GROUP 8 CASE 4

Monday
September 19th 2011
 Dr. Linda Tutor
Ahmad Farid Haryanto Leader
Johan Yap Secretary
Marcelly Raymando Satyo Scriber
Kevin Barnabas Malingkas Member
GR Meida Astriani Member
Anggi Zerlina Darwin Member
OU Megawati Lohanatha Member

P8
Anggelina Angkola Member
Angelia Member
Maria N.E. Bagul Member
Nancy Member
Amelia Febriana Hanjaja Member
 PROBLEM 4A (Adult)

A 25-year-old female has periumbilical pain that began 8 hours

ago; since then she has vomited once with a small, loose bowel
movement. Her last meal was 12 hour ago, and she doesnt
feel hungry. She denies dysuria and urinary frequency; her last
period was a week ago. On examination, she moderately
uncomfortable and her temperature is 38,30C; other vital signs
are normal. Breath sounds are clear; she has no rashes.
Abdominal examination reveals few bowel sounds, rectus
muscle rigidity and tenderness to palpation, particularly
periumbilically. Pelvic examination shows no vaginal discharge,
but there is some abdominal tenderness with gentle bimanual
palpation. She feels pain on digital rectal examination.
 LEARNING OBJECTIVE
Students can explain acute abdomen, make
the diagnosis and exclude the differential
diagnosis
o Appedicitis
o Peritonitis
o Intestinal Obsctruction / Ileus
o Salpingitis
o UTI
 What we need to know
Anatomy of Lower GI.Tract System
Jejunum
Ileum
Colon (Appedix)
Rectum
Abdominal Quadrant and Its Content
Position of the Appendix Vermiformis
ACUTE ABDOMEN
 ACUTE ABDOMEN

The acute abdomen can be defined generally as an

intra-abdominal process causing severe pain and
often requiring surgical intervention. It is a condition
that requires a fairly immediate judgement or
decision as to management.

http://www.ece.ncsu.edu/
Etiology
 Major Sign and Symptoms

Abdominal pain
Guarding (contraction of abdominal muscles and
discomfort when the doctor presses on the
abdomen)
Rigidity (hardness) of abdominal muscles
Rebound tenderness (an increase in severe pain
and discomfort when the doctor abruptly stops
pressing on a localized region of the abdomen)
Leukocytosis (increase in white blood cell count)
 Types of Abdominal Pain

1 2

SOMATIC PAIN VICERAL PAIN

Colic pain Ischemic pain

Peritonitis
 Somatic Pain Visceral Pain
Receptor Pain stimuli start in the parietal Visceral peritoneum
peritoneum, which is
innervated by peripheral
nerves

Stimulus Touch, pressure, heat, Traction, distention, & spasm

inflammation

Mediation CNS & interpreted at a Autonomic Nervous System

specific cortical location interpreted at the thalamic level
of the brain

Specifity Precisely described as sharp, Vague, often dull, poorly

knifelike, cutting described

Localization The pain is localized with great Poor and the patien is placing
accuracy by the patient, who the entire hand over the
can often point to the site with involved region
one finger
 Characteristic of
Abdominal pain
Referred pain
perceived at a site distant
from the source of
stimulus.
example : irritation of
diaphragm can produce
pain in the shoulder.
Migration pain
shifting from one place to
another which can give
insight into the diagnosis
example : pain that moves
from the epigastrium to
the periumbilical and
moves again to the RLQ.
Cholic pain
Continue pain which is
response from parietal
peritoneum
continuely with
guarding.Appears because
of smooth muscle spasm
from hollow visceral
intermitent.
Ischemic pain
Is a alarm sign of necrosis.
Sharp and persistent
Categories of Acute Abdomen Based on Patology

Bleeding or rupture of
vessels or tumor
Ischemia or Infarction
Obstruction
Perforation
Inflammation
 DIAGNOSIS OF ACUTE ABDOMEN
Anamnesis
Labolatory Testing
Physical Examination
Diagnostic Imaging
 Anamnesis
Past history
appendectomy, cholecystectomy, and so forth
Medication
corticosteroid, anticoagulants, cocaine
Age
Patients position
Menstrual history
 PHYSICAL EXAMINATION
Patient overall appearance
pale,iritable,activity

Evaluation of the vital signs

Temperature, Heart rate, Respiratory rate, Blood pressure

Inspection
Auscultation
Palpation
Percussion
cullen's sign kehr's sign

iliopsoas sign

murphy's sign
grey-turner's sign
 DIAGNOSTIC IMAGING
Radiographic studies
Abdominal ultrasound
Computerized tomography (CT) of the
abdomen
Magnetic resonance imaging (MRI)
Barium x-rays
Capsule enteroscopy
APPENDICITIS
 Definition
Acute appendicitis is a common cause of abdominal pain
requiring surgery, particulary in the West, where there is
low roughage diet
Inflammation & obstruction of the vermiform appendix
 Epidemiology
Peak incidence : ages 10 30 years
Most common acute surgical condition of
abdomen
Males and females are equally affected,
except between puberty and age 25, when
males predominate in a 3:2 ratio.
 Risk Factor
Most cases of appendicitis occur between the
ages of 10 and 30 years.
Having a family history of appendicitis may
increase a child's risk for the illness
Having cystic fibrosis also seems to put a child
at higher risk.
 ETIOLOGY
Obstuction, by:
Fecal mass
Enlarged lymphoid follices, associated with a
variety of inflammatory and infectious disorders
including Crohn disease, gastroenteritis,
amebiasis, respiratory infections, measles, and
mononucleosis
Worms (pinworms, Ascaris, and Taenia)
Viral infections ( measles )
Tumors
 Patophysiology Necrosis
I
f

Mucus, stool, or The blood supply to Perforation

Reduced
parasites the appendix is cut
blood flow
of
Appendicular Peritonitis
Inflammation abcsess

Obstructs the Obstruction of Pressure in

appendix mucus outflow appendix
increases

Multiplying bacteria,
Restricting blood flow inflammation and Appendix
to the organ pressure continue to contracts
increase

Severe abdominal pain

 SIGN and SYMPTOMS
The abdominal pain usually
begins near the belly
button and then moves
lower and to the right
( from epigastric to RLQ )
gets worse in a matter of
hours
gets worse when moving
around, taking deep breaths,
coughing, or sneezing
Other symptoms of
appendicitis may include
loss of appetite
nausea
vomiting
constipation or diarrhea
inability to pass gas
a low-grade fever that
follows other symptoms
abdominal swelling
the feeling that passing
stool will relieve
discomfort
SIGN AND SYMPTOM
Rovsing Sign: Pain in the
right lower quadrant when
pressure is exerted on the
left lower quadrant
PSOAS SIGN
ILIOPSOAS SIGN
OBTURATOR SIGN
 DIAGNOSIS
1. Anamnesis 4. Diagnostic Imaging
Abdominal x-ray
2. Physical examination
CT scan of the abdomen:
Low grade fever Very good test for diagnosing appendicitis
Pain at Mc Burneys point Ultrasound of the abdomen
Rebound tenderness MRI scan of the abdomen
May be helpful in diagnosing acute appendicitis in
Guarding the pregnant female.
Psoas sign (+)
3. Labolatory Testing
WBC count > 10,500
cells/mm3 Neutrophilia
greater than 75%
CRP test
 Management
Choice of therapy
Surgery
Medications

If the diagnosis is too late, perforation may

occur already and the mortality may increase
if it happens
 MEDICATION
Antibiotics Analgesics
Metronidazole (Flagyl) Morphine sulfate
Gentamicin (Gentacidin, (Astramorph, Duramorph, MS
Garamycin) Contin, MSIR, Oramorph)
Cefotetan (Cefotan)
Cefoxitin (Mefoxin)
Meropenem (Merrem)
Piperacillin and tazobactam
sodium (Zosyn)
Ampicillin and sulbactam
(Unasyn)
 SURGERY
Surgery to remove the appendix is called an
appendectomy
The two types of appendectomy include:
Open appendectomy:
An incision is made in the right lower abdomen and the
appendix is removed through the incision.
Laparoscopic appendectomy:
A small incision is made in the umbilicus and the surgeon
uses a flexible fiberoptic scope to remove the appendix
through the small incision.
The laparoscope cannot be used if the surgeon suspects
that the appendix has ruptured
 Complication
Abdominal wall complications Intraperitoneal complications
Early Early
Superficial wound infection Appendix stump blowout-spillage of
colonic contents into the peritoneal
Deep wound infection cavity.
Dehiscence Generalised peritonitis-perforated or
Late gangrenous appendix , virulent
organisms, late presentation or diagnosis
Incisional hernia Abscesses-local, pelvic, subhepatic,
subphrenic
Retained fecolith causing chronic local
infection
Haematoma due to slippage of a
vascular ligature or a mesenteric or
omental tear
Early or late (even many years later)
Intestinal obstriction due to adhesion
Late
Infertility due to tubal occlusion
following pelvic infection
 PROGNOSIS
The prognosis is excellent.
With uncomplicated appendicitis, most people recover with
no long-term complications.
 PERITONITIS
Peritonitis is an inflammation (irritation) of
the peritoneum, the tissue that lines the
wall of the abdomen and covers the
abdominal organs.
 2 Major Types
Primary: Caused by the spread of an infection
from the blood & lymph nodes to the peritoneum.
Very rare < 1%

Usually occurs in people who have an

accumulation of fluid in their abdomens (ascites).

The fluid that accumulates creates a good

environment for the growth of bacteria.
 Secondary: Caused by the entry of bacteria or
enzymes into the peritoneum from the
gastrointestinal or biliary tract.

This can be caused due to an ulcer eating its way

through stomach wall or intestine when there is a
rupture of the appendix or a ruptured diverticulum.

Also, it can occur due to an intestine to burst or injury

to an internal organ which bleeds into the internal
cavity.
Intra-abdominal infections result in 2
major clinical manifestations

Early or diffuse infection results in localized or

generalized peritonitis.

Late and localized infections produces an intra-

abdominal abscess.
Etiology
Pathophysiology
 Signs and Symptoms
The signs and symptoms of peritonitis include:
Swelling rigidity and tenderness in the abdomen with
pain ranging from dull aches to severe, sharp pain
Fever and chills
Loss of appetite
Thirst
Nausea and vomiting
Limited urine output
Inability to pass gas or stool
 Diagnosis
The following procedures also may be performed:
Blood tests -- to see if there is bacteria present in
your blood
Samples of fluid from the abdomen -- identify the
bacteria causing the infection
CT scan -- identifies fluid in the abdomen, or an
infected organ
X-rays -- detect air in the abdomen, which
indicates that an organ may be torn or perforated
 Evaluation :
The usual sounds made by the active intestine and
heard during examination with a stethoscope will
be absent, because the intestine usually stops
functioning.
The abdom may be rigid and boardlike
Accumulations of fluid will be notable in primary
due to ascites.
 Examination
Leukocytosis
Marked acidosis are common laboratory findings.
Plain abdominal films may show dilation of large and small bowel with edema
of the bowel wall.
Free air under the diaphragm is associated with a perforated viscus.
CT and/or ultrasonography can identify the presence of free fluid or an abscess.
When ascites is present, diagnostic paracentesis with cell count (>250
neutrophils/L is usual in peritonitis), protein and lactate dehydrogenase levels,
and culture is essential.
In elderly and immunosuppressed patients, signs of peritoneal irritation may
be more difficult to detect.
 THERAPY
The therapy goal in curing peritonitis, is to
rehydrate, correction of electrolytes
abnormalities, preventing further infections,
and to correct the underlying problem(s)
It has high mortality rate for patient that have
suffered more than 48 hours ( up to 40 % )
Terapi Antibiotik
 Complications
Sepsis -- an infection throughout the blood
and body that can cause shock and multiple
organ failure
Abnormal clotting of the blood (generally due
to significant spread of infection)
Formation of fibrous tissue in the peritoneum
Adult respiratory distress syndrome -- a severe
infection of the lungs
 Prognosis
With treatment, patients usually do well. Without
treatment, the outcome is usually poor.
Peritonitis can be life threatening and may cause a
number of different complications. Complications
depend on the specific type of peritonitis.
 Perforation

Definition
Gastrointestinal perforation is a hole that develops through the
entire wall of the stomach, small intestine, large bowel, or
gallbladder. This condition is a medical emergency.

Etiology
Gastrointestinal perforation can be caused by a variety of illnesses,
including appendicitis, diverticulitis, ulcer disease, gallstones or
gallbladder infection, and less commonly, inflammatory bowel
disease, including Crohn's disease and ulcerative colitis.
It may also be caused by abdominal surgery.
 Perforation
Symptoms
Perforation of the intestine leads to leakage of intestinal
contents into the abdominal cavity. This causes inflammation
called peritonitis.
Examinations
Symptoms may include: X-rays of the chest or abdomen
Abdominal pain - severe may show air in the abdominal
Chills cavity (not in the stomach or
intestines), suggesting a
Fever
perforation.
Nausea
CT scan of the abdomen often
Vomiting shows the location of the
perforation.
The white blood cell (WBC) count
is often higher than normal.
Treatments
Treatment usually involves
surgery to repair the hole
(perforation). Occasionally, a
small part of the intestine
must be removed. A
temporary colostomy or
ileostomy may be needed.
In rare cases, antibiotics alone
can be used to treat patients
whose perforations have
closed. This can be confirmed Prevention depends on the cause.
by a physical exam, blood
tests, CT scan, and x-rays.
Prognosis
Surgery is usually successful, but
depends on the severity of the
perforation and the length of time to
treatment.
Complications
Bleeding
Infection ( including a widespread
infection called sepsis, which can lead
to death )
Intra-abdominal abscess
Preventions
Diseases that may lead to intestinal
perforation should be treated
appropriately.
 Ileus
Adynamic ileus
Mechanical ileus
 ILEUS
DEFINITION
is a term for a difficulty of intestine passage.
Ileus is divided into two:
Ileus obstructive
Ileus paralytic.
Ileus obstructive is caused by an obstruction.
Ileus is paralytic is caused by nerve problems.
 The Difference between Paralytic Ileus and
Obstructive Ileus
Paralytic Ileus Obstructive Ileus
Bowel sounds minimal Bowel sounds hyperactive
Air Fluid level provides Air fluid level provides a
line up stepladder
Not accompanied by a Accompanied by a
paroxysmal colicky paroxysmal colicky
abdominal pain abdominal pain
 Adynamic ileus
Paralysis of intestinal motility

Causes
A. Abdominal trauma
B. Abdominal surgery (i.e. laparatomy)
C. Serum electrolyte abnormality Hypokalemia,
Hyponatremia, Hypomagnesemia, Hypermagensemia
D. Infectious, Inflammatory or irritation (bile, blood)
1.Intrathoracic Pneumonia, Myocardial Infarction
2.Intrapelvic Pelvic Inflammatory Disease
3.Intraabdominal Appendicitis, Diverticulitis,
Cholecystitis, Pancreatitis, Perforated Duodenal Ulcer
E. Intestinal Ischemia Mesenteric embolism, ischemia
or thrombosis
F. Skeletal injury Rib fracture, Vertebral fracture
G. Medications Narcotics, Phenothiazines, Diltiazem or
Verapamil, Clozapine, Anticholinergic
Symptoms
A. Abdominal distention
B. Nausea and Vomiting are variably
present
C. Generalized abdominal discomfort
Colicky pain of Mechanical Ileus is
usually absent
D. Flatus and Diarrhea may still be passed
Signs
E. Quiet bowel sounds
F. Abdominal distention
Differential Diagnosis
G. Mechanical Ileus
H. Bowel Pseudoobstruction
Radiology: Refractory ileus course
A. Indicated to evaluate for Mechanical Ileus
B. Upper GI series and small bowel follow through
1. May be diagnostic and therepeutic
2. Use gastrograffin instead of barium
3. Barium may further obstruct bowel lumen
4. Gastrograffin may stimulate bowel motility
C. Decompress stomach with Nasogastric Tube
D. Instill gastrograffin via Nasogastric Tube

Management
E. Initial
1. Limit or eliminate oral intake
2. Intravascular fluid replacement
3. Correct electrolyte abnormalities (e.g.
Hypokalemia)
4. Consider Nasogastric Tube placement
F. Refractory Management
1. Consider Prokinatics
2. Consider lower bowel stimulation (e.g. Enema)
 Mechanical ileus
Types
A. Simple mechanical obstruction
1. Bowel lumen is obstructed
2. No vascular compromise
B. Closed loop obstruction
1. Both ends of a bowel loop are
obstructed
2. Results in strangulated obstruction if
untreated
3. Rapid rise in intraluminal pressure
C. Strangulated obstruction
1. Bowel lumen and vascular supply is
compromised
Causes
A. Most Common Causes
1. Postoperative Adhesions (accounts
for 50% of cases)
2. Hernia (25% of cases, especially
younger patients)
3. Neoplasms (10% of cases, esp.
older patients)
a. Colon Cancer (most common)
b. Ovarian Cancer
c. Pancreatic cancer
d. Gastric Cancer
Examples of Causes of Intestinal Obstruction

Obstruction due to Obstruction due to Obstruction due

adhesions mesenteric occlusion to hernia

Obstruction due to Obstruction due to Obstruction due to

intussusception tumor volvulus
Symptoms
Frequent and recurrent Generalized Abdominal Pain
Duration: Seconds to minutes
Character: Spasms of crampy abdominal pain
Frequency
a. Intermittent pain initially
b. Every few minutes in proximal obstruction
c. Constant pain suggests ischemia or perforation

Symptoms more severe in proximal obstruction

1. Proximal obstruction
a. Severe, colicky abdominal pain
b. Constant pain suggests ischemia or perforation
c. Develops over hours and occurs every few
minutes
d. Bilious Emesis
e. Mild abdominal distention
2. Distal obstruction
a. Develops over days and becomes progressively
worse
b. Emesis may occur and is brown and feculent
c. Significant abdominal distention
Signs
Bowel sounds
Initial: High pitched, hyperactive
bowel sounds
Later: hypoactive or absent bowel
sounds
Tender abdominal mass Closed loop
Bowel Obstruction may be palpable
Abdominal distention and tympany on
percussion Indicates distal
obstruction
Rectal examination for blood
Management: Conservative
Therapy
A. Fluid replacement
B. Bowel decompression
1. Nasogastric Tube
2. Long intestinal tube offers no
advantage
C. Antibiotic
1. Indications
a. Surgery planned
b. Bowel ischemia or infarction
c. Bowel perforation
2. Cover Gram Negatives and
Anaerobes
a. Second-generation
Indications for surgery
1. Inadequate relief with Nasogastric
tube placement
2. Persistant symptoms >48 hours
despite treatment (strangulation)
3. Neoplasms

Complications
A. Intestinal Ischemia or infarction
B. Bowel necrosis, perforation and
bacterial peritonitis
C. Hypovolemia
Diferential Diagnosis
Pancreatitis
 Pancreatitis
Pancreatic inflammatory disease may be
classified as
Acute Pancreatitis
Chronic Pancreatitis
 Acute Pancreatitis
Etiology
Alcohol
Gallstones
metabolic factors ( hypercalcemia, renal failure )
Drugs ( NSAIDs )
Abdominal trauma/surgery
The pathologic divide into
Edematous pancreatitis
usually mild and self limited
Necrotic pancreatitis
 Acute Pancreatitis
Pathophysiology
Autodigestion proteolytic enzyme (esp. trypsin)

Viral infection, endotoxin, eksotoxin,

Digest cellular membrane

Edema and vascular damage

Acute Necrotic pancreatitis

 Acute Pancreatitis
Clinical feature
Abdominal pain located in periumbilical and
often radiates to the back
Nausea and vomiting
Chemical peritonitis
Pain is more intense when the patient is
supine
Low-grade fever
 Acute Pancreatitis
Local Complication Systemic
Pancreatic abscess Complication
Pancreatic ascites Hypovolemia
Rupture pancreas Pleural effusion
Sudden death
Peptic ulcer
Renal artery
thrombosis
 Acute Pancreatitis
Treatment
Analgesic for pain
Intravenous fluids and colloids to maintain
normal intravascular volume
nasogastric suction
Prophylactic antibiotics
 Chronic Pancreatitis
Chronic pancreatitis may present as episodes
of acute inflammation in a previously injured
pancreas or as chronic damage with persistent
pain or malabsorption.
SALPHINGITIS
 Definition
Inflammation of the fallopian tube. When the
ovaries are involved, it is termed Pelvic
Inflammatory Disease (PID)
As a result of the infection spreading to the top
of the uterus
Because at most gonorrhea infections, puerperal
infection, postabortum
Can also be caused by the actions (kerokan,
laparotomy, insertion of IUD)
 Sign and symptoms
Pain is usually bilateral
Pelvic pressure
Back pain radiating down one or both legs
Nausea and headache
Distended abdomen and hypoactive bowel
sounds
Extreme tenderness with bimanual exam
Purulent cervical discharge
 TREATMENT
For uncomplicated infection due to N. gonorrhoeae, options
include:
Ceftriaxone 125 mg IM
Cefixime 400 mg po
Ciprofloxacin 500 mg po

Because C. trachomatis often accompanies N. gonorrhoeae, the

following may be used:
Doxycycline 100 mg po bid for 7 days
Azithromycin 1 g po in a single dose
Ofloxacin 300 mg bid for 7 days
 Conclusions and Suggestions
This patient had an acute abdomen that most
likely caused by appendicitis.
We suggest him to take further examination
(labolatory and imaging test) to exclude the
other differential diagnosis.
 Saran
Melakukan pemeriksaan darah lengkap , foto
polos abdomen, dan radilogy lanjut (CT scan)
untuk menentukan diagnosis pasti
RUJUK BEDAH UMUM! Dr.zaenal di sumber
waras atau gading pluit
Kamsia =D
 References
Carol Mattson Porth, Glenn Matfin. Pathophysiology
Concepts of Altered Health States. 8 th ed. China:
Lippincott Williams & Wilkins, 2009.
Fauci, Braunwald, Kasper, dkk. Harrisons Principles
of Internal Medicine. 17th ed. USA: Mc Graw Hill, 2008.
Stephen J McPhee, Maxine A Papadakis. 2009
Current Medical Diagnosis & Treatment. 48 th ed.
United States of America: McGraw Hill, 2009.
Marschall S Runge, M Andrew Greganti. Netters
Internal Medicine. 2nd ed. China: Saunders, 2009..