Clinical Aspect of Acute Abdomen

Department of Surgery

Ciptomangunkusumo Hospital

Acute Abdomen
Be defined generally as an intraabdominal process causing severe pain and often requiring surgical intervention.
It is a condition that requires a fairly immediate judgment or decision as to management

Epidemiology
US 2002:
abdominal pain was the chief complaint of over 7 million patients in emergency department 6.5 % of all emergency department visit

RSCM:
Emergency department operation 2004 : 564 (52.9%) acute abdominal of 1155 emergency operations.

Acute Abdomen
Acute conditions of the abdomen are produced by inflammatory, obstructive, vascular mechanisms or high intra abdominal pressure and are manifested by sudden onset of abdominal pain, gastrointestinal symptoms and varying degrees of local and systemic reaction.

General causes of the acute abdomen

a. inflammatory b. mechanical c. neoplastic d. vascular f. Traumatic/Blast injury g. Abdominal hypertension

Cause and Pathophysiology of the following acute abdomen :

a. Acute appendicitis - inflammatory b. Acute small bowel obstruction - mechanical c. Mesenteric vascular occlusion - vascular d. Perforated duodenal ulcer perforated viscous e. Peritonitis

Characteristics of the Acute Abdomen

Since pain is the most prominent presenting complaint in a patient with an acute abdomen, it is important to know the origin, location, radiation and character of abdominal pain in order to understand its significance.
The perception of abdominal pain is first visceral and then becomes somatic

Acute Abdomen
Visceral pain Somatic pain

Visceral sensation Ischemic/extension Vague Dull Autonom symptoms

Parietal sensation Mechanic /chemical kimia Localized sharp

Type of Onset
sudden - rupture of viscous, mesenteric thrombosis gradual cholecystitis, appendicitis

Quality
Dull - initial epigastric pain of appendicitis Sharp - renal or biliary colic or obstruction of gut Aching - pelvic inflammatory disease Lancinating - acute pancreatitis Tearing - dissecting aneurysm

Intensity
Severe - rupture of viscous or blood in the peritoneal cavity Moderate - RLQ appendiceal Mild peptic ulcer, without perforation

Temporal Features
continuous - acute pancreatitis pulsatile - abdominal aneurysm colicky - lumen obstruction, intermittent severe pain with pain-free intervals frequency & duration transient pain of short duration which does not recur is usually insignificant. The longer the duration the more likely a surgical condition

Acute Abdomen Symptoms & sign

Pain Vomiting Abdominal distension Constipation Diarrhea Hematemesis & Melena Haematochezia.

Patient's symptoms
All of the patient's symptoms must be carefully considered and analyzed, especially with regard to organs most likely to give rise to acute conditions Extra abdominal conditions which simulate the acute abdomen arise most often in the heart, lungs, urinary tract and female reproductive organs

Acute Abdomen
Symptoms & sign

Grey-Turner, Cullen sign Murphy sign GI Obstruction Free air /Pneumoperitoneum Free fluids Increasing Bowel sound

Acute Abdomen

GI tract Acute appendicitis Perforated Typhoid Strangulated bowel obstruction Strangulated groin hernia Perforated peptic ulcer Massive bleeding

Acute Abdomen
HPB

Liver abscess Bleeding liver tumor Acute cholecystitis Hemorrhagic pancreatitis

Acute Abdomen

Gynecologic Ectopic Pregnancy Ovarial cyst torsion

Vascular problem Aortic aneurysm Mesenteric thrombosis

Action on Acute Abdomen

require immediate surgery require watchful expectancy, require medical rather than surgical management. Often the patient's condition is such that extensive laboratory investigation requiring many hours would compromise the patient's life and thus the outcome often depends on a precise and detailed history and physical examination.

Compartment Syndrome

Acute Abdomen
Surgery interventions

Severe contaminated peritonitis Strangulated GI Obstruction GI obstruction + Respiratory distress Perforation Abdominal shot gun wound Penetrated Abdominal wound Massive GI bleeding ABOMINAL COMPARTMENT SYNDROME (ACS)

Acute Abdomen
LAB.

Routine Blood Test Specific Test (amylase) Urine test

Acute Abdomen
Other Imaging Technique Plain abd X `rays USG CT Scan
Other Diagnostic Tools Diagnostic Peritoneal Lavage Endoscopy Laparoscopy

Certain tests when associated with characteristic clinical features

Markedly elevated serum amylase levels - acute pancreatitis Free air under diaphragm in an upright x-ray film perforation of a hollow viscous - usually a duodenal ulcer Distended loops of small bowel above the level of obstruction in small bowel obstruction with absence of gas below by x-ray; generalized distention of large and small bowel - paralytic

Conclusion
Acute Abdomen is a common problem in emergency department Clinical examination is an important diagnostic value to acute abdomen Radiography findings helps clinicians to implement the right therapy

Thank You