1. Nurhayat Usman, dr Sp.B-KBD*
07/16/96
Acute Abdomen
Nurhayat Usman, dr Sp.B-KBD
11/7/2018 *

2. Acute Abdomen (acute abdominal pain)*
07/16/96
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) *

3. Why is it important ? Patient with acute abdomen: Sudden onset*
07/16/96
Why is it important ?
Patient with acute abdomen:
Sudden onset
Unknown etiology (not clear)
Need immediate diagnosis & treatment
Prevent morbidity & mortality *

4. Morbidity & Mortality Death Obstruction Fluid imbalance*
07/16/96
Morbidity & Mortality
Obstruction Fluid imbalance
Perforated viscus Peritonitis
Infection Sepsis Shock
Bleeding Hypovolemic Shock
Ischaemia Perforation Peritonitis
Death *

5. Acute abdominal pain Most can be diagnosed clinically*
07/16/96
Acute abdominal pain
Most can be diagnosed clinically
Require accurate and focused history taking
Need meticulous & rationale physical examination
Appropriate special investigations *

6. The Diagnostic Process*
07/16/96
HISTORY
Patient perception of symptoms
Patient description of symptoms
Physician perception
Physician interpretation of symptoms
LABORATORY SYNTHESIS PHYSICAL FINDINGS RECORDING EXAM
DECISION
The Diagnostic Process *

7. *
07/16/96
History Taking
% of accurate diagnosis arises from good & meticulous history taking
Physical diagnosis confirms accurate diagnosis
% of accurate diagnosis arise from laboratory & radiological examinations *

8. History Taking May confirm : Suspected diagnosis Possible etiology*
07/16/96
History Taking
May confirm :
Suspected diagnosis
Possible etiology
Disease stages/ complications
Differential diagnosis *

9. History Taking Introduction*
07/16/96
History Taking
Introduction
Greet the patient, and develop a warm and helpful environment
Introduce yourself to the patient *

10. *
07/16/96
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) *

11. Acute abdominal pain in specific groups*
07/16/96
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 *

12. *
07/16/96
Chief complaint: Ask the patient regarding why the patient comes to you.
Onset
Site at onset
Radiation
PAIN
Site at present
Type
Progression
Severity
Duration
Aggravating /relieving factors *

13. *
07/16/96
Site of pain *

14. Upper abdominal pain Peptic or gastric ulcer*
07/16/96
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 *

15. Central abdominal pain*
07/16/96
Central abdominal pain
Early appendicitis
Bowel obstruction, strangulated
Pancreatitis
Gastroenteritis
Mesenterial Emboli /Thrombosis
Dissecting aortic aneurism
Mesenteric adenitis
Early sigmoid diverticulitis *

16. Lower abdominal pain Colonic Gangrene/Obstruction Appendicitis*
07/16/96
Lower abdominal pain
Colonic Gangrene/Obstruction
Appendicitis
Mesenteric adenitis
Diverticulitis
Ruptured tubo-ovarial abscess
Tuboovarial Torsion
Ectopic gestation *

17. *
07/16/96
Onset of pain
Sudden onset *

18. *
07/16/96
Onset of pain
Gradual pain *

19. *
07/16/96
Type of pain
Visceral pain &
Parietal pain *

20. Type and severity of pain*
07/16/96
Type and severity of pain A C
A. Toothache
C. Colicky pain of inflammed hollow organs *

21. Type and severity of pain*
07/16/96
Type and severity of pain
Intermittent colicky pain of obstructed hollow organ at early stage. *

22. Type and severity of pain*
07/16/96
Type and severity of pain
Progressive & Continous colicky pain due to strangulated bowel obstruction (ischemic stage) *

23. *
07/16/96
Other related symptoms: Ask the patient concerning related/concomitant symptoms of
Gastro-intestinal function:
Nausea
Vomiting
Loss of appetite
Faintness
Previous indigestion (habitual) *

24. Other related symptoms:*
07/16/96
Other related symptoms:
Jaundice
Bowel habit:
Constipation?
Diarrhoea?
Colour of the stool?
Presence or absence of blood and mucus (slime) *

25. Other related symptoms:*
07/16/96
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) *

26. Previous history Similar pain Abdominal surgery*
07/16/96
Previous history
Similar pain
Abdominal surgery
Major illness: incl. fever, abdominal injury.
Drugs
Allergies *

27. PHYSICAL EXAMINATION Preparation*
07/16/96
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. *

28. Implementation: A General Examination*
07/16/96
Implementation:
A General Examination
General appearance : Consciousness
Mood : Distressed? Anxious?
Immobile
Move cautiously
Colour : Pallor? Flushing? Jaundice?
Cyanosis? *

29. Implementation: Examine the vital signs: Temperature Pulse rate*
07/16/96
Implementation:
Examine the vital signs:
Temperature
Pulse rate
Blood Pressure
Respiratory rate *

30. *
07/16/96
Implementation:
Perform other systems examination, including cardio-pulmonary system.
Ask the patient politely to expose his/her abdomen. *

31. Abdominal Examination: Inspection*
07/16/96
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? *

32. Abdominal Examination: Inspection*
07/16/96
Abdominal Examination: Inspection
Is there any rashes and discolouration?
Cullen’s sign
Gray Turner’s sign
Ecchymosis of the abdominal wall
Is there any masses:
Tumors?
Hernial sites?
Masses with pulsation? *

33. Gray-Turner Sign Cullen Sign*
07/16/96
Gray-Turner Sign
Cullen Sign *

34. Abdominal Examination: Palpation*
07/16/96
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. *

35. *
07/16/96
While palpating, look to the face expression of the patient, and look for any signs of :
Tenderness
Rebound tenderness
Muscle guarding
Rigidity
Murphy’s sign *

36. *
07/16/96
While palpating, look to the face expression of the patient, and look for any signs of :
Swelling or masses
Rovsing’s sign
Expansile pulsation
Hernial orifices
Scrotum in male *

37. *
07/16/96
Expansile pulsation *

38. *
07/16/96
Specific signs
Rovsing’s sign
Obturator sign
Psoas sign *

39. Abdominal Examination : Percussion*
07/16/96
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 ? *

40. *
07/16/96
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 ? *

41. Digital Rectal Examination*
07/16/96
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. *

42. Digital Rectal Examination*
07/16/96
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? *

43. *
07/16/96
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 *

44. Extra peritoneal causes of acute abdomen*
07/16/96
Extra peritoneal causes of acute abdomen
Cardiothorax
Urology
Vascular
E.t.c *

45. *
07/16/96
Acute peritonitis *

46. *
07/16/96
Patology *

47. Degree of peritoneal irritation*
07/16/96
Degree of peritoneal irritation
(Lowenfels, 1975)
Pancreatic juice
Bowel bontent
Gastric juice
pus
Urine
blood
bile
Mild
Severe *

48. Signs of Intrabdominal Sepsis*
07/16/96
Signs of Intrabdominal Sepsis
Fever, nausea, vomiting, tachicardia, tachipneu
Abdominal pain
Peritoneal signs
Signs of dehydration
Leucositosis
Shock, Multiple organ failure *

49. Tips Sense of Crisis > 6 hours: surgically related diseases !!!*
07/16/96
Tips
> 6 hours: surgically related diseases !!!
Limited movement: peritonitis / ischaemia
Persistent pain on morphine : ischaemia
Sense of Crisis
Repeated exams : Very important *

50. Perforated duodenal ulcer*
07/16/96
Perforated duodenal ulcer *

51. Perforasi Ulkus Ventrikuli

52. *
07/16/96
GI bleeding *

53. *
07/16/96
Pancreatitis *

54. *
07/16/96
Acute appendicitis *

55. *
07/16/96
Intusucseption *

56. *
07/16/96
Sigmoid volvulus *

57. Mesenteric thrombosis*
07/16/96
Mesenteric thrombosis *

58. Iskemi Usus, Thrombosis Mesenterial

59. Mechanical Intestinal Obstruction*
07/16/96
Mechanical Intestinal Obstruction *

60. Obstetrics & gynecological causes*
07/16/96
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 *

61. Abdominal pain in Obgyn*
07/16/96
Ruptured
organ
Content
Pus
Materials :
sebum
meconeum
Blood
Acute
abdomen
torsion
Strangulation
distention
ischaemia
Abdominal pain in Obgyn *

62. A Good Diagnostician is not Born, but is Developed*
07/16/96
A Good Diagnostician is not Born, but is Developed *