Acute Abdomen

Acute Appendicitis
Peritonitis
Intestinal obstruction
Gastro intestinal bledding

Syahbudin Harahap
[SYAHARA]
Department of Surgery
Adam Malik Hospital
 Acute Abdomen
Definition
The acute abdomen may be defined generally as
an any sudden ,spontaneous intraabdominal
process causing severe abdominal pain and often
requiring surgical intervention.
It is a condition that requires a fairly immediate
judgement or decision as to management.
Decision requires
1.Patient ‘s history
2.Abdominal Examination
3.Laboratory data
4.Imaging test
 CLINICAL DIAGNOSIS

1.Patient ‘s history
Abdominal pain is mediated through both the

1.Autonomic nervous systems.

2.Somatic sensory nervous systems.

1.Autonomic nervous system
irritation of peritoneum visceral
Visceral pain
•Increased hollow viscus wall tension
•Solid viscus capsule stretching
•Ischemia
•Inflammation

Type of pain
•Cramp
•Poorly localized,
•Nausea and vomiting.
 Embryological division of the gastrointestinal tract
Visceral Pain  midline abdomen
Foregut
Oesophagus
Stomach
Duodenum
Pancreas
Liver
Gall bladder
pain radiating to the epigastrium
Midgut
Jejunum
Ileum
Right colon
Transverse colon
Appendix
pain radiating to the periumbilical
Hindgut
Left colon
Sigmoid colon
Rectum
pain radiating to the hypogastrium.
2.Somatic sensory nervous systems.
Somatic pain /Parietal pain
•Irritation of Parietal peritoneum

Type of pain
• Sharper
•More distinct
•Well localized to the site of stimulation.

Sign of PERITONITIS
spasm of overlying muscles
tenderness
rebound tenderness
Nine sites of abdominal pain.
 ABDOMINAL PAIN
Persist for 6 hours or more with severe intensity
increase- surgical operation
Ebbs after few hours the probability of surgical
diseases decreases, but not to zero

A.LOCATION OF PAIN
VISCERAL PAIN
(distension,inflamation,ischemiadull,poorly
midabdomen)
PARIETAL PAIN
( sharper and better localized, 4 kwadran )
REFERRED PAIN ( biliary diseases right shoulder)
SHIFTING PAIN
( acute appendicitis ,perforasi PUD—>epigastric –>right
kwd )

B.MODE OF ONSET AND PROGRESSION OF PAIN

EXPLOSIVE WITHIN SECONDS
(perforation gaster,duodenum, emboli AMS)
RAPIDLY PROGRESSIVE WITHIN 1 – 2 HOURS
(acute cholecystitis,acute pctitis)
GRADUAL OVER SEVERAL HOURS
(incarcerated hernia)

C.CHARACTER OF PAIN
STEADY PAIN
COLICKY PAIN
OTHER SYMPTOMS ASSOCATED WITH ABDOMINAL PAIN
A.VOMITING
CLEAR VOMITUS
BILE STAINED VOMITUS
FECULENT VOMITUS
B.CONSTIPATION
PARALYTIC ILEUS
MECHANICAL BOWEL OSTRUCTION
C.DIARRHEA
WATERY DIARRHEA
BLOOD STAINED DIARRHEA
D.OTHER SPESIFIC SYMPTOMS
JAUNDICE
HEMATEMESIS
HEMATOCHEZIA
MELENA
HEMATURIA

OTHER RELEVANT ASPECTS OF THE HISTORY

A.GYNECOLOGIC HISTORY
MENSTRUAL HISTORY - ECTOPIC PREGNANCY
VAGINAL DISCHARGED  PID

B.DRUG HISTORY
CORTICOSTEROID
NSAID
 CLINICAL DIAGNOSIS

2.PHYSICAL EXAMINATION OF THE ACUTE ABDOMEN

A.INSPECTION
B.AUSCULTATION
C.PERCUSSION
D.PALPATION
E. RECTAL EXAMINATION
F.EXAMINATION INGUINAL AND FEMORAL RINGS
G.COUGHING TO ELICIT PAIN
 CLINICAL DIAGNOSIS

3.LABORATORY INVESTIGATION
A.BLOOD STUDIES
B.URINE TEST
C.STOOL TEST

4.IMAGING STUDIES
A.PLAIN CHEST X RAY
B.PLAIN ABDOMINAL X RAY
C.ULTRASONOGRAPHY
D.CT SCAN
 Acute Appendicitis
Etiology:
Obstruction of the lumen appendix followed by infection may
be from :
Catarrhal appendicitis.
lymphoid hyperplasia of the submucosal follicles  60% of
patients in children
-Gastro enteritis
-Virus
-Acute respiratory infection
-Mononucleosis

Obstructive appendicitis
-Fecalith  35% observed in adults.
-Foreign body / parasites (4%)
-Tumors (1%)
 Etiology and Pathophysiology
Wangensteen proposed
1. Closed loop obstruction
 bacterial overgrowth
2. Increase in luminal pressure >> visceral pain
 regio umbilical
3.Parietal peritoneum becomes irritated if perforation
>>classic migrating abdominal pain  parietal pain now
localizes to the right lower quadrant (RLQ) >>>>SHIFTING
PAIN
4. Necrosis  perforation occur about 48 hours .
If the body successfully walls off the perforation Appendiceal
Mass
If the perforation is not successfully walled off  Diffuse
peritonitis will develop.
 Differential diagnosis of acute appendicitis
Surgical Urological
• Acute Intestinal obstruction • Right ureteric colic

• Intussusception • Right pyelonephritis

• Acute cholecystitis • Urinary tract infection

• Perforated peptic ulcer • Right Acute epididymitis

• Mesenteric adenitis Gynaecological

• Acute Meckel's diverticulitis • Ectopic pregnancy

• Acute Pancreatitis • Ruptured ovarian follicle

Medical • Torted ovarian cyst

• Gastroenteritis
• Basal Pneumonia dextra • Salpingitis/pelvic inflammatory disease
• Terminal ileitis
 CLINICAL DIAGNOSIS

•Lying down  Flexing their hips

•The most common symptom of appendicitis is :

- Acute abdominal pain.
- Periumbilical or epigastric pain migrating to the
right lower quadrant (RLQ) of the abdomen.
- Vomiting, nausea, and anorexia
- Afebrile or has a low-grade fever , 38 º C

•Higher fevers are associated with a perforated appendix

 Alvarado score 1986
MANTRELS SCORE Symptoms
Characteristic Score
Migatory right iliac fossa pain 1 point
M = Migration of pain to
1
the RLQ Anorexia 1 point
A = Anorexia 1 Nausea and vomiting 1 point
Signs
N = Nausea and vomiting 1
Right iliac fossa tenderness 2 points
T = Tenderness in RLQ 2
Rebound tenderness 1 point
R = Rebound pain 1 Fever 1 point

E = Elevated temperature 1 Laboratory

Leucocytosis 2 points
L = Leukocytosis 2
Shift to left (segmented
neutrophils)
S = Shift of WBC to the left 1
10
Total 10 Total score
points

A score of 7 or more is strongly predictive of acute appendicitis.

 Special maneuvers
McBurney sign

Blumberg sign

Rovsing sign

Dunphy sign Cough Test

Obturator sign

Psoas sign
 IVESTIGATIVE STUDIES

LABORATORY INVESTIGATION
-.BLOOD STUDIES
IMAGING STUDIES
A.ULTRASONOGRAPHY
B.CT SCAN
 Complications
• PerforationGeneral Secondary Peritonitis
• Appendiceal Mass
• Appendiceal Abscess
• Pylephlebitis is suppurative thrombophlebitis of the
portal venous system
-chills
-high fever
-low grade jaundice
-hepatic abscess
 TREATMENT

Resuscitated
Preoperative prophylactic antibiotics
Antibiotic treatment may be stopped.
-Becomes afebrile
-WBC count normalizes,

Two approaches to appendectomy

1. Open Emergency Appendicectomy ( Appendectomy)
2. Laparoscopic appendectomy

 If normal appendix removed need to look for:

- Meckel's diverticulum
- Acute salpingitis
- Crohn's disease
Treatment of
Appendiceal Mass
Nonoperative management
Periappendiceal infection becomes walled off by omentum and ajacent
viscera.
Initially treated with intravenous broad-spectrum antibiotic

Appendiceal Abscess  USG or CT scan

-percutaneous aspiration
-drain placement
Intravenous antibiotics are continued until the patient
- afebrile for 24 hours
- return of normal gastrointestinal function
- normal WBC count with a normal differential.
At this time, patients are switched to oral antibiotics for a total antibiotic
course of 10-14 days.

Traditionally, interval appendectomy is performed 6-8 weeks later.

 Peritonitis
Inflammation of the serosal membrane that lines the
abdominal cavity and the organs contained therein ,often as a
result of infection.

Peritonitis is often caused by:

- Perforation

- Infected (Inflammation )

- Chemically irritating material

(blood,pancreatic/gastic juice)
Peritonitis are classified as :

1. Primary peritonitis
2. Secondary peritonitis
3. Tertiary peritonitis

Peritonitis are usually divided into

1. Generalized peritonitis
2. Localized peritonitis
Primary peritonitis
Peritonitis occurring in the absence of an obvious source of
contamination , no pathologic process in a visceral organ

Via hematogenous In Children

Translocation of bacteria across the gut wall mesenteric

lymphatics Patients with ascites

Ascending infection in female

gonorrhea and chlamydial infection  spreads into the
abdominal cavity.

Systemic infections tuberculosis

Secondary peritonitis
Related to a pathologic process in a visceral organ
hollow viscus
- Perforation
- Infected
Most common cause of peritonitis, perforations of :
- stomach
- intestine
- gallbladder
- appendix

Tertiary peritonitis
- Anastomotic leakage
-Abscess with or without fistulization.
Clinical:

The diagnosis of peritonitis is usually clinical.

1. Chief complaint Acute abdominal pain

2. Peritoneal irritation  Anorexia and nausea ,vomiting.

3. Fever exceed 38°C

4. Hypovolemia  Hypotensive

5. Hypothermia  severe sepsis  Septic shock

Peritonitis generally represents a surgical emergency.

Abdominal examination of Peritonitis
1. Position/lighting/draping
2. Inspection
-abdominal distensi  paralytic ileus
-hip flexie
3.Palpation all four quadrants
Tenderness
 Rebound tenderness
 Abdominal wall rigidity.
 Abdominal Guarding
Inflammatory mass (appendiceal mass)
4.Percussion
-Tenderness all four quadrants
-Percuss the liver span  free air

5.Auscultation
-Paralytic Ileus

6 . Digital rectal exam

Appendicitis the right tender inflammatory
Cul de sac abscess anterior fullness and fluctuation

Female patients
Vaginal and bimanual examination  Pelvic inflammatory
disease
 IVESTIGATIVE STUDIES
LABORATORY INVESTIGATION
Blood test
Liver function tests if clinically indicated
Serum electrolytes
Renal function
Amylase and lipase if pancreatitis is suspected
Urinalysis
Aerobic and anaerobic blood cultures

IMAGING STUDIES
Chest x-ray
 Complications
• Hypovolaemia shock

• Electrolyte disturbances

• Acute renal failure

• Peritoneal abscess

• Abdominal Sepsis may develop  Septic shock

 Treatment
 INFORMED CONSENT
 General supportive measures
 Antibiotics
 Surgical therapy:
• 2 principles
1. Early and definitive source control
2. Elimination of bacteria and toxins from the abdominal cavity
Surgery
 Exl .laparotomy  full exploration
 Lavage of the peritoneum

The exception is spontaneous / primary bacterial peritonitis, which does

not benefit from surgery.
 INTESTINAL OBSTRUCTION
Definisi
• Bowel /Intestinal obstruction occurs when the normal
propulsion and passage of intestinal contents does not
occur
BO can involve:
– SBO  Small intestine
– LBO  Large intestine
– Generalized Ileus  via systemic
alterations,involving both the small and large
intestine
Intestinal /Bowel Obstruction
Etiopathogenesis
- Mechanical obstruction
- Non mechanical (Functional ) obstruction

Mechanical obstruction (Dynamic ) ileus refers to a lack

of passage due to an “obstruction of the bowel”,
which can be located anywhere in the bowel

Non mechanical Obstruction (Paralytic )(adynamic)

(Fungsional) ileus
Paralytic ileus refers to a lack of passage due to
“paralysis of the bowel”
Intestinal /Bowel Obstruction can also be classified
according to :
Time of presentation and duration of obstruction:
- Acute
- Chronic
The extent of obstruction
-Partial
-Complete
The type of obstruction
-Simple
-Closed-loop
-Strangulation
 Nonmechanical Obstruction
Paralytic (adynamic) (Fungsional) ileus due to :
1. After abdominal operations
2. Response to any acute medical condition /Inflammation
Peritonitis
3. Systemic disorders e.g. sepsis, hyponatremia, hypokalemia,
hypomagnesemia
4. Retroperitoneal disorders e.g. ureter, spine fractures ,
hematoma
5. Thoracic conditions e.g. pneumonia, rib fractures
6. Drugs e.g opiates, psychotropics , General anesthesie
 Pseudo-Obstruction
Imbalance in the parasympathetic and sympathetic influences on
Colonic motility.
Acute colonic pseudo-obstruction, also known as Ogilvie
syndrome.
 MECHANICAL OBSTRUCTION
Common causes of mechanical obtruction at each age group

• Neonate -Congenital atresia

-Volvulus neonatum
-Meconeum ileus
-Hirschsprung”s disease
-Imperforate anus

• Infant -Stranggulated inguinal hernia

-Intussuception
-Complication of Meckel”s diverticulum
-Hischsprung”s diseases
• Young adult -Adhesions and bands
-Strangulated ing.hernia

• Middle age -Adhesesion and band

-Strangulated Ing.hernia
-Strangulated fem.hernia
-Carcinoma colon
-Volvulus

• Elderly -Adhesion and bands

-Strangulated Ing.hernia
-Strangulated fem.hernia
-Carcinoma colon
-Volvulus
-Impacted faeces
 Clinical Manifestations
The classic quartet
1. Colicky abdominal pain
2. Abdominal distension
3. Nausea and Vomiting
4. Decreased or absent passage of stool or flatus

Vital Sign
Hypovolumic shock
Tachicardia
Hypotension
RR ↑
Fever
Oliguria
Altered mental status
 Pathophysiology
Dependent upon :
1. Degree of obstruction
2. Duration of obstruction
3. Presence and severity of ischaemia

Result in :
1. Hypovolumic shock oliguria, hypotension,hemoconcentration
2. Electrolyte depletion
3. Bacterial overgrowth Rapid colonisation
-Maximal by 24 hrs after obstruction
-Bacterial translocation to node and portal system
4. Bowel distension Abdominal compatment syndrom
5. LBO
Ileocaecal valve plays prominent role in pathophysiology of LBO.
If competent valve = Closed loop obstruction
In 10 – 20 % of individual ICV incompetent
Caecal around 10 – 12 cm  the risk of perforation
 Abdominal Examination
Patient Supine position with the legs flexed at the hip

Abdominal Colicky pain

On Inspection
Abdominal distension
Visible peristalsis
Abdominal Scars

On Auscultation
Metallic sound
Borborygmi

On Palpation
Inguinal ,Femoral , Umbilical ,Incisional Hernias
Palpable mass
On Percuss
Dull  Fluid or Mass
Tympanic  Air (Intraluminal or not )
Peritoeal irritation

DRE (Digital Rectal Examination )

For Mass , Impacted faeces
Vomiting

Consists food and gastric chyme bile 

faeculent

GOO  Clear , food and gastric chyme

Mid to distal SBO  Bilious/Bile
Distal SBO to LBO  Feculent
 IVESTIGATIVE STUDIES
LABORATORY INVESTIGATION
-.BLOOD STUDIES

IMAGING STUDIES
Plain abdominal X ray
Water-soluble contrast enema X ray
 Management of Bowel Obstruction
Principles
• Fluid resuscitation
• Close monitoring hemodinamic
– Foley catheter urine output
– CVP
• Electrolyte, acid-base correction
• NGT decompression
• Antibiotics
• Diagnostic study
• Informed concent
• Exploratory laporotomy
 Gastrointestinal Bleeding
Upper Gastrointestinal Bleeding (proximal to ligament of treitz)
Lower Gastrointestinal Bleeding (distal to ligament of treitz)

Clinical features of GI bleeding

Overt GI bleeding
• Signs of upper GI sources of blood
-Hemetemesis
-Coffee-ground vomitus
• Blood per rectum occurs with any GI source
-Hematochezia
-Melena
Occult GI bleeding
-not clinically evident
FOBT
Iron deficiency anemia
Causes of Upper GI Bleed (UGIB)
Peptic Ulcer Disease (60% )
Erosive Gastritis/Esophagitis (15%)
Esophageal and Gastric Varices (6%)
Others
Stress ulcer
Arteriovenous malformation
Malignancy

Causes of Lower GI bleed (LGIB)

Hemorrhoids – Most common
Nonhemorrhoidal bleeding
Diverticulosis – painless, elderly
Angiodysplasia – right colon, elderly
Treatment
1.ABCD

2.NGT  ICE WATER LAVAGE

3.FOLEY BAG CATH.

4.PPI

PERFORMED WITHIN 24 HOURS

1.HEMODINAMIC STABLE
Gastroscopy diagnostic and therapeutic
Colonoscopy diagnostic and therapeutic

2.HEMODINAMIC UNSTABLE
SURGERY