Acute Abdominal Pain

Nyeri Abdomen Akut

Isma Resti Pratiwi

I11111029
SMF Emergensi
RS Abdul Aziz Singkawang
2015

Definition
Intraabdominal

process causing
severe pain and often requiring
surgical intervention
It is a condition that requires a
fairly immediate judgement or
decision as to management

Anatomic Essentials
Visceral

abdominal pain
Somatic (parietal) abdominal
pain
Referred pain

Visceral
Involves

hollow or solid organs

Steady ache or vague discomfort to
excrutiating or colicky pain
Poorly localized
Epigastric region: stomach,
duodenum, biliary tract
Periumbilical: small bowel, appendix,
cecum
Suprapubic: colon, sigmuid, GU tract

Parietal
Involves

parietal peritoneum
Localized pain
Causes tenderness and guarding
which progress to rigidity and
rebound as peritonitis develops

Reffered
Produces

symptoms not signs

Based on developmental embryology
Ureteral obstruction testicular pain
Subdiaphargmatic irritation ipsilateral
shoulder or supraclavicular pain
Gynecologic pathology - back or
proximal lower extremity
Biliary disease right infrascapular pain
MI epigastric, neck, jaw or upper
extremity pain

Other Symptoms
Gastrointestinal

Nausea, vomitting, hematemesis, anorexia,

diarrhea, constipation, bloody stools, melena
stools
Genitourinary

Dysuria, frequency, urgency, hematuria,

incontinence
Genicologic

Vaginal discharge, vaginal bleeding

Cardiopulmonary
General

Fever, lightheadedness

DD

DD-2

DD-3

DD-4

Immediate Life-Threatening
Causes of Abdominal Pain
Ruptured

abdominal aortic
aneurism (AAA)
Rupture of the spleen or liver
Ruptured ectopic pregnancy
Bowel infarction
Perforated viscus
Acute myocardial infarction (MI)

Diagnosis
Anamnesis
Physical

Examination
Diagnostic Studies

Anamnesis-1
1.

Location

2.

Quality & Type of Pain

3.

On the scale of 0-10, how severe is the pain?

Onset

5.

What does the pain feel like?

Severity

4.

Where is your pain? Has it always been there?

Does the pain radiate anywhere?

How and when did the pain begin?

Duration

How long have you had the pain?

Anamnesis-2
6.

Modifying Factors

7.

Medication

8.

Does anything make the pain

better or worse?
NSAIDs? H2 blockers? PPI?
Immunosupresan?

Social

Tobacco? Drugs? Cocaine? alcohol?

Anamnesis-3
9.

History

Have you had this pain before?

Past abd. surgeries? Gallblader disease,
ulcers
Past surgeries? H/o kidney stones,
pyelonephritis, UTI
Last menses, sexual activity,
contraception,h/o PID/STDs, h/o ovarian
cysts, pregnancy
H/o MI, heart disease, a-fib,
anticoagulation, CHF, PVD
DM, HIV/AIDS, cancer

Phsyical Examination

General

Pallor, diaphoresis, general

appearance, level of distress or
discomfort, lying or moving

Vital signs

Orthostatic Vs when volume

depletion is suspected

Physical Examination-2
Inspection
Auscultation
Percussion
Palpation

Inspection

Cardiac

Lungs
Abdomen

Look for distension, scars, masses

Back

Arrhytmias

Costo Vertebra Angle tenderness

Pelvic exam

Vaginal Discharge culture

Adenexal mass or fullness

Auscultation
Listen

for bowel sound or bruits

Hyperactive, obstructive, absent or
normal bowel sound
High pitched or tinkling bowel obs.
Continuous & hyperactive acute
gasteroenteritis
Absent Ileus or peritonitis (listen for
1 min)
Audible without stethoscope
borborygmi

Percussion
Should

tap with 2 fingers on all 4

quadrants (minimum)
If tympanitic: implies bowel obs.
If dull: implies intraabdominal
bleeding or fluid (ascites)
If tender: correlate with tender
areas noted on palpation

Palpation
Should

be done following inspection &

auscultation
Asses for tenderness, guarding, mass,
crepitus, referred tenderness
Look for guarding, rigidity, rebound
tenderness, organomegaly or hernias
Women should have pelvic exam and
check for pregnancy
Anyone with a rectum should have
rectal exam

Abdominal Findings
Guarding
Rebound
Pain

referred to the point of maximum

tenderness when palpating an adjacent
quadrant is suggestive of peritonitis
Rovsings sign in appendicitis

Rectal

exam

Little evidence that tenderness adds any

useful information beyond abdominal
examination
Gross blood or melena indicates an GIB

Special Signs/Techniques
Murphys

Sign
Psoas Sign
Obturator Sign
Rovsings Sign
Carnetts Sign

Diagnostic Studies
Laboratory

studies
Electrocardiogram
Radiographic test

Lab studies
Type

and cross (most if patient has shock)

Complete blood count
Urine or serum pregnancy test (HCG)
Serum amylase, lipase
Urinalysis, urine culture and sensitivity
Liver function tests (bilirubin, SGOT, SGPT, alk phos)
Electrolytes, glucose, creatinin, blood urea nitrogen
(BUN)
Serum alcohol, serum or urine drug urine
Serum medication levels (such as digoxin)
Clotting studies
Cardiac enzymes (if coronary ischemia suspected)
Blood culture (if sepsis or bacteremia suspected)
Nonemergent tumor markers

Interpretation of Lab
Studies

WBC

typically elevated (+/- shifted) in any

cause of peritonitis & in bowel infarction & in
spleen & liver bleeding.
However, often NOT elevated appropriately in the
elderly, imunocompromised patients, or patients
with chronic corticosteroid

Hematocrit

may be normal in early stages of

severe hemorrhage.
BUN to creatinine ratio of >20 to 1 upper GI
bleed with digestion of blood in upper GI tract
Amylase may also be chronically elevate in
patients with renal dysfunction

Radiography
3

view acute abdomen (upright chest X-ray,

upright and flat plate of abd.)
Chest X-ray shows amounts of free air
Upright abdomen films bowel air-fluid levels
(bowel obs. or ileus
Abnormal calcifications

USG

Unstable patient in shock or susp. Intraabd. Bleeding

Gallstones (cholecystitis)
Ectopic pregnancy
Other complications of pregnancy (placent previa,
abruptio, etc)
Renal or ureteral stones in pregnant px

Radiology findings

Post-Exam Procedures
Insertion

of foley catheter

Unstable patient or urinary retention

Insertion

of NG tube

Allow decompression
May demonstrate upper GI bleeding
Required before peritoneal lavage
Contraindicated for fractured nasal or midface

Paracentesis

Suspected infected ascites

Relieveng tense ascites
Dx of bowel perforation or intraabd. bleed

General Approach to the Patient

Present with Abdominal Pain
Evaluate

the ABC
Determine if an immediate life-threatening
cause of abdominal pain may be present
& if there is any history of possible
abdominal trauma
Start resuscitation and emergently consult
a surgeon if the laparotomy is needed
Complete the secondary survey, decide
the diagnostic test
Volume repletion, pain relief, antibiotics,
others (e.g. antiemetics)

Reference
1.
2.
3.

4.

Acute Abdominal Pain, UNC Emergency

Medicine
Current Chrisnel Jean, D.O, 2005, Acute
Abdominal Pain, Power Point Presentation
Jim Holliman, M.D., F.A.C.E.P., Management
of Patients with Abdominal Pain in the
Emergency Department, USA: George
Washington University
Mahadevan SV, Garmel GM, An
Introduction to Clinical Emergency
Medicine, USA: Cambridge University
Press

THANK YOU