Acute Abdomen

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Acute Abdomen
Nurhayat Usman, dr Sp.B-KBD
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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)

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Why is it important ?

• Patient with acute abdomen
• Sudden onset
• Unknown etiology (not clear)
• Need immediate diagnosis treatment
• Prevent morbidity mortality

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Morbidity Mortality

• Obstruction Fluid imbalance
• Perforated viscus Peritonitis
• Infection Sepsis Shock
• Bleeding Hypovolemic Shock
• Ischaemia Perforation Peritonitis

Death
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Acute abdominal pain

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

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TheDiagnosticProcess

• HISTORY
• Patient perception of symptoms
• Patient description of symptoms
• Physician perception
• Physician interpretation of symptoms
• LABORATORY SYNTHESIS
  PHYSICALFINDINGS RECORDING
  EXAM
• DECISION

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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

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History Taking

• May confirm
• Suspected diagnosis
• Possible etiology
• Disease stages/ complications
• Differential diagnosis

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

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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

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Chief complaint Ask the patient regarding why
the patient comes to you.
Onset
Site at onset
Radiation

• PAIN

Site at present
Type
Severity
Progression
Aggravating /relieving factors
Duration
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Site of pain
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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

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Central abdominal pain

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

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Lower abdominal pain

• Colonic Gangrene/Obstruction
• Appendicitis
• Mesenteric adenitis
• Diverticulitis
• Ruptured tubo-ovarial abscess
• Tuboovarial Torsion
• Ectopic gestation

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Onset of pain

• Sudden onset

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Onset of pain

• Gradual pain

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Type of pain
Visceral pain Parietal pain
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Type and severity of pain
A
C

• A. Toothache
• C. Colicky pain of inflammed hollow organs

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Type and severity of pain

• Intermittent colicky pain of obstructed hollow
  organ at early stage.

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Type and severity of pain

• Progressive Continous colicky pain due to
  strangulated bowel obstruction (ischemic stage)

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Other related symptomsAsk the patient
concerning related/concomitant symptoms of

• Gastro-intestinal function
• Nausea
• Vomiting
• Loss of appetite
• Faintness
• Previous indigestion (habitual)

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Other related symptoms

• Jaundice
• Bowel habit
• Constipation?
• Diarrhoea?
• Colour of the stool?
• Presence or absence of blood and mucus (slime)

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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)

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Previous history

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

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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.

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Implementation

• A General Examination
• General appearance Consciousness
• Mood Distressed? Anxious?
• Immobile
• Move cautiously
• Colour Pallor? Flushing? Jaundice?
• Cyanosis?

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Implementation

• Examine the vital signs
• Temperature
• Pulse rate
• Blood Pressure
• Respiratory rate

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Implementation

• Perform other systems examination, including
  cardio-pulmonary system.
• Ask the patient politely to expose his/her
  abdomen.

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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?

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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?

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Gray-Turner Sign
Cullen Sign
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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.

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

• Tenderness
• Rebound tenderness
• Muscle guarding
• Rigidity
• Murphys sign

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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

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Expansile pulsation
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Specific signs

• Rovsings sign
• Obturator sign
• Psoas sign

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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 ?

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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 ?

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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.

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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?

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• 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

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Extraperitonealcauses of acute abdomen

• Cardiothorax
• Urology
• Vascular
• E.t.c

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Acute peritonitis
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Patology
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Degree of peritoneal irritation

• (Lowenfels, 1975)

Bowel bontent
Gastric juice
Pancreatic juice
pus
Urine
blood
bile
Mild
Severe
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Signs of Intrabdominal Sepsis

• Fever, nausea, vomiting, tachicardia, tachipneu
• Abdominal pain
• Peritoneal signs
• Signs of dehydration
• Leucositosis
• Shock, Multiple organ failure

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Tips

• gt 6 hours surgically related diseases !!!
• Limited movement peritonitis / ischaemia
• Persistent pain on morphine ischaemia
• Sense of Crisis
• Repeated exams Very important

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Perforated duodenal ulcer
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Perforasi Ulkus Ventrikuli
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GI bleeding
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Pancreatitis
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Acute appendicitis
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Intusucseption
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Sigmoid volvulus
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Mesenteric thrombosis
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Iskemi Usus, Thrombosis Mesenterial
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Mechanical Intestinal Obstruction
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Obstetrics gynecological causes

• gynecology
• Ruptured ovarial cyst
• Ovarial Torsion, Myoma
• Ruptured abscess
• Perforated Uterus

• Obstetrics
• Ectopic gestation
• Abdominal pregnancy
• Rupture of the uterus
• Mola Destruen

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Abdominal pain inObgyn
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• A Good Diagnosticianis not Born,
  but is Developed