The Acute Abdomen

dr KISMAN HARAHAP SP B
Bagian Bedah FK UNRI/SMF Bedah
RSUD Arifin Achmad
PEKANBARU
 Outline
• Definitions
• What causes an “acute abdomen”
• To examine the physiologic background of abdominal
pain As An aid to accurate interpretation
ofSymptoms & Signs .
• Differential Diagnosis
– History and physical
– Labs
– Diagnostic imaging
• Special emphasis
– Appendicitis
– Bowel infarction
– Perforated viscous
Acute Abdomen
• Symptoms and signs of
acute intra- abdominal
disease processes,
usually treated best by
surgical operation
• The term acute abdomen refers to a sudden,
severe abdominal pain of unclear etiology that
is less than 24 hours in duration. It is in many
cases a medical emergency, requiring urgent
and specific diagnosis. Several causes need
surgical treatment.
• = Surgical abdomen
 Acute Abdomen-Symptoms
• Symptoms linked to visceral distention or
ischemia
• Inflammation of the peritoneum
– Parietal component provides localization
– End result of a process involving viscera
• Early diagnosis means understanding the
patterns that lead up to peritoneal irritation
Anatomic background
 Parietal peritoneum
clothes the anterior & posterior
abdominal walls the under surface
of the diaphragm & the cavity of
the pelvis.( supplied segmentally by
the spinal nerves ) .
 Visceral peritoneum
is the continuation of the parietal
peritoneum, which leaves the
posterior wall of the abdominal
cavity to invest certain viscera
therein . ( has no nerve supply ).
 T6-T9
foregut
1 2 3 T6-T9
4 5 6 T10
7 9
8

T8-T12

T8
midgut
L2

S4 hindgut
 Lokasi Nyeri
Akut
pada abdomen
 Anatomi luar
Abdomen

• Anterior: 9 regio
– epigastrium
– hipokondrium ki/ka
– umbilikal
– lumbar ki/ka
– hipogastrium/suprapubis
– inguinal ki/ka
• Pembagian lain: 4 regio
– kuadran ki/ka atas
– kuadran ki/ka bawah
Lokasi normal
viscera
abdomen
Patologi
 Nyeri
abdomen
oleh sebab
extra
peritoneal
• Kardiotorasik
• Urologi
• Vaskular
• Lain-lain
 Lokasi Nyeri
Akut
pada abdomen
 DEFINITION OF PAIN

It is an unpleasant sensation of varying

intensity .

Pain fibers are stimulated any time a tissue is

being damaged . However , it is not felt very long
after the damage has been accomplished.
 STIMULANTS

1 Mechanical trauma to the tissue .

2 Excess heat or cold .
3 Chemical damage.
4 Radiation damage .
5 Inadequate blood flow.
 Abdominal Extra-abdominal

Systemic dysfunction
Functional abdominal
Diabetes ,tabes dorsalis
Abdominal wall
+ pain organs
porphyria
Intra-thoracic
Pelvic organs
Intra-peritoneal
Retro-peritoneal organs
organs
 Types
of abdominal pain

1
2
Visceral pain is primitive
Somatic pain is entirely
and therefore related to
different fromdevelopment
embryologic visceral pain.
Visceral pain
1- Receptor

( Visceral peritoneum )
Visceral pain
2 - Stimulus

Pat. Experienced pain by traction

,distention & spasm

The visceral peritoneum is

insensitive to touch & heat
or any condition that
promotes an inflammatory
reaction
 Visceral pain
3 - Mediation

Autonomic nervous System Interpreted at

the thalamic level of the brain

C
ere
bra
lCo
rte
x T
hala
m u
s

H
ypo
tha
lamu
s
C
orp
usc
ollo
sum

P
ons
C
ere
bellu
m

M
edu
lla

S
pin
alc
ord
 Visceral pain
4- Specificity

Vague , often dull , poorly described &

associated with nausea & vomiting
 Visceral pain
5- Localization

Is poor & the pat. Placing the entire

hand over the involved region
 Somatic pain

1- Receptor

Pain stimuli start in the parietal peritoneum ,

which is innervated by peripheral nerves

P/ peritoneum
 Somatic pain

2- Stimulus

Pat. experienced pain by

Pressure
Touch
Heat
Inflammation
 Somatic pain

3- Mediation

Central nervous system

&
Interpreted at a specific
cortical location
 Somatic pain

4- Specificity

Precisely described as

Sharp
Cutting
Knifelike
 Somatic pain

5- Localization

The pain is localized with great accuracy

by the patient , who can often point to
the site with one finger
 Diagnostic Work-up

lab

History-PE X-rays

Echo
CT scans
Diagnostic Work-up
History-PE

X-rays

Lab

Echo

CT scans

Exploratory laparotomay
 Analysis of pain
need

DATA COLLECTION

1 2 3

History Physical exam.

Lab.inv.

apply

your medical knowledge***

 Site of pain & radiation

Radiation of the pain

Stomach &
GB duodenum Pancreas

Small bowel Small bowelindicates

Radiation pain doessource
not usually
of theradiate
pain
Kidney
but Pancreatic
Lower
also theabdominal
pain pain
may
Kidney Caecum &
rp.structure
& Kidney pain
extent of the disease
Stomach & duodenal pain
GB. Pain
move rarely
when
tends radiate
radiates
somatic
to gothrough
as well
T. Colon may
The structures radiate
goes
in pelvis may radiate to the
App. & Sig. to visceral
as thelower
back &
nervesto the right
become
back or perineum
Caecum bladder
uterus &
colon down
through
,strait
to reach into
through
tothe
the
irritated the
theofgroin
back
tip back
but
the
adnexae to the left
shoulder blade
 Mode of onset

Sudden onset
[The patient can tell you exactly when the pain started ]
The pain that start suddenly has a mechanical basis
Some thing has been

Twisted
Occluded
Ruptured
 Cont’ Mode of onset

Gradual Onset

( The pat. Usually responds vaguely to questions

about time of onset )
Non mechanical or
chronic process
 Cont’ Mode of onset

Gradual Onset

( The pat. Usually responds vaguely to questions

about time of onset )
Non mechanical or
chronic process
 Nature of pain
Two Large Categories
(1)Conditions associated with obstruction of a muscular
conducting tube
( Small bowel , Ureter , Biliary )

(2)Conditions associated with inflammation

( Mild & Localized Response or
Severe , Generalized Response )
1 Obstruction
prolonged Sudden

Distention of the viscus Colic pain = visceral pain

( constant stretching pain )

Three Types

(3) (Renal
(2) system
1 )Small = ( retroperitoneal
Intestine
Biliary System foregut)) )
= (( midgut
Foregut pain is experienced in the epigastrium
Pain is felt
Painin the flank
is experienced & periumbilical
in the radiates region
to the groin
 Important features of colic pain

I. Pat . Is often restless & agitated during

exacerbations.
II. Pat. Does not experience a totally pain –free
interlude.
III. Colic pain is an intermittent pain .

IV. Colic pain is an visceral pain . ( not

influenced by changing relationships between the peritoneal layers )

V. Failing to demonstrate guarding , tenderness ? ????

2 Inflammation
Intra-abdominal inflammation is peritonitis

Peritonitis causes somatic pain

Peritonitis
Generalized
Localized
2 Inflammation
Intra-abdominal inflammation is peritonitis

Peritonitis causes somatic pain

Contamination
BY
Foreign body
Chemicals
Bacteria
Trauma
 Important features of somatic
pain
I. Pat. Laying quite in bed . ( movement is limited )

II. Examination may demonstrate guarding , tenderness

.
III. The pain is localized over the inflamed organ.

IV. Fever , tachycardia & tachypnea are systemic

manifestation for generalized inflammation .
 Ischemic pain
Is a somatic pain
Occlusion of blood supply

cause
Tissue Hypoxia
Necrosis With metabolic
changes
After 6-12 h
Severity of acute abdominal pain
 Factors influencing clinical
manifestation

(1)
Extent of the pathologic process
The more severe the process , the
more impressive the manifestation .
 Factors influencing clinical
manifestation

(2)
Time of Assessment
Depending on the time of assessment
, the characteristics will reflect what is
present at that time – not previously &
not subsequently .
 Factors influencing clinical
manifestation

(3)
Emotional factors
Objective criteria are more reliable than
subjective factors .When there is a discrepancy
between the severity of pain & objective
findings ,caution should be exercised .
 Factors influencing clinical
manifestation

(4)
The Patient’s Intelligence
A clinical history is only as reliable as its source .
If the pat. is
Or
Very
Psychotic
Senile
Veryyoung
Intellectually
illimpaired
The information obtained must be interpreted
carefully . Objective & subjective findings should
be compatible .
 Factors influencing clinical
manifestation

(5)
Level of consciousness
Some neurologic problems make the
interpretation of acute abdominal pain difficult .
Paraplegia
Unconsciousness
Sympathetic denervation

Bizarre manifestation of abd. Pain .

 Symptom Quality

• Timing
– Matched to clinical condition
• Emerges over time and then concentrates (acute appy)
• Sudden onset (perforated viscous)
• Referred pain
– Linked to anatomic distribution
• Required reading
– Copes “ Early diagnosis of the Acute abdomen”
History of Present Illness
• O nset
• P recipitating/ relieving
• Q uality
• R adiation
• S everity
• T iming
 Physical Examination
• Overall appearance
– Walking and recumbent
• Vital signs
– Temperature
• High/low/low-grade
– Tachycardia
– Hypotension
• Inspection: scars, hernias, masses
• Auscultation
• Palpation
 Physical Examination
• Percussion:
– Tenderness
• No sudden moves
• Take your time
• Rigidity and guarding
• “Board-like abdomen”
– Tympanitic
– Dull
 Lab Tests
• WBC + differential
• Basic chemistry panel
–K
– Bicarbonate
• Amylase
• Liver function tests
• Urinalysis
• Pregnancy test
Diagnostic Imaging
 Plain Films

• Upright CXR
– “Free” air
• KUB (kidney/ureter/bladder)
– Calcifications
– Air/ Fluid levels
– Reactive bowel patterns
– Foreign bodies
Lateral Decubitus Film
 Ultrasound
• Rapid, safe, low cost
• Operator dependent
• Fluid, inflammation, air in walls, masses
• Liver, GB, CBD, Spleen, Pancreas, Appendix,
Kidney, Ovaries, Uterus
Ultrasound

Textbook of Sabiston, 16th ed.

 CT Scans
• Better than plain films and US for evaluation
of solid and hollow organs
• Intravenous contrast
• Oral contrast
• Per rectal contrast
• High use in appendicitis, diverticulitis,
abscess, pancreatitis
 When to Operate ?
• Peritonitis
– Excluding primary peritonitis
• Abdominal pain/tenderness + sepsis
• Acute intestinal ischemia
• Pneumoperitoneum
• Make sure pancreatitis is excluded
 What if it’s not clear?
• Challenging patients
• Neurologically compromised
• Intoxicated
• Steroids
• Inmmunosupressed
• If signs and symptoms are equivocal
• Serial exams (same person)
• Imaging
• Serial labs (check for WBC increases)
• Keep off antibiotics
• “Tincture of time”
 When NOT to Operate ?
• Cholangitis
• Appendiceal abscess
• Acute diverticulitis + abscess
• Acute pancreatitis or hepatitis
• Ruptured ovarian cysts
• Long standing perforated ulcers?
 Non Surgical Causes
• MI, Acute pericarditis
• PN, pulmonary infarction
• GE reflux, hepatitis
• DKA, Ac Adrenal Insufficiency
• Acute Porphyria
• Rectus muscle hematoma
• Pyelonephritis, Acute salpingitis
• Sickle cell crisis
Appendicitis
ACUTE APPENDICITIS

Dr. Kisman Harahap, SpB

Bag. Bedah FK Unri
RSUD Arifin Achmad Pekanbaru
 Pathophysiology of Appendicitis
• obstruction • inflammation
• bacterial overgrowth • edema
• mucous secret • ischemia
• distention • necrosis
• Increased intraluminal • perforation
pressure • abscess or localized
• lymphatic obstruction peritonitis
• venous obstruction • diffuse peritonitis
 Pathophysiology
• Acute appendicitis is thought to begin with
obstruction of the lumen
• Obstruction can result from food matter,
adhesions, or lymphoid hyperplasia
• Mucosal secretions continue to increase
intraluminal pressure
 Pathophysiology
• Eventually the pressure exceeds capillary
perfusion pressure and venous and lymphatic
drainage are obstructed.
• With vascular compromise, epithelial mucosa
breaks down and bacterial invasion by bowel
flora occurs.
 Pathophysiology
• Increased pressure also leads to arterial stasis
and tissue infarction
• End result is perforation and spillage of
infected appendiceal contents into the
peritoneum
 Pathophysiology
• Initial luminal distention triggers visceral
afferent pain fibers, which enter at the 10th
thoracic vertebral level.
• This pain is generally vague and poorly
localized.
• Pain is typically felt in the periumbilical or
epigastric area.
 Pathophysiology
• As inflammation continues, the serosa and
adjacent structures become inflamed
• This triggers somatic pain fibers, innervating
the peritoneal structures.
• Typically causing pain in the RLQ
 Pathophysiology
• The change in stimulation form visceral to
somatic pain fibers explains the classic
migration of pain in the periumbilical area to
the RLQ seen with acute appendicitis.
 Pathophysiology
• Exceptions exist in the classic presentation
due to anatomic variability of the appendix
• Appendix can be retrocecal causing the pain
to localize to the right flank
• In pregnancy, the appendix ca be shifted and
patients can present with RUQ pain
 Pathophysiology
• In some males, retroileal appendicitis can
irritate the ureter and cause testicular pain.
• Pelvic appendix may irritate the bladder or
rectum causing suprapubic pain, pain with
urination, or feeling the need to defecate
• Multiple anatomic variations explain the
difficulty in diagnosing appendicitis
 Signs and Symptoms
• Umbilical then migrates towards the RLQ
• Tenderness, then rebound
– Rovsing
– Psoas
• Extension of leg-pt on left
– Obturator
• Rotation of flexed thigh-pt supine
• Rectal
• Perforation related symptoms
 History and Physical Exam
Table 6 --Clinical Features of Appendicitis

Symptoms

Duration of symptoms (hrs, median) 22.0 hrs

Abdominal pain (% of cases) 100.0
Nausea or vomiting (% of cases) 67.5
Anorexia (% of cases) 61.0
Fever by history (% of cases) 17.9
Dysuria or frequency (% of cases) 10.6
Physical Findings

Right lower quadrant tenderness (% 95.9

of cases)
Rebound tenderness (% of cases) 69.5
Rectal tenderness (% of cases) 41.5

Source: Berry J Jr, Malt RA. Appendicitis near its centenary. Ann
Surg 1984;200:567.
Distinguishing Appendiceal
Perforation
Appendicitis Appendicitis
With Perforation w/o Perforation

N=70 N=176
Duration of symptoms (hrs, 48.5 hrs 18.0 hrs
median)
Fever as presenting 34.3 11.4
complaint (% of cases)
Nausea or vomiting (% of 60.0 70.5
cases)
Anorexia (% of cases) 52.9 64.2
Urinary symptoms (% of 10.0 10.8
cases)
Rebound tenderness (% of 64.3 71.6
cases)
Rectal tenderness (% of 41.4 41.5
cases)
Impression of a mass (% of 21.4 6.2
cases)

Source: Berry J Jr, Malt RA. Appendicitis near its centenary. Ann
Surg 1984;200:567.
 Differential Diagnosis
• Women • Both sexes
– PID – Gastroenteritis
– Ovarian torsion – Pyelonephritis
– Ectopic pregnancy – Diverticulitis
– Ovarian cyst – Crohn’s disease
– Meckel’s diverticulum
– Pancreatitis
 Disposition
• Abdominal pain patients can be put in 4
groups
• Group 1: classic presentation for Acute
appendicitis- prompt surgical intervention
• Group 2: suspicious, but not diagnosed
appendicitis- benefit from imaging and 4-6h
observation with surgical consult if serial exam
changes or imaging studies confirm
 Disposition
• Group 3: remote possibility of appendicitis-
observe in ED for serial exams; if no change
and course remains benign patient can D/C
with dx of nonspecific abd pain
• Patients are given instructions to return if
worsening of symptoms, and they should be
seen by PCP in 12-24 h
• Also advised to avoid strong analgesia
 Disposition
• Group 4: high risk population(including
elderly, pediatric, pregnant and
immunocomprimised)- require high index of
suspicion and low threshold for imaging and
surgical consultation
Perforation of Appendix
 When Does Perforation Happen?
• Statistics
– 25% risk of perforation after 24 hours
• What does it mean?
– Change in type of surgery
– Risk of abscess
– Peritonitis
• Increased mortality
 Treatment
• Urgent appendectomy
• Antibiotics
– Only preoperative abx needed for uncomplicated
cases
– For complicated appendicitis 7-10 days
Laparoscopic Appendectomy
 Postoperative Complications
• Infection: < 5 % to 60 %
• Wound Closure
– Primary
– Delayed primary
– Secondary
• Bowel obstruction
• Infertility-no longer suspected
Mortalitas pada appendektomi
# Tanpa komplikasi < 0,05 – 1%
# Mulai ada komplikasi 0,05%
# Dengan perforasi 0,05%
Open Appendectomy
Infarcted/Ischemic Bowel
 Mesenteric Infarction/Ischemia
• Always consider in patient with atypical presentation
of abdominal pain-
– Older patients
– Hx of arrhythmias or previous emboli
– Pain out of proportion to exam
– Evidence of visceral complaints without peritonitis
– Systemic complications
– Acidosis
Infarction by Endoscopy
Anatomy of the SMA
 Occlusion of the SMA
• Source
– Embolic (>50%)
– Venous, Atherosclerotic (thrombotic), NOMI
• Chronic
– Mesenteric/intestinal angina
– 30-60 minutes post eating
– Voluntary anorexia/wt loss
• Acute (>60% mortality)
– “Abdominal apoplexy”
– Variable symptoms at first with progression
– System collapse
Arteriogram of Normal SMA
Occluded SMA
Treatment of Acute SMA Occlusion
• High index of suspicion
• Arteriogram
• Medical therapy
– Papavarin
– Heparin
• Surgical intervention
Perforated Viscous
 Perforated Viscous

• Sudden onset of pain

– “Set your watch to it”
• Epigastric/shoulder/RLQ-often DU
• Lower quadrant-often diverticulum
• Often pre-existing history of ulcer or
diverticular disease
 Diagnosis
• Plain x-rays often demonstrate
• Upright CXR
– 75% of perforated DU will have free air
– Sensitive to 5 cc
• CT scan
– Sensitive to <2 cc air
 Management
• Acute perforation of a viscous requires
emergent exploration
• Delayed presentations are more complex
– Can avoid operation if the perforation is contained
– May require delayed interventions
 Acute Abdomen-Summary
• History and physical more important than tests
• Making the decision to operate is much more
important than making the diagnosis
• Treatment is often (BUT NOT ALWAYS) surgical
• “Very old, very young, very odd…be very careful!” de
Domball