Problem 06

Group 04
Monday, 28 October 2019
 Identitas Kelompok
• Tutor : Marcella Erwina Rumawas dr.,M.S.,Ph.D.
• Ketua : Patrecia Tjuanda
• Sekretaris : Atarit Zulfikar Wiraraja
• Penulis : Normalisa Aulia

• Anggota :
1. Jimmy chua
2. Zevani Olivia Panjaitan
3. Rani Afriyanti
4. Felicia Aileen
5. Caesarizky agriyandita putra
6. Edwin Destra
7. Rizka Irayani
8. Gita Prinita
 “Wine Barrel Belly Bleed Slow"

• A 50-year-old male came to the Emergency Department with severe epigastric abdominal pain that lasted for
approximately 6 hours. The pain was sudden in onset, radiating to the back, and associated with nausea, greenish vomiting
and bloating. He has a history of alcohol abuse and his last alcoholic drink was 1 day prior to presentation. He had pain on
right lower abdominal quadrant 3 month before. He is a heavy smoker. He is not on new medication and history of
abdominal trauma. On physical examination, he is afebrile with blood pressure 130/80 mmHg, heart rate 105 beats per
minute and respiratory rate 22 breaths per minute. On abdominal examination: there were epigastric tenderness and purple
color around his belly button. His laboratory tests on admission revelead a WBC of 12.600/uL, a hemoglobin level of
13,6g/dL, and platelets 172.000/uL. His comprehensive metabolic panel was remarkable for AST 98 IU/L and ALT 43 IU/L

• At the same time , a 6-year-old boy was brought to the ED by his mother with severe abdominal pain since 12 hours ago.
The boy had a fever 3 days prior and was vomiting everytime he ate. According to his mother, the patient has been
complaining for abdominal pain since 3 months ago, but the pain sometimes resolved itself. The patient loves to eat spicy
food and rarely ate veggies. Physical examination results : the patient looks in pain, blood pressure 90/60 mmHg, heart rate
120 beats per minute, respiratory rate 25 breaths per minute, temperature 38 °C. Abdominal examination results : peristaltic sound
(+), McBurney sign (+), liver/spleen are not palpable. Other physical examinations are within normal limits. Initial laboratory results : Hb 13
g/dL, WBC 20.000/uL, platelets 250.000/uL.

• Identify and discuss the problems in these cases chronologically, while considering all possibilities!
Mind
Map Kegawatdaruratan
Abdomen

Intususepsi
Acute abdomen Syok
Hernia

Pankreatitis
Perforasi Peritonitis
Kolelitiasis

Appendisitis akut GI bleeding

Korosif esophageal
Peptic ulcer
Varises esophageal
 SHOCK
• Shock is the clinical syndrome that
results from inadequate tissue
perfusion
• Hypoperfusion-induced imbalance
between the delivery of &
requirements for O₂ & substrate
 cellular injury  DAMPs &
inflammatory mediators 
change in microvasculature 
maldistribution of blood flow 
compromising cellular perfusion
 multiple organ failure  death

Rosen’s Emergency Medicine (2016)

Rosen’s Emergency Medicine (2016) Tintinali’s Emergency Medicine, 8th ed.
Rosen’s Emergency Medicine (2016)
Advanced Trauma Life Support (ATLS). Chapter 3: Shock
 Respons Terhadap Resusitasi Cairan

Advanced Trauma Life Support (ATLS). Chapter 3: Shock

Acute abdomen
Judith A. O’Connor MD, in
Berman's Pediatric Decision
Making (Fifth Edition), 2011
Judith A. O’Connor MD, in
Berman's Pediatric Decision
Making (Fifth Edition), 2011
Cydulka RK, Cline DM, Ma OJ. Tintinalli’s Emergency Medicine Manual. 8th ed. New York: McGraw-Hill, 2018
Rosen’s Emergency Medicine (2016)
Rosen’s Emergency Medicine (2016)
 Treatment
• Resuscitation
• Most common: IV fluids with normal saline or lactated Ringer’s solution
• During the initial evaluation, the patient should have nothing by mouth
• Analgesics
• Morphine 0.1 mg/kg IV or hydromorphone 0.2-1 mg IV, (can be reversed by
naloxone 0.4-2 mg SC/IV if necessary)
• NSAIDs: ketorolac 30 mg IV or ibuprofen (200-400 mg PO)
• useful in patients with renal colic
• use in other conditions is controversial and can mask peritoneal inflammation

Cydulka RK, Cline DM, Ma OJ. Tintinalli’s Emergency Medicine Manual. 8th ed. New York: McGraw-Hill, 2018
• Antiemetics: ondansetron 4 mg IM/IV or metoclopramide 10 mg IM
or slow IV
• When appropriate, antibiotic treatment (gentamicin 1.5 mg/kg IV +
metronidazole 1 g IV; or piperacillin-tazobactam, 3.375 g IV) should be
initiated, depending on the suspected source of infection
 • Surgical or obstetric & gynecologic consultation for patients with suspected acute
abdominal or pelvic pathology requiring immediate intervention: abdominal
aortic aneurysm, intraabdominal hemorrhage, perforated viscus, intestinal
obstruction or infarction, ectopic pregnancy, or gynecologic emergencies
• Indications for admission: toxic appearance, unclear diagnosis in elderly or
immunocompromised patients, inability to reasonably exclude serious etiologies,
intractable pain or vomiting, altered mental status, inability to follow discharge or
follow-up instructions
• Alternative: continued observation with serial examinations
• Many patients with nonspecific abdominal pain can be discharged safely with 12-24 hours
of follow-up & instructions to return immediately for increased pain, vomiting, fever, or
failure of symptoms to resolve

Cydulka RK, Cline DM, Ma OJ. Tintinalli’s Emergency Medicine Manual. 8th ed. New York: McGraw-Hill, 2018
simdos.unud.ac.id
simdos.unud.ac.id
Cydulka RK, Cline DM, Ma OJ. Tintinalli’s Emergency Medicine Manual. 8th ed. New York: McGraw-Hill, 2018
 Physical findings
• tenderness to palpation will often occur at McBurney's point
• Abdominal tenderness may be completely absent if a
retrocecal or pelvic appendix is present  tenderness in the
flank or on rectal or pelvic examination
• Referred rebound tenderness is often present and is most likely to be
absent early in the illness
• Flexion of the right hip and guarded movement by the patient
are due to parietal peritoneal involvement
• The temperature is usually normal or slightly elevated [37.2°–
38°C (99°–100.5°F)], >38.3°C (101°F)  perforation
• Rigidity and tenderness  more marked as the disease
progresses to perforation and localized or diffuse peritonitis
• Perforation is rare before 24 h after onset of symptoms, but
the rate may be as high as 80% after 48 h

Source : Kasper, D.L, Hauser, S.L, Jameson, JL, et al. Harrison’s Principles of Interna Medicine. 19 th ed. McGraw-Hill Education; 2015. 202-4
Walls RM, Hockberger RS, Gausche-Hill M. Rosen’s Emergency Medicine Concepts and Clinical Practice. 9th ed.
Philadelphia, PA: Elsevier, 2018
Walls RM, Hockberger RS, Gausche-Hill
M. Rosen’s Emergency Medicine
Concepts and Clinical Practice. 9th ed.
Philadelphia, PA: Elsevier, 2018
Berdasarkan score alvarado Diagnosis and management of acute appendicitis. EAES consensus development conference
2015
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299622 /
Secondary survey abdominal pain
 Diagnostic Imaging :
• Plain radiographs
• Ultrasound
• Abdominal-pelvic CT Scan

Cydulka RK, Cline DM, Ma OJ. Tintinalli’s Emergency Medicine Manual. 8th ed. New York: McGraw-Hill, 2018
 Laboratorium findings
• moderate leukocytosis of 10,000–18,000 cells/microL is
frequent
• Leukocytosis of >20,000 cells/microL  perforation
• Anemia and blood in the stool suggest a primary diagnosis
of carcinoma of the cecum, especially in elderly individuals
• urine may contain a few white or red blood cells without
bacteria if the appendix lies close to the right ureter or
bladder
• Urinalysis is most useful in excluding genitourinary
conditions that may mimic acute appendicitis

Kasper, D.L, Hauser, S.L, Jameson, JL, et al. Harrison’s Principles of Interna Medicine. 19 th ed. McGraw-Hill Education; 2015. 202-
4
 Radiographs
• opaque fecalith (5% of patients) is observed in the right
lower quadrant (especially in children)
• intestinal obstruction or ureteral calculus may be present
• Ultrasound  an enlarged and thick-walled appendix
• CT will include a thickened appendix with periappendiceal
stranding and often the presence of a fecalith

Source : Kasper, D.L, Hauser, S.L, Jameson, JL, et al. Harrison’s Principles of Interna Medicine. 19 th ed. McGraw-Hill Education;
2015. 202-4
Peritonitis
• Laboratorium
Leukositosis
Asidosis
• Radiografi
Dilatasi & edema dinding intestinal
Pneumoperitonium/ tanda kebocoran
lainnya  bisa surgical emergency
• Paracentesis diagnostic (pd pasien ascites
stabil)  mengukur protein, lactate
dehydrogenase & cell count

Kasper, D.L, Hauser, S.L, Jameson, JL, et al. Harrison’s Principles of Interna Medicine. 19 th ed. McGraw-Hill Education; 2015.
 INTUSUSEPSI / INVAGINASI
Salah satu bentuk obstruksi usus yang menunjukkan adanya satu segmen usus yang masuk ke dalam segmen usus
lainnya. Hal ini sering dijumpai pada ileum terminal.

Diagnosis
• Paling sering ditemukan pada pasien umur
6 bulan – 1 tahun, namun dapat pula
terjadi pada pasien yang lebih tua.
• Gambaran klinis:
• Awal: kolik yang sangat hebat disertai
muntah. Anak menangis kesakitan
• Lebih lanjut: kepucatan pada telapak
tangan, perut kembung, tinja
berlendir bercampur darah (currant
jelly stool) dan dehidrasi.

• Palpasi abdomen teraba massa seperti Sumber: https://www.ncbi.nlm.nih.gov/pubmed/12488701

sosis.
• Ultrasonografi: tampak tanda donat /
pseudo-kidney

Buku saku pelayanan kesehatan anak di rumah sakit. WHO 2009

Incarcerated
Hernia

http://radiopaedia.o
rg/cases/incarcerate
d-ventral-hernia-1
 Strangulated
Hernia

http://www.bjui.o
rg/ContentFullIte
m.aspx?id=660
Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of
survival in human septic shock. Crit Care Med. 2006;34:1589–96 (level 3).
bedahunmuh
Source: http://www.rch.org.au/clinicalguide/guideline_index/Intussusception_Guideline/
GI bleeding
https://www.bmj.com/content/bmj/suppl/2018/10/25/bmj.k4023.DC1/upper_gi_v14_web.pdf
https://www.bmj.com/content/bmj/suppl/2018/10/25/bmj.k4023.DC1/upper_gi_v14_web.pdf
Kasper, D.L, Hauser, S.L, Jameson, JL, et al. Harrison’s Principles of Interna Medicine. 19 th ed. McGraw-Hill Education; 2015.
 Diagnosis

Kasper, D.L, Hauser, S.L, Jameson, JL, et al. Harrison’s Principles of Interna Medicine. 19 th ed. McGraw-Hill Education; 2015.
50 year old man
Severe epigastric pain Irritation of somatic innervation (T5-T6)
DD/: pancreatitis
Complaint : radiating to the back
Nausea
Green vomiting DD/: peptic ulcer Erosion of mucosa Dyspepsia,
bloating epigastric pain,
History of alcohol abuse nausea
DD/:Pancreatitis
Pain on RLQ 3 months Proceeds into
DD/ : before hematemesis
Intestinal blood vessel
PF :
blockage Bleeding to esophagus
Afebrile
Hernia Bleeding to stomach
Blood pressure 130/80 DD/: pancreatitis
Peritonitis
HR
Pancreatitis Oxidized by HCl but
RR
Passes through GIT, moves back to esophagus
Grey turner and Cullen sign
Oxidized
Epigastric tenderness
LAB :
WBC 12.000 (meningkat) Melena Emesis coffee-ground
HB DD/: GI bleeding
Platelet 172.000 (Batas bawah)
AST & ALT
 6 year old boy
Complaints : DD/ APP, peritonitis,
Severe abdominal pain pancreatitis,
Fever 3 days prior intestinal obstruction
Vomiting
Abdominal pain since 3 months ago DD/ : APP,
Loves spicy food, rarely ate veggies intestinal obstruction
Obstruction of
PF; appendiceal lumen
BP :
HR : DD/: shock
RR : Appendix distention & spasm
Febrile
Mc Burney sign (+) Appendicitis

LAB : Lumen pressure, Blood flow

Hb Appendicitis,
WBC GI bleeding
Platelet Bacterial invasion of the appendice wall

Perforation of colon wall

Peritonitis, abscesses or death

Kesimpulan dan Saran
• Kami telah mempelajari tentang syok, akut abdomen, GI bleeding
• Diperlukan tatalaksana awal dan pemeriksaan lanjutan untuk
mengetahui etiologi dan tatalaksana selanjutnya