Acute Abdominal Pain

Sigid djuniawan
 HISTORY
Onset-duration-frequency-character-
location-chronology-radiation-intensity-
aggravating/alleviating factors-associated
symptoms
Standardized history & physical forms
with/without diagnostic computer programs
Using open-ended questions
Avoid leading questions. If cantmake
negative questions
 HISTORY
Intermittent pain/colic :obstruction of hollow
viscus
Constant pain : indicative of peritoneal
inflammation or ischaemia
Burning pain: perforated gastric; tearing pain:
dissecting aneurysm
Location of painonly a rough guide to
diagnosis, ex : right upper quadrant
cholecystitis ; right lower quadrant
appendicitis; epigastrium pancreatitis; left
lower quadrant sigmoid diverticulitis
 HISTORY
Radiation/refferal of pain : characteristic pattern, ex :
billiary pain to right subscapula area
Chronology : often more important, ex : appendicitis
begin in periumbilical regionsettles in right lower
quadrant
Intensity of pain : ~magnitude of the underlying insult, ex
: typical pain of acute pancreatitis is exacerbated by lying
down & relieved by sitting up
Assosiated symptoms : nausea, vomitting, anorexia,etc
Female patient : gynecologic history & obstetric history
Complete history of medical condition, family history,
social history
 Tentative Differential Diagnosis
Most common diagnosis : NSAP (Non
Spesific Abdominal Pain)
Most common dx that required operation :
acute appendicitis, cholecystitis, intestinal
obstruction
 Tabel 1. Penyebab Nyeri Abdomen Akut (Intraperitoneum)
Peradangan Abses pancreas
Peritoneum Abses hepar
Peritonitis bakteri dan kimia Abses lien Hemoperitoneum
Perforasi ulkus Mesenterium Ruptur tumor hepar
peptikum /saluran bilier, Limfadenitis(bakteri,virus) Ruptur lien spontan
pankreatitis, ruptur kista Appendagitis epiploik Ruptur mesenterium
ovarium, mittelschmerz Pelvis Ruptur uterus
Peritonitis bakteri PID (salpingitis) Ruptur folikel gravidus
Peritonitis primer Abses tuba falopi Ruptur kehamilan ektopik
Pneumokokus, Endometritis Ruptur aorta, aneurisma visceral
streptokokus, tuberculosis.
Peritonitis bakteri spontan Mekanik (obstruksi, distensi Iskemik
Perforasi organ berongga akut) Trombosis mesenterium
Esofagus, lambung, Organ berongga Infark hepar (toksemia, purpura)
duodenum, usus kecil, Obstruksi intestinum Infark lien
saluran empedu, kandung Adesi, hernia, tumor, Iskemik omentum
empedu, kolon, kandung volvulus intusepsi, ileus batu Strangulasi hernia
kencing. empedu, badan asing
Organ berongga Parasit, bezoar Tumor
Appendicitis Obstruksi bilier Primer atau tumor
Kolesistitis Batu, tumor, kista intraperitoneum metastase
Ulkus peptikum Gastroenteritis koleduktus, hemobilia
Gastritis Organ padat Trauma
Duodenitis Splenomegali akut Trauma tumpul
Bowel disease Hepatomegali akut (gagal Trauma tembus
Divertikulum Meckel jantung kongestif, syndrome Trauma iatrogenic
Kolitis(bakteri, amuba) Budd-Chiari) Kekerasan domestic
Divertikulitis. Mesenterium
Organ padat Torsi omentum Lain-lain
Pankreatitis Pelvis Endometriosis
Hepatitis Kista ovarium
Torsi, degenerasi fibrus
Kehamilan ektopik
 PHYSICAL EXAMINATION
Inspection, auscultation, percussion &
palpation all area of abdomen, flanks,
groin
In addition :Rectal & genital examination
In female : full gynecologic examination
 Basic Investigative Studies

Laboratory Test
Complete blood count, blood chemistry,
urinalysis

Imaging
Plain film of abdomen (radiography)
Ultrasonography
CT-scan
Electrocardiogrameldery & atherosclerotic
disease
 Working Diagnosis
Management 4 basic pathway
Need immediate laparotomy
Believed to have underlying surgical condition
Uncertain diagnosis
Believed to have underlying non surgical
condition
If not respond reassess based
differential diagnosis list
 Acute Abdominal Crisis
Indication for immediate laparotomy
Ex:
Ruptured AAA or visceral aneurysm
Ruptured ectopic pregnancy
Spontaneus hepatic or splenic ruptured
 Suspected Surgical Abdomen
Indication for urgent laparotomy or
laparoscopy
Appendicitis, perforated hollow viscus,
strangulated hernia, ectopic pregnancy
(unruptured)
Hospitalization & Observed
Diagnosis laparoscopy if pain persist after
observation
Additional investigative studies (endoscopy,
angiograpy, MRI, etc)
 Diagnosis Uncertain
Determine whether patient :
Hospitalized
Analgesic as aprpropriate
Additional investigative studies ( CT & USG)
Observe & reevaluated
Managed as outgoing patient
Reevaluated as appropriate
Suspected Non Surgical Abdomen
Often extremely difficult to differentiate
Should be hospitalized & observed
observe & reevaluated
Additional investigative studies
Terima Kasih