severity of pain

Intermittent colicky pain of obstructed hollow organ at

early stage.

Type and severity of pain

Progressive & Continous colicky pain due to

strangulated bowel obstruction (ischemic stage)

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
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.

Implementation:
A General Examination
General

appearance : Consciousness Mood : Distressed? Anxious? Immobile Move cautiously Colour : Pallor? Flushing? Jaundice? Cyanosis?

Implementation:
Examine the vital signs:
Temperature Pulse

rate Blood Pressure Respiratory rate

Implementation:
Perform other systems examination, including

cardio-pulmonary system.
Ask the patient politely to expose his/her

abdomen.

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?

Cullens sign Gray Turners sign Ecchymosis of the abdominal wall Is there any masses: Tumors? Hernial sites? Masses with pulsation?

Cullen Sign

Gray-Turner Sign

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.

While palpating, look to the face expression of the patient, and look for any signs of :

Tenderness Rebound tenderness Muscle guarding Rigidity Murphys sign

While palpating, look to the face expression of the patient, and look for any signs of :
Swelling

or masses Rovsings sign Expansile pulsation Hernial orifices Scrotum in male

Expansile pulsation

Specific signs
Rovsings sign Obturator sign

Psoas sign

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 ?

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 ?

Digital Rectal Examination


Put on surgical hand

gloves and ask the patient to expose his/her buttock and anus, and place the patient in lithotomy position.Apply lubricating jelly on to the right index finger.

Digital Rectal Examination


Gently insert your right index finger into the anus, move

toward the anal canal slowly, and evaluate the followings: Anal margin: piles? Mucosal surface of the anal canal and the ampulla (collaps?) Sites of any pain elicited Masses or swelling: consistency, location, surface, fixity to the surroundings. Bowel contents: consistency of faeces? Mucus? Blood?

Perform bimanual palpation in female patient to

examine the uterus, pelvic cavity and adnexa.


Write up

Write up all significant findings in the medical record. Conclude your diagnosis and differential diagnosis, and order any necessary special investigations

Extra peritoneal causes of acute abdomen


Cardiothorax Urology Vascular E.t.c

Acute peritonitis

Patology

(Lowenfels, 1975)

Degree of peritoneal irritation

Mild
blood Urine bile

pus
Pancreatic juice Bowel bontent Gastric juice Severe

Signs of Intrabdominal Sepsis


Fever, nausea, vomiting, tachicardia, tachipneu

Abdominal pain
Peritoneal signs Signs of dehydration Leucositosis Shock, Multiple organ failure

Tips
> 6 hours: surgically related diseases !!!

Limited movement: peritonitis / ischaemia


Persistent pain on morphine : ischaemia

Sense of Crisis
Repeated exams : Very important

Perforated duodenal ulcer

Perforasi Ulkus Ventrikuli

GI bleeding

Pancreatitis

Acute appendicitis

Intusucseption

Sigmoid volvulus

Mesenteric thrombosis

Iskemi Usus, Thrombosis Mesenterial

Mechanical Intestinal Obstruction

Obstetrics & gynecological causes


Obstetrics Ectopic gestation Abdominal pregnancy Rupture of the uterus Mola Destruen gynecology Ruptured ovarial cyst Ovarial Torsion, Myoma Ruptured abscess Perforated Uterus

Ruptured organ

Content
Pus Materials : sebum meconeum

Blood

Acute abdomen

Abdominal pain in Obgyn

ischaemia
Strangulation

distention
torsion

A Good Diagnostician

is not Born,
but is Developed

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