You are on page 1of 20

Pemicu 1

Cardiogenic shock
• Cardiac Failure
– Clinical evidence of impaired forward flow of heart,
including presence of dyspnea, tachycardia, pulmonary
edema, peripheral edema, or cyanosis
• Cardiogenic Shock
– Cardiac failure plus
– 4 of the following
• Ill appearance or altered mental status
• HR > 100bpm
• RR > 20bpm or PaCO2 <32 mmHg
• Arterial base deficit <-4mEq/L or lactate >4mM/L
• Urine output <0.5 mL/kg/hr
• Arterial hypotension >30 continuous minutes duration
Septic shock
Diagnostic Approach and
Management of Acute Abdominal
Pain Murdani Abdullah, M. Adi
Firmansyah Department of
Internal Medicine, Faculty of
Medicine, University of Indonesia -
Cipto Mangunkusumo Hospital
Acute Appendicitis
• Common condition requiring emergency surgery
• Caused by acute obstruction of the appendiceal lumen
– Appendicolith (often), calculi, tumor, parasite, enlarged lymph nodes
• Acute obstruction  intraluminal pressure rise  mucosal
secretions are unable to drain  distension stimulates visceral
afferent pathways  dull, poorly localized pain
• Intraluminal pressure > venous pressure  ulceration & ischemia
develops  bacteria & PMN cells invade the appendiceal wall
• Appendix become swollen, begin to irritate surrounding structures
(including the peritoneal wall)  pain: more localized to right lower
quadrant
• If swelling persists  hypoxia  necrosis & perforation through the
appendiceal serosal layer  abscess formation / diffuse peritonitis
Clinical Features
• History
– Onset of dull periumbillical pain  right lower quadrant
– Anorexia, nausea, vomiting
– Low-grade fever
– Less typical: increased urinary frequency & desire to defecate
• Physical examination
– Localized abdominal tenderness  right lower quadrant
– Guarding & rigidity
– McBurney’s sign (+)
– Rovsing sign (+)
– Rebound tenderness  indicative of peritoneal inflammation,
usually occurs after appendix is significantly inflamed or
ruptured
Diagnostic Test
• Laboratory Testing
– Leukocyte count  leukocytosis
– C-reactive protein
– Urinalysis
– Pregnancy test (women of childbearing age with
abdominal pain)
• Diagnostic scores
– Alvarado score
Imaging Studies
• Behind the caecum (ascending retrocaecal) 65%
• Inferior to the caecum (subcaecal) 31%
USG
• Using graded compression technique
• Findings:
– Aperistaltic, noncompressible, dilated appendix (>6 mm outer diameter)
– Appendicolith
– Target appearance (axial section)
CT scan
• Dilated appendix with distended lumen (>6mm d)
• Thickening of caecal apex: caecal bar sign, arrowhead sign
• Extraluminal fluid
• Appendicolith may also be identified
Plain radiograph
• Free gas
• Appendicolith
• Small bowel obstruction pattern w small bowel dilatation and air-fluid levels
 if perforation
Intussusception
• Rare, 1-5% of cases of adult bowel obstruction
• Mostly are of the small bowel
• Lesion (“lead point”) changes the motility
properties of the intestine, allowing a proximal
segment to invaginate into a more distal segment
• Peristaltic activity pushes the invaginated
segment along with its mesentery and
mesenteric blood vessels  blood supply to the
segment can be compromised  ischemia
• Edema  mechanical obstruction of the bowel
Clinical Features
• Acute partial intestinal obstruction:
– Abdominal pain
– Vomiting, bleeding, constipation (may be present)
– Abdomen may be distended, bowel sounds are
often decreased
– Children  triad: abdominal pain, palpable mass,
heme-positive stools
• Complete obstruction
– Intermittent abdominal pain for months or years
Radiology
• Ileocolic: most common (75-95%), presumably due to the abundance of lymphoid
tissue related to the terminal ileum and the anatomy of the ileocaecal region
Plain radiograph
• Abdominal x-rays may demonstrate an elongated soft tissue mass (typically in the
upper right quadrant in children) with a bowel obstruction (and therefore air-fluid
levels and bowel dilation) proximal to it. There may be an absence of gas in the distal
collapsed bowel.
Ultrasound
• Ultrasonography has a false-negative rate approaching zero and is a reliable screening
tool for children at low risk for intussusception 5-9. Children with classic findings of
intussusception, however, need to be investigated with contrast enema, which is both
diagnostic (the gold standard in the diagnosis of intussusception) and therapeutic.
• Ultrasound signs include:
– target sign (also known as the doughnut sign)
– pseudokidney sign
– crescent in a doughnut sign
Fluoroscopy
• Acontrast enema remains the gold standard, demonstrating the intussusception as an
occluding mass prolapsing into the lumen, giving the "coiled spring” appearance
(barium in the lumen of the intussusceptum and in the intraluminal space). The main
contraindication for an enema is a perforation.
Pneumoperitoneum
• Gas within peritoneal Radiology
cavity • Abdominal radiograph
• Most common cause is – Free gas w/in peritoneal
from the disruption of the cavity
wall of a hollow viscus; Bowel related signs
– peptic ulcer, ischaemic – Double wall sign (Rigler’s
bowel, bowel obstruction, sign or bas-relief sign)
necrotising enterocolitis, • Chest radiograph
appendicitis, diverticulitis,
– Free intraperitoneal gas
vaginal aspiration
– Subdiaphragmatic free gas
– Cupola sign (supine)