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BAB I
PRELIMINARY OF ACUTE ABDOMEN

Acute abdomen or acute abdomen is a picture of the clinical situation due to gravity in the abdominal cavity which is traumatic and non-traumatic and usually begins suddenly with pain as main complaint. This situation requires an immediate response is usually in the form of surgery. For example in the infection, obstruction, or strangulation can cause gastrointestinal perforation resulting in contamination of the abdominal cavity by the contents of the gastrointestinal tract, so there was peritonitis that requires surgical treatment. In the case of abdominal distress, every second is precious. The decision to perform surgery must be taken because any delay will lead to complications that can result in increased morbidity and mortality. Accurate diagnosis and to overcome the examiner relies on the confidence and ability to conduct an analysis of anamnesis, physical examination, and investigations. Therefore, knowledge of anatomy and physiology of the abdomen and its contents is crucial in getting rid of one after another of the many possibilities that cause acute pain. Acute abdominal pain is a frequent emergency department presentation. Pain may be located in any quadrant of the abdomen and may be intermittent, sharp or dull, achy or piercing; it may radiate from a focal site and there may be associated symptoms such as nausea and vomiting. Immediate assessment should focus on distinguishing those cases of true acute abdomen that require urgent surgical intervention from those that do not, which can initially be managed conservatively.

BAB II
DISCUSSION OF ACUTE ABDOMEN

Anatomy
Anatomy of the abdomen is an important knowledge to be able to diagnose the acute abdomen. Clinical symptoms usually appear closely related to the anatomic location of the composition of the abdomen, although in reality there are some abdominal pain, which is reffered pain or pain that is located in contrast to the anatomical location of these organs. To facilitate studying the anatomy of the abdomen, the abdomen is usually divided into four quadrants:

1. Right Upper Quadrant (RUQ) Right lobe of the liver Gall bladder Pylorus of stomach Duodenum 2. Left Upper Quadrant (LUQ) Left lobe of the liver Spleen Stomach Jejunum proximal and ileum Pancreas caudal Left kidney Transversal colon Descending colon corpus and Caput pancreas Right kidney Colon ascending Colon transversal

3.

Right Lower Quadrant (RLQ) Caecum Appendix Illeum Ascending colon Right ovarium Tuba uterina Right ureter Right funikulus spermatikus Uterus (if bigger ) Bladder

4. Left Lower Quadrant (LLQ) Sigmoid colon Descending colon Left Ovarium Left Tuba uterina Left Ureter Left Funikulus spermatikus Uterus (if bigger) Bladder

Picture of abdomen region

The type of abdominal pain :

The chief complain of acute abdominal is pain, the pain came from many processed in abdominal organ or from outside the abdominal. The pain was define in three kind :

1. Visceral pain comes from the abdominal viscera, which are innervated by autonomic nerve fibers and respond mainly to the sensations of distention and muscular contractionnot to cutting, tearing, or local irritation. Visceral pain is typically vague, dull, and nauseating. It is poorly localized and tends to be referred to areas corresponding to the embryonic origin of the affected structure. Foregut structures (stomach, duodenum, liver, and pancreas) cause upper abdominal pain. Midgut structures (small bowel, proximal colon, and appendix) cause periumbilical pain. Hindgut structures (distal colon and GU tract) cause lower abdominal pain. 2. Somatic pain comes from the parietal peritoneum, which is innervated by somatic nerves, which respond to irritation from infectious, chemical, or other inflammatory processes. Somatic pain is sharp and well localized.

3. Referred pain is pain perceived distant from its source and results from convergence of nerve fibers at the spinal cord. Common examples of referred pain are scapular pain due to biliary colic, groin pain due to renal colic, and shoulder pain due to blood or infection irritating the diaphragm.

Location of Abdominal Pain

Visceral pain of an organ normally correspond to the location of the origin of these organs in the embryo, while the location of somatic pain is usually close to the source of pain, making it relatively easy to determine the cause. Gastrointestinal tract from the front intestine (foregut) will cause pain in the pit of the stomach or epigastrium. Organs derived from foregut that is: Stomach Duodenum System hepatobilier pancreas

Gastrointestinal tract from the middle USU (midgut) will cause pain around the umbilicus. Organs derived from the midgut that is: The small intestine The large intestine until the mid-transverse colon

Gastrointestinal tract from the gut back (hindgut) will cause pain around the lower abdomen. Organs derived from the hindgut are: Mid-transverse colon to the sigmoid colon Buli-pot Location of somatic pain is usually in accordance with the anatomical location of the corresponding organ.

Location
Right upper abdomen

Organ
Gall bladder, liver, duodenum, pancreas, colon, lung, miokard

Epigastrium

stomach, pancreas, duodenum, lung, colon

Left upper abdomen Right lower abdomen

spleen, colon, kidney, pancreas, lung Appendix, ureter adneksa, caecum, ileum,

Left lower abdomen Supra pubic Periumbilikal Hips / backs Shoulder

Colon, adneksa, ureter Bladder , uterus, small intestine Small intestine Pancreas, aorta, kidney Diaphragm

The nature of pain

Based on the location or distribution, the pain can be divided into pain and referred pain is pain that is projected. For some diseases, widespread pain can help make a diagnosis. For example, typical biliary pain radiating to the waist and toward the shoulder blade, pancreatitis pain is felt through to the waist.

Transfer Pain Referred pain occurs when a segment of innervation serves more than one area. Diaphragm from the neck region of the C3-5 move down in the embryo so that stimulation of the diaphragm by bleeding or inflammation will also be felt in the

shoulder. Similarly, in acute cholecystitis, pain felt in the end of the scapula. An abscess under the diaphragm or the stimulus because of trauma to the upper surface of the spleen or liver can also cause pain in the shoulder. Ureteric colic or renal colic pielum usually felt up to the external genitalia.

Pain Projection Projection pain is pain that is caused by stimulation of sensory nerve injury or nerve inflammation. Famous example is the phantom pain after amputation. Local peripheral pain in herpes zoster is caused by nerve inflammation also can cause severe pain in the abdominal wall before symptoms or signs of herpes zoster become apparent.

Hiperestesia Hiperestesia or hyperalgesia frequently found in the skin if there is inflammation of the cavity underneath. In the acute abdomen, these signs are often found in local or general peritonitis. Pain is felt right parietal peritoneum in peritoneal terangsangnya place so people can point to the right, and at the place there is tenderness, motion, cough, loose, and
other signs of peritoneal stimuli and is often accompanied by muscular defans hiperestesia local skin.

Continuous pain Continuous pain is pain that is felt continuously. For example, the pain in the peritoneum (peritonitis) caused by stimulation of the peritoneum parietale that will be felt constantly. At the time of examination of patients with peritonitis will be found local tenderness, abdominal wall muscles showed defans muscular reflex to protect the inflamed part and avoid movement or local pressure. Gastrointestinal bleeding usually does not cause pain. In patients with bleeding in the abdominal cavity usually felt pain due to stimulation of the peritoneum, rather than from the gastrointestinal tract.

Pain Move Sometimes abdominal pain can be changed in accordance with the development of pathology. For example, in the early stages of appendicitis, before reaching the surface of the peritoneum inflammation, visceral hyeri felt around the center and accompanied by nausea as an appendix including the middle intestine. Once the inflammation occurs in the entire wall including the peritoneum viserale, there is pain due to stimulation of the peritoneum is somatic pain and feels right at the lower right abdomen. If the appendix then undergoes necrosis and gangrene, pain turned again into ischemic pain is severe, persistent and does not subside, then people can fall in a toxic state.

Diagnosis of Acute Abdomen

In upholding the diagnosis of acute abdomen should begin by gathering information and valuable clinical course of disease patients obtained from anamnesis, physical examination, and investigations. The unification of the information obtained can help a doctor to reach a diagnosis of work so as to determine the treatment plan, or other special examination to determine plans that can help establish the diagnosis.

Anamnesis
In patients with acute abdominal anamnesis there are seven key questions (7 golden questions) that can petrify diagnosis.

1. Beginning there is pain. In the anamnesis important questions about the beginning of the onset of pain in both time and location of the initial onset of pain, because the trip knowing the pain the patient will make it easier to establish the diagnosis. For example, pain in appendicitis is characterized by pain that stems from epigastrikum area or umbilicus and radiating to the Mc Burney

point. On the pain syndrome, dyspepsia begins epigastrikum area but did not spread, or the female reproductive organ inflammation, pain may be felt only in the lower right abdomen, so similar to appendicitis. 2. Location of pain. Location of pain certainly important to ask patients for a designated location in a particular area are usually derived from the organ that is anatomically located behind the designated area. Differential diagnosis can be made after knowing the anatomy of the organ behind the abdominal pain.

3. The severity and nature of pain. Patients with acute abdominal pain should be asked the nature, whether the pain is intermittent or continuous, whether the pain experienced as tingling, pressure, or burning.

4. Propagation of pain, pain referral, and amendments thereto. Changes in pain until the beginning of the examination also must be asked, whether the pain is severe or is on the wane. Referred pain or pain that should also be asked, such as the ureter colic pain will be felt from the abdominal region radiating to the thigh area.

5. Circumstances that aggravate the pain.

6. Circumstances that mitigate the pain. In patients with peritonitis will usually feel the pain more severe when walking and standing upright, and would feel more comfortable when in a sleeping position, as if in an upright position will stretch the abdominal wall, whereas when sleeping positions stretching of the abdominal wall occurs at a minimum.

7. Gastrointestinal and systemic symptoms that accompany abdominal pain. Accompanying symptoms of acute abdomen will greatly assist the examiner in diagnosis. Symptoms such as fever, nausea, vomiting, difficult defecation and micturition difficult diagnosis can help to get rid of the existing appeal. On gastritis for example, the pain felt by the patient can be extended to the lower right abdomen, resulting in symptoms similar to

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appendicitis pain will, but when obtained diagnose that the patient had vomited a lot more than ten times, then the differential diagnosis of appendicitis can be ruled out.

Physical examination
On physical examination, to consider the general situation, face, pulse, respiration, body temperature, and the attitude of lying. Symptoms and signs of dehydration, bleeding, shock, infection, and sepsis is also noteworthy.

On abdominal examination, inspection is an important part of the examination. Auscultation, percussion and palpation was held before done. Groin hernia and other places specifically examined. Digital rectal generally required to help establish the diagnosis. Examination of the abdomen that is difficult to obtain as the retroperitoneal, subfrenik region, and pelvis can be reached directly by secaratidak particular test. Iliopsoas test can be obtained with information regarding the retroperitoneal region. Obturator test can be obtained information about abnormalities in the pelvis. Percussion test subfrenik Boxing region can be achieved. By pulling the testis to the caudal region of the pelvic floor can be achieved.

In patients with complaints of abdominal pain should generally be performed digital rectal examination and vaginal examination. Diffuse pain in the folds of peritoneum in Douglas pouch provides information on peritonitis is less pure. Pain on one side showed abnormalities in the pelvic area, such as appendicitis, abscess, or adneksitis. Digital rectal can also distinguish between intestinal obstruction with intestinal paralysis, due to paralysis of the ampulla found a wide sheath, whereas in the ampulla of intestinal obstruction sheath usually collapse. Vaginal examination adds information to the possibility of abnormalities in the female genitals.

Additional diagnostic examination

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Investigations sometimes need to make decisions, such as blood, urine, and feces. Sometimes need to also do plain or endoscopic examination.

Some specific laboratory tests performed, including hemoglobin and hematocrit values, to see the possibility of bleeding or dehydration. White cell count may show an inflammatory process. Platelet count and coagulation factors, in addition to surgery is needed for preparation, it can also help to provide the possibility of dengue fever-like symptoms of acute abdomen.

Diagnostic imaging is usually necessary to ensure the photo abdomen for signs of peritonitis, free air, obstruction, or bowel paralysis. Ultrasound examination is very helpful for diagnosing abnormalities of the liver, bile ducts, and pancreas. Acute appendicitis can dipastkan by ultrasound, so as to avoid unnecessary surgery.

Gravity of the Abdomen

Acute appendicitis

Appendicitis is a case of intraabdominal inflammation is most often found at all levels of age and gender. Appendicitis is more common in adolescents and young adults. Acute appendicitis is the case of inflammation caused by bacterial infection.

Various factors that act as originators. Blockage of the lumen of the appendix is presented as a factor precipitating factors in addition to hyperplasia of lymphoid tissue, fekalit, tumors of the appendix, and worms askariasis.

In the early stages, the inflammatory process limited to the mucosa of the appendix, within 24-48 hours and then the inflammatory process involving all levels of the appendix wall. Body's defense business is to limit inflammatory process by closing the appendix to the omentum, small intestine, or adnexa, thus forming a mass known as infiltrates periapendikuler appendix.

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Patients feel the visceral pain in the area periumbilikal that within a few hours the pain will move to the lower right, to the point of perceived pain intensity McBurney with sharper and more clearly the location (somatic). Over time, inflammation of the appendix walking toward suppuration. In it can occur in the form of abscess tissue necrosis that can be perforated. Clinical symptoms usually begin with pain or discomfort in the area periumbilikal accompanied by nausea and anorexia. The pain is felt constantly, but not a severe pain. It may also be symptoms of vomiting, and within a few hours the pain moved to the lower right quadrant, the location of the pain becomes more apparent, and the pain was compounded when moving, walking, and coughing.

Examination at this point there are probably only a little resistance from local muscle palpation examination. Peristaltic normal or slightly decreased. Slightly increased body temperature (about 37.8 C). Some important things to remember: 1. Patients with early symptoms of appendicitis often do not look sick, sometimes patients feel guilty for coming to the doctor just because of mild abdominal pain. Find a local pain at McBurney's point can be the basis for diagnosing appendicitis. 2. Rules that can be quite helpful atiptikal cases is to put the differential diagnosis of appendicitis in order both acute abdomen in patients with a history of previous health conditions. 3. Common complication of acute appendicitis is perforation, peritonitis, and abscesses. 4. Perforation of the appendix accompanied by symptoms of severe pain and fever with a higher temperature (38.3 C). Perforation of the appendix is rare in the first 12 hours after an acute appendicitis. 5. Local peritonitis caused by only a small perforation of the appendix which had suffered necrosis. Pus from the appendix to stimulate peritoneal perforation, so that the pain intensified, arising defans muscular, abdominal distension, and decreased bowel sounds. Pus can continue to spread throughout the peritoneal cavity and causing diffuse peritonitis.

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6. Appendix mass or abscess occurs when the infection of the appendix appendix surrounded by omentum and nearby organs. Clinical symptoms similar to acute appendicitis plus the mass of the right lower quadrant of the abdomen.

Gastrointestinal perforation
One case that may lead to diffuse peritonitis was perforation of the gastrointestinal tract that contain acids and infectious material. Duodenal and gastric ulcers are the most common cause of cases of gastrointestinal perforation. Although there are some patients who have a history of perforation which previously preceded the discomfort in the area epigastrikum for a few days, but this is not unusual for the perforation of a sudden.

Gastric acid is the most powerful liquid stimulate the peritoneum. When there is perforation and perforation of the contents of the stomach acid and other digestive juices spread throughout the abdominal cavity, then the contents of the perforation will result in inflammatory processes and stimulate the entire surface of the peritoneum, so that the perforation of the gastrointestinal tract will be marked by abdominal pain is so great that arrives -comes with defans muscular. Sequence of substances that irritate the peritoneum from the weak to the most powerful is the blood, urine, bile, pus, pancreatic fluid, smooth USU contents, gastric fluid.

Strangulated hernia and Inkarserata

Of some types of hernia, which is the case of emergency abdominal inkarserata and Strangulated hernia type. Two cases are cases of hernia that requires immediate treatment because it can lead to tissue death and disability in a matter of hours.

Can be called a hernia hernia hernia Strangulated inkarserata or when the contents of the hernia sac ring sandwiched by a hernia, so the bag can not be caught and returned to the abdominal cavity. As a result, passage, or vascular disorders. Inkarserata hernia clinically more intended for hernia ireponible with the passage of intestinal disorders.

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While Strangulated hernia is when an interruption occurs vascularization which can cause tissue necrosis.

Clinical symptoms inkarserata hernia is a disorder of the intestinal passage, so that the hernia symptoms usually will be accompanied by vomiting and defecation disorders. Clinical symptoms similar to symptoms inkarserata Strangulated hernia, but there are additional symptoms are very severe pain at the hernia is caused by necrosis of the intestinal tissue.

Acute Pancreatitis
Acute pancreatitis usually occur suddenly. Symptoms of pancreatitis can be mild and self limited or can quickly become emergency cases were localized in the abdomen or abdominal life-threatening. Cases of acute abdomen is the phase of pancreatitis and hemorrhagic pancreatitis nekrotikan. Clinical manifestations can rapidly develop into retroperitoneal and intraperitoneal inflammation, tissue damage, and bleeding.

Cholecystitis and cholangitis

Cases the pain is often associated with disorders of the gallbladder is usually caused by mechanical obstruction of the bile duct system, or dyskinesia. Patient's symptoms are usually abdominal pain like pressure on the right upper quadrant or area epigastrikum subscapular area radiating to the right. Visceral pain is felt usually associated with nausea or vomiting. The symptoms are often felt after eating and sometimes when I wake up. This phenomenon is often referred to as "the gallbladder or biliary colic" and vary in duration, intensity, intermittent or constant.

When the obstructive process is not self-limited and there is an infection in the gallbladder wall, the pathological process has evolved into a cholecystitis. Gallbladder wall

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thickening due to inflammatory process (edema) along with the accumulation of pus in the lumen, or gas are derived from bacteria (emphysema of the gallbladder). The severity of the infection process are varied, but can progress to necrosis of the gallbladder.

Clinical patients will have fever, tachycardia, malaise, and leukocytosis. On examination found abdominal pain in right upper quadrant abdominal and muscular defans. Bloated feeling or a palpable mass may be found. Murphy's sign, the patient suddenly attempt to hold his inspiration on palpation in the right subkostal area, occurs when the gallbladder is inflamed against the pressure of a finger probe. Acute cholecystitis can be found with the help of ultrasound and can sometimes be found also by using a CT-Scan. Treatment may be performed immediately cholecystectomy.

E. Surgical considerations
The decision to perform surgery on a serious act depends on the diagnosis. If it is difficult to determine if it needs surgery or not, the patient should be monitored carefully and repeatedly checked.

Meanwhile, the gastrointestinal tract by having the patient rested for fasting, decompression of the stomach with a gastric tube fitting, and the infusion. Almost all acute abdominal disorders need surgery to address the cause. Some circumstances such as acute cholecystitis, acute pancreatitis, or inflammation of the pelvis at a particular stage can be overcome without surgery.

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BAB III

Summary
The term acute abdomen represents the rapid onset of severe symptoms that may indicate potentially life-threatening intra-abdominal pathology that requires urgent surgical intervention. Abdominal pain is usually a feature, but a pain-free acute abdomen can occur, particularly in the elderly, in children, in the immunocompromised, and in the last trimester of pregnancy. Acute abdominal complaints are common Estimates vary, but a prevalence of around 50% was identified in one study of upper abdominal pain while one large telephone survey found that 45% of people experienced at least one upper GI symptom in the previous 3 months. Acute abdominal pain is a frequent emergency department presentation. Pain may be located in any quadrant of the abdomen and may be intermittent, sharp or dull, achy or piercing; it may radiate from a focal site and there may be associated symptoms such as nausea and vomiting. Immediate assessment should focus on distinguishing those cases of true acute abdomen that require urgent surgical intervention from those that do not, which can initially be managed conservatively. Abdominal pain lasting more than 48 hours is less likely to require surgery than pain of shorter duration. A patient with acute surgical pathology may deteriorate rapidly; thus, severe, unremitting symptoms in the first few hours warrant vigorous investigation and close monitoring. Additionally, for patients who are clinically stable and have not undergone surgery due to the lack of an obvious cause, diagnostic laparoscopy may be considered.

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An acute abdomen is diagnosed by a combination of history, physical examination, radiography, and laboratory results. When symptoms do not necessitate immediate surgery, and when imaging has not led to a definitive diagnosis, further abdominal examinations by an experienced physician may help determine the underlying cause. Alternatively, diagnostic laparoscopy can be considered in selected patients. Laparoscopy not only is a useful tool for diagnosis, but is increasingly used as a therapeutic modality of choice for conditions such as appendicitis, cholecystitis, lysis of adhesions, hernia repair, and many gynaecological causes of an acute abdomen. Assessment of acute abdominal pain in terms of diagnostic accuracy may be improved with the use of algorithms or decision tools. These approaches have been evaluated and noted to improve the specificity for diagnostic accuracy.

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Blibiography
1. Skandilaksis (2004). Skandilaksiss Surgical Anatomy. New York: Mc Graw Hill Medical. 2. Lowry, S.F (2005). Learning Surgery: The Surgery Clerkship Manual. New York: Springer 3. Goherty, G.M., Way, L.W. (2005). Current Surgical Diagnosis and Treatment 12th Edition. Callifornia: Mc Graw Hills Access Medicine. 4. Doherty GM: Current Surgical Diagnosis and Treatment, 12th edit Lange International edition, 2006 5. Markovchick VJ Pons PT: Emergency medicine secrets, 3rd edit. Hanley & Bedfus. 2003 6. Krestin GP, & Choyke PL: Acute abdomen, diagnostic Imaging in the clinical content. Thieme medical publishers, Inc, 1996 7. Silen W: Copes early diagnosis of the acute abdomen, 19th edit. Oxford 1996 8. Nyhus LM, Vitello JM, & Condon RE: Abdominal pain, a guide to rapid diagnosis: Appleton & lange. 1995