Clinical Examination

of Acute Abdomen
12/29/2018
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 HISTORY

Diagnostic Patient perception of symptoms

Process
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.
Onset

Site at onset
Radiation

Type

Progression
PAIN Site at present

Severity

Duration Aggravating /relieving factors

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
Type of
pain

Visceral pain &

Parietal pain
Type and severity of pain
A

 A. Toothache
 C. Colicky pain of inflammed hollow organs
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?
 Cullen’s sign
 Gray Turner’s 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
 Murphy’s sign
While palpating, look to the face expression
of the patient, and look for any signs of :

 Swelling or masses
 Rovsing’s sign

 Expansile pulsation

 Hernial orifices

 Scrotum in male
Expansile pulsation
Specific signs:
 Rovsing’s 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
Mild
blood (Lowenfels, 1975)

Urine

bile

pus
Degree of peritoneal irritation

Pancreatic juice

Bowel bontent

Gastric juice
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 gynecology
 Ectopic gestation  Ruptured ovarial cyst
 Abdominal pregnancy  Ovarial Torsion, Myoma
 Rupture of the uterus  Ruptured abscess
 Mola Destruen  Perforated Uterus
 Ruptured
organ

Content
Materials : Blood
Pus • sebum
• meconeum

Acute
abdomen

Abdominal
pain in ischaemia distention
Obgyn Strangulation

torsion
A Good Diagnostician
is not Born,
but is Developed