LECTURE 3.

5
ACUTE ABDOMEN NON TRAUMA
OF GASTROINTESTINAL

Dr. dr. Adeodatus Yuda Handaya, SpB-KBD

Digestive Surgery Division, Department of Surgery, Faculty of Medicine,
Universitas Gadjah Mada/Dr. Sardjito Hospital

2020
Dr dr Adeodatus yuda handaya SpB KBD
EDUCATION
• GP, Medical Faculty University ofGadjahmada, 2000
• Surgeon,MedicalFaculty University ofGadjahmada,2006
• Doctor, Medical Faculty University ofBrawijaya, 2012
• Digestive, Medical Faculty University ofAirlangga, 2013.
CAREER
• Digestive DivisionSardjito/Medical Faculty University ofGadjahmadaYogyakarta, 2015-
present;BethesdaandPantirapihprivathospital

SPECIAL NOTE
• 39 publications,National and international (reseachgatedata, 2020)
• 1stWinner Poster at Asian Case Report and Original Article Competition, 2018.
• Reviewerat Annals of Coloproctology international Scopus indexing Journal, 2018-
• Award-winning“ Best Lecture“GadjahUniversity Medical faculty in 2019.
• Invited SpeakerThe 2ndSurgical Infection Society AsiaPasific,Korea4-5Juli2019
• Board AdvisorSurgical InfectionSosciety-Asia Pacific2018-
• CoAuthorand Contributor, Indonesian Guidelines Complicated intra-abdominal infections
2018
 OUTLINES : ACUTE ABDOMEN NON TRAUMA
OF GASTROINTESTINAL
Acute Abdominal

Pathophysiology of Abdominal Pain

Gastrointestinal Bleeding

Gastrointestinal Obtruction

Gastrointestinal Infection
ACUTE ABDOMEN

Acute abdomen
• acutely painful condition in the abdominal cavity
• initially cannot be specified as a nonsurgical or
surgical aetiology
Acute abdomen àcomplex of symptoms
• disturbed circulatory regulation
• and requires emergent therapeutic intervention.
Kumar MS et al. The non traumatic acute abdomen and its clinical spectrum. Int Surg J. 2019
May;6(5):1710-1715. DOI: http://dx.doi.org/10.18203/2349-2902.isj20191895
 SIX FEATURES ABDOMINAL PAIN

onset

progression

migration

character

Intensity

and localization.

Sherman R. Abdominal Pain. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and
Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 86
 PATHOPHYSIOLOGY OF ABDOMINAL PAIN
Sensory Receptor Pain Localization Stimulation
Nerve Specificatio
n

VISCE Autono Visceral Slow in Poorly Ischemic

RAL mic periton onset dull Localized inflammation
PAIN afferen eum protracte (mid line) distention
tC d traction
fibers Colicky
SOMA Central Parietal Sharp Localized Irritation
TIC C–A periton (pus, bile
PAIN delta eum GI secretion)
fibers
Ferdane Sapmaz, et al. Non-Surgical Causes of Acute Abdominal Pain, Actual Problems of Emergency Abdominal
Surgery. IntechOpen (September 21st 2016). DOI: 10.5772/64176. Available from:
https://www.intechopen.com/books/actual-problems-of-emergency-abdominal-surgery/non-surgical-causes-of- 6
acute-abdominal-pain
Sensory Nerve – Abdominal Pain

7
VISCERAL PAIN
Bilateral sensory supply to the spinal cord

FORE GUT
Gaster, duodenum,
hepar, pankreas

MID GUT
Jejnunum – flex
lienalis

HIND GUT
Colon – rectum
Proximal

8
 Complication : COMPLICATIONS
untreated, not
optimal, acute abdomen may
result in the following:
• Sepsis
• Necrosis and/or gangrene of bowel
• Fistula
• Death
Patterson JW, Kashyap S, Dominique E. Acute Abdomen. In: StatPearls. Treasure Island (FL):
StatPearls Publishing; July 14, 2020.
ACUTE ABDOMEN NON TRAUMA

GI Bleeding
GI Obtruction
GI Infection
 TYPE SURGERY OF ACUTE ABDOMEN

Kumar MS et al. The non traumatic acute abdomen and its clinical spectrum. Int Surg J. 2019
May;6(5):1710-1715. DOI: http://dx.doi.org/10.18203/2349-2902.isj20191895
Gastrointestinal Bleeding
 Etiology Duodenal Ulcer-30%
Upper GI Gastric Ulcer-20%
Bleeding Varices-10%
Gastritis&duoden
itis-5-10%
Esophagitis-5%
GI Malignancy-1%
Biecker Erwin, et al. Diagnosis and Management of Upper Gastrointestinal Bleeding. Dtsch Arztebl Int 2008; 105(5): 85–94. DOI:
10.3238/arztebl.2008.0085
Wilkins T, et al. Diagnosis and management of upper gastrointestinal bleeding. American family physician. 2012 Jan 1;85(5):469-476.
Upper GI Bleed Gastric Cancer
 UpperGI Hematemesis (50%)
Bleed
NGT with positive blood on
aspirate
Hematochezia(11%)

Melena (black tarry stools)—

150-200cc blood UGI tract.
Stool turns blackà8 hours.

Kim BSM, et al. Diagnosis of gastrointestinal bleeding: A practical guide for clinicians. World J Gastrointest Pathophysiol 2014; 5(4):
467-478. DOI: http://dx.doi.org/10.4291/wjgp.v5.i4.467
Wilkins T, et al. Diagnosis and management of upper gastrointestinal bleeding. American family physician. 2012 Jan 1;85(5):469-476.
 Etiology Diverticular-20%
Lower GI Malignancy-2-26%
IBD-10%
Ischemic Colitis
Acute Infectious Colitis
Radiation Colitis/Proctitis

Ghassemi Kevin A. and Jensen Dennis M. Lower GI Bleeding: Epidemiology and Management. Curr Gastroenterol
Rep. 2013 July ; 15(7): . doi:10.1007/s11894-013-0333-5
Lower GI Bleed : Polip Colon (FAP)
 Lower Hematochezia
GI Bleed
Blood in Toilet

Clear NGT aspirate

Usually
Hemodynamicallystable
Kim BSM, et al. Diagnosis of gastrointestinal bleeding: A practical guide for clinicians. World J Gastrointest
Pathophysiol 2014; 5(4): 467-478. DOI: http://dx.doi.org/10.4291/wjgp.v5.i4.467
 Management GI Bleeding

Emergency resuscitation (Surgery/ Non Surgery)

Pharmacological
• Stop NSAIDS/anti-platelets/anti-coagulants
• Tranexamic acid
CT angiogram – diagnostic only

Beck David E, et al. Evaluation and Management of Gastrointestinal Bleeding. The Ochsner Journal 7:107–113,
2007
 Management GI Bleeding

Endoscopic Surgical
diagnostic and therepeutic
(injection, diathermy, clipping) very difficult to determine
bleeding point at laparotomy

OGD àupper GI source

Segmental colectomy;Subtotal
Colonoscopyà Lower GI colectomy,Total Colectomi
Source

Gaiani Federica, et al. Clinical approach to the patient with acute gastrointestinal bleeding. Acta Biomed 2018; Vol.
89, Supplement 8: 12-19 DOI: 10.23750/abm.v89i8-S.7861
Beck David E, et al. Evaluation and Management of Gastrointestinal Bleeding. The Ochsner Journal 7:107–113,
2007
Gastrointestinal Obtruction
 Clasification GI Obtruction

Gore Richard M, et al. Bowel Obstruction. Radiol Clin N Am 53 (2015) 1225–1240. Doi:
http://dx.doi.org/10.1016/j.rcl.2015.06.008
 GI OBTRUCTION SYMPTOMS

High SBO Low SBO Large BO

Vomiting Distention
early,profuse, Pain dominan
is early &
rapid pronounced
dehidration Central Pain is mild
distention
lateVomiting &
Distention dehydration
minimal Vomiting
delayed Distention
proximal colon
Little evidence Multipelair and caecum
fluid level (Rx) fluid level (Rx) (Rx)
Etiology Small BO
Intraluminar
• Invaginasi
• Gallstone
Intramural
• Crohn’s
• Radiation stricture
• Adenocarsinoma
Extramural
• Adhesion
• Hernia
• Karsinomatosisperitoneal

Kulaylat MN, Doerr RJ. Small bowel obstruction. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment:
Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.
LOW SBO
Etiology Large BO
Intraluminar
• Constipation

Intramural
• Adenocarsinoma
• GIST
• Diverticulitis
• IBD Stricture
• Radiation stricture
Extramural
• Volvulus
• Adhesion
• Tumor Intraabdominal
LARGE BO
INTRAMURAL : ADENO CARSINOMA
EXTRAMURAL : PERITONEAL CARCINOMATOSIS
 Examination
• Dehidration
• Abdominal Mass (±)
• Distended
• Increasing Bowel sound
• DRE (RT)àMass, Blood
Bower Katie Love, et al. Small Bowel Obstruction. Surg Clin N Am - (2018). Doi:
https://doi.org/10.1016/j.suc.2018.05.007
Griffiths Shelly and Glancy Damian G. Intestinal obstruction. Surgery (Oxford) Volume 35, Issue 3, March 2017,
Pages 157-164. Doi: https://doi.org/10.1016/j.mpsur.2016.12.005
 Investigation
• AXRàCausa, level obstuction
• Bloodtestàanemia (ca)
• USGàmechanical VS paralitik
• ColonoscopyàCausa,biopsi
• CT Scanàcausa, Staging

Griffiths Shelly and Glancy Damian G. Intestinal obstruction. Surgery (Oxford) Volume 35, Issue 3, March 2017, Pages
157-164. Doi: https://doi.org/10.1016/j.mpsur.2016.12.005
Gore Richard M, et al. Bowel Obstruction. Radiol Clin N Am 53 (2015) 1225–1240. Doi:
http://dx.doi.org/10.1016/j.rcl.2015.06.008
 Management GI Obtruction

• Decompresion: NG / Rectal Tube

• Antibiotic &Analgetic
• SurgeryàTumor,hernia,Adhesionetc
• Fluid &Electrolit
• Fluid replacement (IV)
• ElectrolytesàCorection
• Urine output monitoring
Griffiths Shelly and Glancy Damian G. Intestinal obstruction. Surgery (Oxford) Volume 35, Issue 3, March 2017,
Pages 157-164. Doi: https://doi.org/10.1016/j.mpsur.2016.12.005
Gastrointestinal Infection
SOURCE OF GI INFECTION
39
 40

Patterson JW, Kashyap S, Dominique E. Acute Abdomen. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July
14, 2020.
ABDOMINAL PAIN
Migrating pain /Shifting pain :
• Appendicitis, Gastric perforated

Referred pain :
• Cholelithiasis

Radiating pain :
• Ureteral colic
41
Woessner James. Referred Pain vs. Origin of Pain Pathology. Practical PAIN MANAGEMENT, Nov/Dec
2003
Referred pain

42
 ABDOMINAL INFECTION (AI)

Uncomplicated
abdominal infections
• intramural inflammation(GI)
• without anatomic disruption.
• simple to treat
• risk of progressioninto a CAI

Lopez, N., Kobayashi, L. & Coimbra, R. A Comprehensive review of abdominal infections. World J Emerg
Surg 6, 7 (2011). https://doi.org/10.1186/1749-7922-6-7
ACUTE APPENDICITIS
CHOLELITHIASIS CHOLESISTITIS
CHOLELITHIASIS & CHOLESISTITIS

46
https://www.health.harvard.edu/a_to_z/cholecystitis-a-to-z
 COMPLICATED
INTRA-ABDOMINAL INFECTIONS (CIAIS)
Extend beyond the source

• organ to peritoneal space

peritonealinflammation

Peritonitis:

• Localized
• Diffuse
Lopez, N., Kobayashi, L. & Coimbra, R. A Comprehensive review of abdominal infections. World J Emerg Surg 6, 7
(2011). https://doi.org/10.1186/1749-7922-6-7
PERITONITIS

48
 Diffuse Intra-abdominal
Peritonitis Type infections
clinical classification

Lopez, N., Kobayashi, L. & Coimbra, R. A Comprehensive review of abdominal infections. World J Emerg Surg 6, 7
(2011). https://doi.org/10.1186/1749-7922-6-7
5
3
Microbial flora of secondary peritonitis
Type Organism Percentage
Aerobic
Gram-negative Escherichia coli 60
Enterobacter / Klebsiella 26
Proteus 22
Pseudomonas 8
Gram-positive Streptococci 28
Enterococci 17
Staphylococci 7
Anaerobic Bacteroides 72
Eubacteria 24
Clostridia 17
Peptostreptococci 14
Peptococci 11
Fungi Candida 2

Adler SN, Gasbarra DB. A Pocket Manual of Differential Diagnosis. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005. Available at:

http://emedicine.medscape.com/article/180234-overview#a5. Accessed February 2016.

3
CLINICAL PRESENTATION CAI

Abdominal pain

Epigastric pain

Nausea, vomiting, diarrhea/constipation

Muscle rigidity

Decreased or absent bowel sounds

Signs and symptoms of sepsis and septic shock

IMAGING STUDIES CAI
X-ray
• bowel distension, obstruction, free air

Ultrasound
• fluid collections/abscesses ;also guide drainage

Computerized tomography (CT)

• Cause and Location intra-abdominal infection
processes; guide fluid collections/abscesses
drainage

Sartelli, M. A focus on intra-abdominal infections. World J Emerg Surg 5, 9 (2010).

https://doi.org/10.1186/1749-7922-5-9
 IAI TREATMENT
Source Control/Drainage
• surgically or with radiological assistance

Empirical antimicrobial treatment

• initiatedwithout waiting for a specific infectious diagnosis.
• Effectiveagainst a polymicrobial flora that includes:
• Enteric Gram-negative bacilli,streptococcaceaeand
anaerobes
Lack of clinical improvement
• should prompt further investigation for source of infection,
rather than prolonged antimicrobial therapy.
Sartelli, M. A focus on intra-abdominal infections. World J Emerg Surg 5, 9 (2010). https://doi.org/10.1186/1749-7922-5-9
Perrone Gennaro, et al. Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on
remote areas and low-income nations. International Journal of Infectious Diseases 99 (2020) 140–148.
Lalisang Toar J.M., et al. Clinical Practice Guidelines in Complicated Intra-Abdominal Infection 2018: An Indonesian
Perspective. SURGICAL INFECTIONS Volume 19, Number X, 2018. DOI: 10.1089/sur.2018.120
EMPIRICAL ANTIBIOTIC USE IN CIAI

Empirical antibioticàintravenously an hour

after cIAIS established (Recommendation 2C).

empiric use :
• disease severity, local ecology, and host factors.
Previously antibiotic, risk MDROs
• Broad-spectrum antibioticsàseptic shock, MDRO, and
previous antibiotic treatment (Recommendation 1B).
Lalisang Toar J.M., et al. Clinical Practice Guidelines in Complicated Intra-Abdominal Infection 2018: An Indonesian
Perspective. SURGICAL INFECTIONS Volume 19, Number X, 2018. DOI: 10.1089/sur.2018.120
ANTIBIOTICS FOR INFECTION

Anaerobic
• Metronidazoleàused in combination for empirical
therapy (Recommendation 1B).
Fungal cIAI
• fluconazoleàCandida albicansàin non-critical IAI
patients (Recommendation 2B).
• voriconazoleàinsensitive strains of Candida
(Recommendation 2B).
• echinocandin (anidulafungin or micafungin)àCandida
spp. in critical cIAI patients (Recommendation 1B).
Lalisang Toar J.M., et al. Clinical Practice Guidelines in Complicated Intra-Abdominal Infection 2018: An Indonesian
Perspective. SURGICAL INFECTIONS Volume 19, Number X, 2018. DOI: 10.1089/sur.2018.120