Acute Abdomen

Abdominal Anatomy
Review
Abdominal Cavity
Superior border = diaphragm
Inferior border = pelvis
Posterior border = lumbar spine
Anterior border = muscular
abdominal wall
Peritoneum
Abdominal cavity
Double-walled structure
Peritoneum visceral
Peritoneum parietal
Separates abdominal cavity into two parts
Peritoneal cavity
Retroperitoneal space
Primary GI Structures
Mouth/oral cavity
Lips, cheeks, gums, teeth, tongue
Pharynx
Portion of airway between nasal cavity and
larynx
 Primary GI Structures
Esophagus
 Portion of digestive
tract between pharynx
and stomach
Gaster
 Hollow digestive
organ
 Receives food from
esophagus
 Primary GI Structures
Small intestine
 Between stomach and cecum
 Composed of duodenum,
jejunum and ileum
 Site of nutrient absorption into
body
Large intestine
 From ileocecal valve to anus
 Composed of caecum, colon,
rectum
 Recovers water from GI tract
secretions
Accessory GI Structures
Salivary glands
Produce, secrete saliva
Connect to mouth by ducts
Accessory

GI Structures
Liver
Large solid organ in right upper quadrant
Produces, secretes bile
Produces essential proteins
Produces clotting factors
Detoxifies many substances
Stores glycogen
Gallbladder
Sac located beneath liver
Stores and concentrates bile
Accessory GI Structures
Pancreas
Endocrine pancreas secretes insulin into bloodstream
Exocrine pancreas secretes digestive enzymes,
bicarbonate into gut
Vermiform appendix
Hollow appendage
Attached to large intestine
No physiologic function
Major Blood Vessels
Aorta
Inferior vena cava
Solid Organs
Liver
Spleen
Pancreas
Kidneys
Ovaries (female)
Hollow Organs
Stomach
Intestines
Gallbladder and bile ducts
Ureters
Urinary bladder
Uterus and Fallopian tubes (female)
Acute Abdomen
Istilah akut abdomen mencakup semua gejala dan
tanda penyakit intra-abdomen yang paling baik
ditangani dengan pembedahan.
Dari seluruh pasien yang datang ke unit gawat
darurat, 5-10 % pasien datang dengan nyeri abdomen.
(Sabiston 2007)
Abdominal Pain
Visceral
Somatic
Reffered
Nyeri Abdomen
Nyeri viseral
Peregangan peritoneum atau kapsul
organ akibat distensi atau edema
Streching dari saraf yang
menginervasi dinding atau kapsul
organ solid atau hollow
Ditentukan oleh asal embriologi
organ
Difus, tumpul
Tidak terlokalisir
Nyeri abdomen
Nyeri somatik
Inflamasi peritoneum parietal atau diafragma
Tajam
Terlokalisir dengan baik
Nyeri abdomen
Reffered pain
Nyeri alih yang
dirasakan jauh dari
sumber stimulus
 Shifting pain/nyeri pindah
Merupakan nyeri yang berubah paralel dengan perjalanan kondisi patologis.
Lokasi nyeri abdomen saat pemeriksaan dapat berbeda dengan lokasi saat
onset.
Misalnya, pada tahap awal appendicitis, nyeri dirasakan di sekitar pusat. Setelah
radang terjadi di seluruh dinding peritoneum, nyeri dirasakan di perut kanan
bawah.

 Nyeri kontinu
Nyeri akibat rangsangan pada peritoneum parietal akan dirasakan terus menerus.

 Nyeri kolik
Merupakan nyeri visceral akibat spasme otot polos organ berongga dan biasanya
disebabkan oleh hambatan pasase dalam organ tersebut. Nyeri dirasakan
hilang timbul, disertai mual muntah, dan gerak paksa (trias kolik).

 Nyeri iskemik
Nyeri sangat hebat, menetap, dan tidak menyurut. Lebih lanjut dapat terjadi
takikardia, merosotnya keadaan umum, dan syok.
Penyebab
3G’s :
GI (Gastrointestinal)
GU (Genitourinary)
GYN (Gynecologic)
Vascular emergency
5 kategori mayor akut
abdomen:
• Bleeding or rupture
of vessels or tumor
• Ischemia or
Infarction
• Obstruction
• Perforation
• Inflammation
Anamnesis
O nset
P recipitating/ relieving
Q uality
R adiation
S everity
T iming
Riwayat Peyakit sekarang
Lokasi nyeri? “Differential Diagnosis By Location”
Minta pasien untuk menunjuk dengan jari
Nyeri dirasakan seperti apa?
Steady pain = Inflammatory process
Cramping pain = Obstructive process
Tearing = Aneurism
Burning = Ulcer
Onset nyeri?
Tiba-tiba = Perforation or vascular occlusion
Gradual = Peritoneal irritation, distension of hollow
organ
Nyeri menjalar?
Gallbladder = Angle of right scapula
Pancreas = Straight through to back
Kidney/ureter = Around flank to groin
Heart = epigastrium, neck/jaw, shoulders, upper arms
Spleen = Left scapula, shoulder
Abdominal Aortic Aneurysm = low back radiating to one or both
leg

• Nyeri berpindah?
Periumbilical to Right Lower Quadrant (Appendicitis)
Nausea Vomiting
Anorexia
Urine
Change in urinary habits?
Frequency

Urgency

Color?
Odor?
Uteric Colic
Bowel movements
Change in bowel habits? Color? Odor?
Constipation
a. Progressive intestinal obstruction
from a neoplasm or inflammatory
bowel disease
b. Paralytic Ileus
c. Post Operative
d. Obstructed groin hernia
Bright red blood

Melena = black, tarry, foul-smelling stool

Dark stool
 Suspect bleeding
 Other causes possible (iron or bismuth containing materials)
Modifying factor
Makanan
• Makes It Worse (Biliary Colic)
• Makes It Better (Duodenal Ulcer)
Posisi
• duduk (PID)
History
Riwayat Keluarga
Riwayat Penyakit Dahulu
Riwayat Operasi
Riwayat pemakaian obat-obatan: certain toxic drugs or
Alcohol intake
Riwayat menstruasi pada wanita usia subur
Pemeriksaan Fisik
 Perhatikan:
-Keadaan umum
 Still, refusing to move = Inflammation, peritonitis
 Extremely restless = Obstruction
 Bending Forward = Chronic Pancreatitis
 Jaundice = CBD obstruction

 Vital signs : Temperature, Pulse, BP, Respiratory rate

 Tachycardia = more important sign of volume loss than falling BP
 Rapid, shallow breathing = possible peritonitis
 Suhu tubuh
Ruptured AAA or ectopic pregnancy :
-Pallor
-Hypotension
-Tachycardia
-Tachypnea
 Inspeksi abdomen: distensi, scar, bentuk abdomen, peristaltik
 Auskultasi abdomen: peristaltik usus
 Absent sounds = possible peritonitis, shock
 High-pitched, tinkling sounds = possible bowel obstruction
 Perkusi abdomen : timpani, shifting dullness
 Palpasi abdomen : spasme, tenderness, massa abdomen, nyeri tekan
 Palpate each quadrant
 Palpate area of pain LAST
-Inguinal dan femoral
-Pemeriksaan rektal: tenderness, massa, perdarahan.
-Pemeriksaan pelvik
Pemeriksaan Penunjang
• Pemeriksaan darah
• Pemeriksaan urin
• Pemeriksaan tinja
• Pemeriksaan radiologis: foto polos dada, foto polos
abdomen, angiography, kontras, USG, CT scan
• Endoscopy
• Paracentesis
• Laparoscopy
Standar Kompetensi Dokter Indonesia
Acute Abdomen
• Peritonitis: 2
• Abses kavum Douglas : 2
• Ileus : 3B
• Perforasi : 2
• Salphingitis : 3A
• Appendicitis akut : 3A
• Abses appendikuler : 3B
• Lymphadenitis mesenterika : 1
Appendicitis Akut
Appendix : vermiform (worm-like) tube which arises from the posteromedial
caecal wall, approximately 2 cm below the end of the ileum
Variasi anatomi
posisi appendix:
(1) Preilieal
(2) Postilieal
(3) Promontoric
(4) Pelvic
(5) Subcecal
(6) Paracolic or
Prececal
(7)Retrocaecal or
Retrocolic
(paling sering)

Gray’s anatomy ed
40th
Panjang rata-rata appendix
= 9 cm; diameter : 3–8 mm;
diameter lumen : 1–3 mm
vaskularisasi: a.
appendicular cabang the
ileocolic artery,
Lymphatic drainage :
lymph nodes along the
ileocolic artery.
persarafan parasimpatis:
n.vagus dan persarafan
simpatis : n.torakalis X.
 Apendiks menghasilkan
lendir 1-2 ml perhari.
GALT ( Gut Assoiated 
Lymphoid Tisuue) yang
terdapat pada apendiks
menghasilkan Ig-A.
Appendicitis Akut
Obstruksi lumen appendix proksimal akibat serat-
serat fibrous, hiperplasia limfoid, fecalith, calculi, atau
infeksi.
7% penduduk Amerika Serikat mengalami
appendicitis akut.
Insidensinya 1,1 kasus per 1000 penduduk per tahun.
Insidensi tertinggi terjadi pada kelompok usia 20-30
tahun.
Insidensi pada laki-laki : perempuan = 1,4:1.
Etiologi dan patofisiologi
• Obstruction of the lumen is believed to be the major cause of acute
appendicitis.
• Fecalith or appendicolith, lymphoid hyperplasia, vegetable matter or
seeds, parasites, or a neoplasm –appendix predispose to closed-loop
obstruction.
• Obstruction of the appendiceal lumen → bacterial overgrowth →
secretion of mucus leads to intraluminal distention and increased
wall pressure ( →reflex nausea and vomiting).
• Luminal distention produces the visceral pain sensation
experienced by the patient as periumbilical pain.
• Impairment of lymphatic and venous drainage → mucosal ischemia
→ progress to gangrene and perforation.
• Inflammation of peritoneum → localized pain in the right lower
quadrant.

Obstruction → bacterial overgrowth → secretion of mucus leads to

intraluminal distention and increased wall pressure → Impairment
of lymphatic and venous drainage → mucosal ischemia →
perforation.
Bacteriology
The flora in the normal appendix = colon
Anamnesis (History)
RPS
Nyeri mulai di epigastrium atau regio umbilikus → Nyeri pindah ke kanan bawah
(titik McBurney)
Mual
Anoreksi
Muntah
Konstipasi atau diare (tidak membantu diagnosis, kebanyakan pasien mengalami
konstipasi)
RPD
+/- Riwayat sakit yang sama sebelumnya
RPK
+/- Keluarga yang berpenyakit yang sama
Riwayat pengobatan
+ Riwayat penggunaan obat-obatan (anti nyeri) → Tidak respon setelah terapi
Pemeriksaan Fisik
Keadaan Umum :
Tampak kesakitan, berbaring di atas tempat tidur

Vital sign:
Tekanan darah : ± dbn
Nadi : ± dbn
Respiratori : ± dbn
Suhu : low grade fever (∼38 0C )

Pemeriksaan Fisik
Abdomen:
Inspeksi : kembung (ada komplikasi perforasi), penonjolan perut kanan bawah
Auskultasi : peristaltik normal atau sedikit berkurang
Perkusi : nyeri
Palpasi : nyeri tekan, defens muskuler
Mc Burney Sign:
Nyeri tekan pada titik Mc Burney

Rovsing sign
Nyeri kanan bawah (fossa iliaca dextra) pada tekanan di perut kiri bawah (fossa iliaca
sinistra)

Rebound tenderness (Blumberg Sign)

Nyeri kanan bawah bila tekanan di sebelah kiri dilepaskan (untuk mengetahui ada
tidaknya peritonitis)

Dunphy's sign
Nyeri kanan bawah bila peritoneum bergerak (napas dalam, berjalan, batuk, mengedan)

Psoas Sign
Nyeri pada saat kaki kanan diangkat dan
diberi tahanan (hiperekstensi sendi panggul),
tipikal pada appendix retrocaecal

Obturator sign
Nyeri di hipogastric kanan pada saat rotasi
internal dari pinggul, mengindikasikan appendix pelvis.
Pemeriksaan Penunjang
Laboratorium
Leukositosis (10,000 to 18,000 cells/mm3) dengan
neutrofilia > 75%, >20,000/mL →complicated
appendicitis
Pemeriksaan urin : menyingkirkan diagnosis banding
seperti infeksi saluran kemih atau batu ginjal.
Accute Appendicitis Alvarado Score
Alvarado Score
Aggregate score 7 – 10 : emergency for appendectomy
Aggregate score 5 – 6 : admitted, 24 hours
observation and re scoring
Aggregate score 1 – 4 : symptomatic treatment,
discharge home, back to hospital if the pain persist

Positive predictive value of Alvarado score was 84.3%

(males 88% and females 82.1%)
Pemeriksaan Penunjang
Radiografi
Foto polos abdomen
USG transabdominal
Barium enema
CT
Laparoskopi
Diagnosis Banding
Gastroenteritis
Infeksi panggul
Kehamilan ektopik
Urolithiasis
Komplikasi
Perforasi
Pada saat terjadi perforasi appendix, nyeri abdomen
semakin intens dan lebih difus, spasme musculus
abdomen meningkat, menghasilkan rigidity. Nadi
meningkat, suhu diatas 380 C.
Peritonitis
Abses appendiceal (massa appendiceal)
Penatalaksanaan
Perawatan kegawadaruratan
terapi kristaloid untuk pasien dengan tanda-tanda
klinis dehidrasi 
analgesik dan antiemetik parenteral untuk
kenyamanan pasien
antibiotik intravena pada pasien dengan tanda-tanda
septicemia dan pasien yang akan dilanjutkan ke
laparotomi
Treatment
Antibiotik Pre-Operatif : spektrum luas untuk gram
negatif dan anaerob diindikasikan alam hubungannya
pembedahan

Appendectomy
Prognosis
Mortalitas pada appendicitis akut simpel 0,1%.
Mortalitas akibat perforasi 5%.
Daftar pustaka
Doherty, Gerrad M.. Current surgical diagnosis & treatment. 2006. Lange-Mc
Grawhill.
Gray's Anatomy 40th Ed Susan 2009
Macleod's Clinical Examination 12th Ed Douglas 2009
Maingots Abdominal Operations 11th Ed Zinner 2006
Sabiston Textbook of Surgery 18th Ed Townsend 2007
Schwartz's Principles of Surgery 9th Ed Brunicardi 2010
Shackelford's Surgery of the Alimentary Tract 6th Ed Yeo 2006
Sjamsuhidajat, R., de Jong, W.. Buku Ajar Ilmu Bedah Edisi 2. 2005. Jakarta:EGC.
Sleisenger and Fordtran's Gastrointestinal and Liver Disease Pathophysiology
Diagnosis Management 9th Ed Feldman 2010
Tintinalli's Emergency Medicine A Comprehensive Study Guide 7th Ed
Tintinalli 2010
Terima Kasih