Download - Acute Abdomen Dr Nurhayat
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04/11/23
Acute AbdomenAcute Abdomen
Nurhayat Usman, dr Sp.B-KBD
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Acute Abdomen (acute abdominal pain) “Condition which requires immediate treatment” (FD
Moore, 1977): Surgery? When to perform?
(Buku Ajar Ilmu Bedah, 1997): “Clinical condition which arises from acute critical condition in the abdominal cavity, and usually manifests as pain.
Acute abdominal pain: Chief complaint: acute pain (Nyhus, Vitello, Condon, 1995)
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Why is it important ? Patient with acute abdomen:
Sudden onset Unknown etiology (not clear) Need immediate diagnosis & treatment
Prevent morbidity & mortality
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Morbidity & Mortality
Obstruction Fluid imbalance
Perforated viscus Peritonitis
Infection Sepsis Shock
Bleeding Hypovolemic Shock
Ischaemia Perforation Peritonitis
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Acute abdominal pain
Most can be diagnosed clinically
Require accurate and focused history taking
Need meticulous & rationale physical examination
Appropriate special investigations
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TheDiagnosticProcess
HISTORY
Patient perception of symptoms
Patient description of symptoms
Physician perception
Physician interpretation of symptoms
LABORATORY SYNTHESIS PHYSICALFINDINGS RECORDING EXAM
DECISION
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History Taking 60 - 80% of accurate diagnosis arises from good &
meticulous history taking
Physical diagnosis confirms accurate diagnosis
10 - 15% of accurate diagnosis arise from laboratory & radiological examinations
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History Taking
May confirm : Suspected diagnosis Possible etiology Disease stages/ complications Differential diagnosis
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History Taking
Introduction
• Greet the patient, and develop a warm and helpful environment
• Introduce yourself to the patient
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Patient Identity
Ask the patient politely concerning his/her : name age
Record the gender : Male Female
Ask the marital status of the patient (especially for female)
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Acute abdominal pain in specific groups In children
Acute appendicitis
In the elderly Perforated tumors Bowel obstruction due to tumors
During pregnancy Complicated Ectopic pregnancy
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Chief complaint: Ask the patient regarding why the patient comes to you.
PAINPAIN Site at present
Onset
Radiation
Type
Aggravating /relieving factors
Severity
Duration
Site at onset
Progression
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Site of pain
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Upper abdominal pain Peptic or gastric ulcer Acute Cholecystitis, Acute Cholangitis Pancreatitis Early Appendicitis Hepatitis or liver abscess Extra abdominal:
Inferior Pleuritis, lobar pneumonia, pneumothorax Pericarditis, Myocardial infarction, angina
Pyelonephritis, renal colic
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Central abdominal pain Early appendicitis Bowel obstruction, strangulated Pancreatitis Gastroenteritis Mesenterial Emboli /Thrombosis Dissecting aortic aneurism Mesenteric adenitis Early sigmoid diverticulitis
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Lower abdominal pain Colonic Gangrene/Obstruction Appendicitis Mesenteric adenitis Diverticulitis Ruptured tubo-ovarial abscess Tuboovarial Torsion Ectopic gestation
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Onset of pain
Sudden onset
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Onset of pain
Gradual pain
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Visceral pain &Parietal pain
Type of pain
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Type and severity of pain
A. Toothache C. Colicky pain of inflammed hollow organs
A
C
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Type and severity of pain
Intermittent colicky pain of obstructed hollow organ at early stage.
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Type and severity of pain
Progressive & Continous colicky pain due to strangulated bowel obstruction (ischemic stage)
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Other related symptoms:Ask the patient concerning related/concomitant symptoms of
Gastro-intestinal function: Nausea Vomiting Loss of appetite Faintness Previous indigestion (habitual)
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Other related symptoms:
Jaundice Bowel habit:
Constipation? Diarrhoea? Colour of the stool? Presence or absence of blood and mucus
(slime)
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Other related symptoms:
Urinary function: Micturition: amount of urine, lower abdominal
discomfort, colour of urine
Gynaecological function ( female) Menstrual function Delayed or miss period Abnormal bleeding or discharge (colour, quantity)
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Previous history
Similar pain Abdominal surgery Major illness: incl. fever, abdominal
injury. Drugs Allergies
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PHYSICAL EXAMINATION Preparation
Check all the equipment required and have a good light:
Examination couchStethoscopeExplain the procedure and its goals to the
patient.Wash your hands with antiseptic soap.Dry and warm your hands with tissues.
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Implementation: A General Examination
General appearance : Consciousness Mood : Distressed? Anxious? Immobile Move cautiously Colour : Pallor? Flushing? Jaundice? Cyanosis?
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Implementation: Examine the vital signs:
Temperature Pulse rate Blood Pressure Respiratory rate
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Implementation:
Perform other systems examination, including cardio-pulmonary system.
Ask the patient politely to expose his/her abdomen.
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Abdominal Examination: Inspection
Inspect the movement:Respiratory movementVisible bowel peristaltics
Is there any scars on the skin of the abdomen?
Is there any abdominal distention?Flatus ? , Fluid ? , Fetus?
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Abdominal Examination: Inspection
Is there any rashes and discolouration? Cullen’s sign Gray Turner’s sign Ecchymosis of the abdominal wall
Is there any masses: Tumors? Hernial sites? Masses with pulsation?
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Cullen Sign Gray-Turner Sign
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Abdominal Examination: Palpation
Ask the patient to locate the site of maximum pain with the tip of a finger.
Using the palmar surface of your fingers, gently palpate the abdomen, starting from a site farthest from the area of maximum pain, move gradually towards it.
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While palpating, look to the face expression of the patient, and look for any signs of :
Tenderness Rebound tenderness Muscle guarding Rigidity Murphy’s sign
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While palpating, look to the face expression of the patient, and look for any signs of :
Swelling or masses Rovsing’s sign Expansile pulsation Hernial orifices Scrotum in male
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Expansile pulsation
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Specific signs
Rovsing’s sign Obturator sign Psoas sign
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Abdominal Examination : Percussion
Place the palmar aspect of your left hand on the abdomen, and gently percus its dorsal aspect with the tip of the middle finger of the right hand, moving all around the abdominal region: Is it tymphanitic ? Is it dull ? Is there any shifting dullness? Site of liver dullness ? and is it disappeared ?
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Auscultation Using stethoscope, and place it gently on the
abdomen, listen to the bowel sounds and bruit at least for one minute: Absent ? High pitched and hyperactive ? Metallic sound ? Vascular bruit ?
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Digital Rectal Examination
Put on surgical hand gloves and ask the patient to expose his/her buttock and anus, and place the patient in lithotomy position.Apply lubricating jelly on to the right index finger.
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Digital Rectal Examination Gently insert your right index finger into the anus, move toward
the anal canal slowly, and evaluate the followings: Anal margin: piles? Mucosal surface of the anal canal and the ampulla
(collaps?) Sites of any pain elicited Masses or swelling: consistency, location, surface, fixity to
the surroundings. Bowel contents: consistency of faeces? Mucus? Blood?
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Perform bimanual palpation in female patient to examine the uterus, pelvic cavity and adnexa.
Write up Write up all significant findings in the medical
record. Conclude your diagnosis and differential diagnosis, and order any necessary special investigations
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Extraperitonealcauses of acute abdomen Cardiothorax Urology Vascular E.t.c
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Acute peritonitis
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Patology
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Degree of peritoneal irritation
(Lowenfels, 1975)bl
ood
Urin
e
bile
pus
Panc
reat
ic ju
ice
Bowe
l bon
tent
Gas
tric
juice
Mild Severe
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Signs of Intrabdominal Sepsis
Fever, nausea, vomiting, tachicardia, tachipneu Abdominal pain Peritoneal signs Signs of dehydration Leucositosis Shock, Multiple organ failure
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Tips > 6 hours: surgically related diseases !!!
Limited movement: peritonitis / ischaemia
Persistent pain on morphine : ischaemia
Sense of Crisis
Repeated exams : Very important
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Perforated duodenal ulcer
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Perforasi Ulkus VentrikuliPerforasi Ulkus Ventrikuli
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GI bleeding
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Pancreatitis
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Acute appendicitis
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Intusucseption
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Sigmoid volvulus
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Mesenteric thrombosis
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Iskemi Usus, Thrombosis MesenterialIskemi Usus, Thrombosis Mesenterial
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Mechanical Intestinal Obstruction
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Obstetrics & gynecological causes
Obstetrics Ectopic gestation Abdominal pregnancy Rupture of the uterus Mola Destruen
gynecology Ruptured ovarial cyst Ovarial Torsion, Myoma Ruptured abscess Perforated Uterus
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Ruptured
organ
Content
PusMaterials :• sebum• meconeum
Blood
Acute
abdomen
torsion
Strangulation
distentionischaemia
Abdominal pain inObgyn
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A Good Diagnosticianis not Born, but is Developed