9/22/2014

Clinical Examination
of Acute Abdomen
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 Peritonitis

infection Sepsis Shock

Bleeding hypovolemic Shock

ischaemia Perforation Peritonitis
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 SYNTHESIS PHYSICAL
FINDINGS RECORDING 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.
PAIN
Site at present
Onset
Radiation
Type
Aggravating /relieving factors
Severity
Duration
Site at onset
Progression
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
Visceral pain &
Parietal pain
Type of
pain
Type and severity of pain
A. Toothache
C. Colicky pain of inflammed hollow organs
A
C
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 of :

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

Degree of peritoneal irritation
(Lowenfels, 1975)
b
l
o
o
d

U
r
i
n
e




b
i
l
e




p
u
s










P
a
n
c
r
e
a
t
i
c

j
u
i
c
e

B
o
w
e
l

b
o
n
t
e
n
t




G
a
s
t
r
i
c

j
u
i
c
e







Mild
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: surgical related diseases !!!

Limited movement: peritonitis / ischaemia

persistent pain on morphine : ischaemia

Sense of Crisis

Repeated exams : important
Perforated duodenal
ulcer

GI bleeding
Pancreatitis

Acute appendicitis

Intusucseption

sigmoid volvulus

Mesenteric
thrombosis
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
torsion
Strangulation
distention ischaemia
Abdominal
pain in
Obgyn
A Good Diagnostician
is not Born,
but is Developed