Name NIM Occupation

Adelia Melanti 405070017 Member

Adrian Hartanto L 405070039 Member
Eeng Sapta Hadi 405070078 Leader
Nina Amelia Gunawan 405070092 Member
Dian Natalia 405070097 Member
Anthony Kane B 405070098 Member
Devi Regina 405070099 Member
Agnes Santoso 405070100 Member
Clement Drew 405070104 Member
Risma Kamilah 405070121 Scribber
Christiani 405070161 Secretary
Tutor: dr Jimmy, Sp.A
Group 6
 How Low Can You Endure The
Pain, Mr. Bond?
• Mr.Bond, a 22-year-old man is referred by his
GP to the hospital with pain in the right lower
quadrant. He says that within the last month he
felt epigastric pain or sometimes pain was
located in the periumbilical region. He also felt
nauseated for the past 2 weeks and sice then he
has vomited several times. Last night the pain
begun to shift to its current location.
• Exam: VS = BP 100/70 mmHg, pulse 90 bpm,
temperature 38°C. Tenderness and guarding
over the right lower quadrant are present.
 Learning Objective
• Understanding the regions and qudrants of the abdominal wall and it’s
contents.
• Understanding about pain that occurs in human body.
• Understanding acute abdomen :
1. Definition
2. Etiology
3. Pathophysiology
4. Management
5. Complication
6. Laboratory tests
• Understanding about Appendicitis :
1. Definition
2. Etiology
3. Pathophysiology
4. Management
5. Complication
6. Laboratory tests
 Unknown Term
Epigastric pain: Pain located in the upperand middle region of
the abdomen

Causes of Epigastric pain:

• Dyspepsia • Malabsorption
• Gastroesophageal reflux • Gastric cancer
• Gastritis • Parasitic infection
• Peptic ulcer disease • Myocardial ischaemia
• Pancreatitis • Myocardial infarction
• Pancreatic cancer • Pneumonia
• Indigestion • Abdominal hernia
• Medications • Intestinal ischaemia
• Lactase deficiency • Pregnanc
• Gastric volvulus
• Hiatus hernia
 Unknown Term
• Guarding : The detection of increase
abdominal muscle tone during palpation.
Guarding ma be voluntary, involuntary,
localized, or generalized. Involuntary
guarding means underlying peritonitis
• Rebound terderness : increase in
abdominal pain when hand is
withdrawaled suddenly, this symptom
indicated peritonitis
 Common Causes Tenderness
with guarding
• Peritonitis
• Acute appendicitis
• Incarcerated or strangulated hernia
• Ovarian torsion (twisted Fallopian tube)
 Abdominal Quadrants and It’s
contents
Right Upper Quadrant : Left Upper Quadrant :
Liver Stomach
Gallbladder Liver (part)
Duodenum Pancreas
Transverse colon (part) Spleen
Ascending colon (part) Transverse colon (part)
Descending colon (part)

Right Lower Quadrant : Left Lower Quadrant :

Ascending colon (part) Descending colon
Vermiform appendix Sigmoid colon
Ovary (female) Ovary (female)
Fallopian tube (female) Fallopian tube (female)
Right Hypochondriac Epigastric Left Hyponchondriac
Right lobe of liver Pyloric end of stomach Stomach
Gollbladder Duodenum Spleen
Part of duodenum Pancreas Toil of pancreas
Hepatic flexure of colon Aorta Splenic flexure of colon
Part of right kidney Liver Upper of left kidney
Suprarenal gland Suprarenal gland
Right lumbar Umbilical Left Lumbar
Ascending colon Omentum Descending colon
Lower Kolf’of right kidney Mesentery Lower half of left kidney
Part of duodenum and Tranverse colon Parts of jejunum and ileum
jejunum Lower part of duodenum
Jejunum and ileum
Right Iliac Hypogastric or Pubic Left iliac
Cecum Ileum Sigmoid colon
Appendix Bladder Left ureter
Lower end of ileum Left ovary in female
Right ureter
Right ovary in female
 Physiology of Pain
• Reffered Pain
• Projected pain ( Phantom Pain )
 Work-Up Of Abdominal Pain

History
• Onset
• Qualitative description
• Intensity
• Frequency
• Location - Does it go anywhere (referred)?
• Duration
• Aggravating and relieving factors
 DIAGNOSTIC WORKUP
• chest x-ray to rule out pneumonia
• electrocardiogram (EKG) to rule out myocardial infarction
• complete blood count (CBC)
• Urinalysis
• Amylase
• chemistry panel
• lateral decubitus films of the abdomen are necessary to
show the step ladder pattern of intestinal obstruction
• A pregnancy test is ordered when age and sex dictate it!
• x-ray contrast studies or ultrasound. ((IVP)  renal
calculus, Serial cardiac enzymes  myocardial
infarction, Gallbladder ultrasound  cholecystitis and
cholelithiasis)
 Diagnostic Workup
• Ultrasonography  impending rupture of an abdominal
aneurysm or ectopic pregnancy
• peritoneal tap  ruptured ectopic pregnancy
• Laparoscopy
• urine porphobilinogen helps exclude porphyria.
• double enema may help diagnose intestinal obstruction.
• computed tomography (CT) scan
• exploratory laparotomy must be done before the
patient's condition deteriorates (acute pancreatitis)
• Endoscopy  peptic ulcer, gastritis, gastric tumor, or
reflux esophagitis
• contrast barium enema  appendicitis and diverticulitis,
• Angiography aneurysm or mesenteric infarction.
 Acute Abdomen
• Acute abdomen refers to signs and
symptoms of abdominal pain and
tenderness, a clinical presentation that
often requires emergency surgical therapy.
Indications of an Acute Abdomen

• 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
 The Identification of High Risk
Patients with Acute Abdomen
• Elderly > 65 y • Elevation of Band WBC
• Fever cause
• S/S of Shock • Hypothermia
• Peritoneal sign (+) • Acute renal failure
• silent bowel sound • Not post-surgical obstruction
• Pulsatile mass
• Refractory pain post Tx
• The
immunocompromised.
(e.g. HIV)
• Women of childbearing
age.
 Five Major Categories of Acute
Abdomen (BIOPI)
• Bleeding or rupture of vessels or
tumor
• Ischemia or Infarction
• Obstruction
• Perforation
• Inflammation
 Important Signs In Urgent Abdominal
Disorder
Disorder
Early perforation of Gastrointestinal
tract or other tract
Peritonitis
Infection mass or abscess
Intestinal obstruction
Important Clinical Signs
Abdomen seems scaphoid, tense,
hypoactive bowel sounds, liver
dullness disappears, pressure pain,
muscular defense
Patient is passive, bowel sound
disappears, coughing pain, motility
pain, rebound tenderness, muscular
defense, common inflammation signs,
body function drops
Mass pain, punching pain, local test (
psoas ), common inflammation signs
Abdominal distension, strong
peristlatic ( colic ) seen with naked
eye, borborigmi and felt by the patient;
no peritoneum excitation
Paralytic ileus Abdominal distension; decreased or
even no bowel sounds; there’s no
local pressure pain, ischemia or
strangulation, unclear distension,
bowel sounds may be heard, severe
pain, pressure pain is unclear, there’s
possibility that blood may come out
from rectum, toxic signs
Bleeding Pale, shock, probable distension,
pulse is felt if there is aorta aneurysm,
local pressure pain in ectopic
pregnancies, ascites, anemia
Pathophysiology of Acute Abdomen
Causes of acute abdomen
General causes of the acute abdomen may
be divided into six large categories:

a. inflammatory
b. mechanical
c. neoplastic
d. vascular
e. congenital defects
f. traumatic
• The inflammatory category of causes may be divided into two
subgroups: 1) bacterial, and 2) chemical. Some common examples
of the bacterial causes would include acute appendicitis,
diverticulitis, and some cases of pelvic inflammatory disease. An
example of a chemical cause would be a perforation of a peptic
ulcer, where spillage of acid gastric contents causes an intense
peritoneal reaction.
• Mechanical causes of an acute abdomen include such obstructive
conditions as incarcerated hernia, post-operative adhesions,
intussusception, malrotation of the gut with volvulus, congenital
atresia or stenosis of the gut. The most common cause of large
bowel mechanical obstruction is carcinoma of the colon.
• Vascular entities producing an acute abdomen include mesenteric
arterial thrombosis or embolism. When the blood supply is cut off,
necrosis of tissue results, with gangrene of the bowel.
• Congenital defects can produce an acute abdominal surgical
emergency any time from the minute of birth (with conditions such
as duodenal atresia or diaphragmatic hernia) to years afterward
in conditions such as chronic malrotation of the intestine.
• Traumatic causes of an acute abdomen range from stab and
gunshot wounds to blunt abdominal injuries producing such
conditions as splenic rupture.
 Acute Appendicitis
• Inflammation in the appendix has the same features and follows the
same course as inflammation elsewhere in the gut. Its importance is
a function of its frequency as a serious surgical condition with
significant complications.
• Obstruction of the appendiceal lumen by fecaliths with
interference of the vascular supply are important features in its
pathogenesis. The essential element causing inflammation of
the wall of the appendix is invasion by bacteria. The usual
organisms in the inflamed appendix are colon bacilli and
streptococci, organisms commonly found in the intestinal tract.
Obstruction of the lumen and vascular occlusion probably
contribute by breaking down the resistance of the wall of the
appendix to invasion by potential pathogens in the gut.
• The earliest lesion is a superficial ulceration of the mucosa.
Spread then occurs from the mucosa to the muscle layers and
the serosa and the lumen may become filled with pus.
Interference with circulation leads to areas of necrosis and
perforation of the appendix, with spread of infection to the
peritoneal cavity. If the infection becomes walled off around the
appendix a localized abscess may result. Otherwise a generalized
peritonitis results.
 Acute Small Bowel Obstruction
• Complete obstruction to the passage of intestinal content is caused either
by mechanical obstruction of the lumen or by paralysis of the intestinal
muscles (paralytic ileus) and may cause death in a relatively short period of
time unless relieved. Acute mechanical obstruction of the small bowel is
caused most commonly either by strangulated hernia or by adhesions and
bands, usually post-operative, with the peritoneal cavity.
• Age has a significant influence on the cause of small bowel obstruction.
• There may, however, be an associated interference with the blood and
nerve supply for the intestines, in which case the bowel is said to be
strangulated. Obstruction such as an incarcerated hernia, if not promptly
reduced, causes increasing edema of the gut with impairment of the blood
supply. Volvulus with twisting of the mesentery and intussusception (where one
segment of the small bowel invaginates into another) also cause interference
with nerve and blood supply. Ischemic necrosis or infarction of the bowel
wall occurs unless the blood supply is promptly restored. The involved
portion of the intestine becomes in turn congested, edematous, necrotic
and finally gangrenous.
• The most common cause of lower intestinal obstruction is carcinoma of
the distal portion of the colon.
• Functional intestinal obstruction due to neurogenic factors which cause
paralysis of the intestinal muscle and failure of peristalsis is fairly
common.
• Paralytic ileus is the end-result in a mechanical obstruction, unless the
compromised blood supply is promptly restored. Otherwise there may be
inexorable progression, terminating in gangrene.
 Mesenteric Vascular Occlusion
• Interference with the blood supply to a segment
of the intestine, as in thrombosis or embolism
of the superior mesenteric vessels, results in
a paralytic obstruction without any
mechanical blockage. The majority of
patients with embolism involving the
superior mesenteric artery have a cardiac
lesion that is capable of thrombus formation and
emboli. Recent myocardial infarction and
atrial fibrillation are the two cardiac problems
that give rise most often to mesenteric emboli.
The segment of intestine which is deprived
of its blood supply rapidly becomes
congested, edematous and finally necrotic.
 Perforated Duodenal Ulcer
• While all the factors responsible for the development and
persistence of chronic peptic ulcers are not thoroughly understood,
the one factor of established importance is the action of acidpepsin
gastric content on the duodenal mucosa with ulcer formation. In
some individuals there seems to be too much gastric acid
secretion with respect to the degree of protection provided for
the mucosa.
• Hemorrhage may result from erosion of large vessels in the
base of the ulcer. Perforation may result when the ulcer
continues to penetrate deeply and erodes through the wall of
the duodenum into a remarkable series of dramatic changes.
Spillage of acidpeptic gastric juice, bile, and pancreatic juice causes
a marked chemical inflammation of the peritoneum comparable to a
burn. Bacterial invasion may soon follow. Within a short time
massive amounts of extracellular fluid may be extravasated into the
area of peritoneal injury and this loss of fluid may bring about
hypovolemic shock.
• Acute pancreatitis may closely simulate a perforated duodenal
ulcer. The effects are caused by the escape of lytic pancreatic
enzymes into the gland itself.
 Peritonitis
• General inflammation of the peritoneal cavity is usually
caused by bacterial invasion, which may result by
spread: 1) from a ruptured viscus such as a perforated
peptic ulcer or gangrenous appendix; 2) through an
ischemic and necrotic but unruptured bowel wall, as
in strangulated hernia, mesenteric occlusion, or volvulus;
or 3) as a result of extension of infection from
abdominal organs such as occurs with a liver abscess
or a pelvic inflammatory disease.
• The majority of cases of peritonitis involve
organisms found in the normal flora of the
gastrointestinal tract. Perforation of a hollow viscus
is most frequently the source of entry of these
organisms. The peritoneal infection may become
walled off and limited to a localized area as in an
appendiceal abscess, or there may be generalized
peritonitis, which may be a serious complication
 Diagnostic
• Physical Examination
• Laboratory Tests
urin and blood test
– The serum amylase test is essential when the
possibility of acute pancreatitis exists
– Certain tests are indicated when extraabdominal
conditions are suspected as the cause of an acute
abdomen. These include blood and urine sugar
determinations in diabetic keto- acidosis, hemoglobin
electrophoresis in possible sickle cell crisis, chest x-
ray in pneumonia, EKG in coronary artery disease
• X-ray Examination
Evaluation and Management of
the Acute Abdomen
PRIORITY MANAGEMENT Surgical Nonsurgical
PATTERN

I. Pain, collapse, Immediate peptic ulcer, ectopic Acute pancreatitis

shock (catastrophic), resuscitative and pregnancy with Coronary thrombosis
e.g., perforated supportive massive
ulcer, ruptured measures, hemorrhage Dissecting aneurysm
ectopic pregnancy, diaagnostic studies, Rupture of a solid
acute early operation if organ usually
pancreatitis,mesente indicated traumatic
ric thrombosis, Acute vascular
ruptured aneurysm, occlusion
etc

II. Pain (intermittent), Establish diagnosis Acute intestinal Biliary colic, renal
colic, e.g., acute if possible; correct obstruction small colic, gastroenteritis,
intestinal obstruction, systemic and large bowel
biliary colic, ureteral imbalances; early Acute appendicitis fecal impaction
colic operation if
indicated
III. Pain, tenderness, Clinical diagnosis Acute appendicitis Urinary tract infection
inflammatron, e.g., usually possible; Acute cholecystitis Pelvic inflammatory
acute appedicitis, early operation in Acute diverticulitis
acute cholecystitis, appendicitis, proper disease
acute diverticulitis, timing of all therapy
acute salpingitis (fluids, antibiotics,
operation)
 Appendicitis
• Definition
– Appendicitis is inflammation of the
appendix. The appendix is a small pouch
attached to the beginning of your large
intestine.
 Prevalence
• More than 250,000 appendictomies is
performed annually
• It’s very frequent and it’s at it’s peak at the
age of puberty and 25
• Between puberty and the age 25, the ratio
of men and women is 3:2
• If it does happen to extreme age ( such as
infants or > 60 years old person ), it
usually diagnosed when it’s already
perforated
• There are some causes for appendicitis,
but the most common one is the
obstruction of the appendix with fecalith
• Virus, bacteria, parasites, tumors, and
some foreign materials may cause
appendicitis
• Ulceration of appendix can also be found
in some cases with Yersinia infection
• Causes
– Obstruction of the appendiceal lumen usually
precipitates appendicitis.
– The most common causes of luminal obstruction are
fecaliths and lymphoid follicle hyperplasia.
• Fecaliths form when calcium salts and fecal debris become
layered around a nidus of inspissated fecal material located
within the appendix.
• Lymphoid hyperplasia is associated with a variety of
inflammatory and infectious disorders including Crohn
disease, gastroenteritis, amebiasis, respiratory infections,
measles, and mononucleosis.
– Obstruction of the appendiceal lumen has less
commonly been associated with parasites (eg,
Schistosomes species, Strongyloides species),
foreign material (eg, shotgun pellet, intrauterine
device, tongue stud, activated charcoal), tuberculosis,
and tumors.
 Pathopysiology

Viral inf. → Obstruction of

Hyperplastic lumen Faecolith
lymphoid

Bacterial
proliferation

Inflammation
& ulceration

Suppurative
& gangrenous
Pathofisiology of Appendicitis
 Clinical features
• Most common clinical features of
appendicitis:
– Shifting pain ( from epigastric to RLQ )
– Nausea and vomiting
– Light fever ( 37.2⁰C-38 ⁰C )
– Abdominal tenderness
– Muscular defense
– Leukocytosis ( 10,000-18,000 cells/μL)
Sign Description Diagnosis/condition
Aaron sign Pain or pressure in Aute appendicitis
epigastrium or anterior
chest with persistent firm
pressure applied to
McBurney’s point
Bassler sign Sharp pain created by Chronic appendicitis
compresing appendix
between abdominal wall
and iliacus
Blumberg’s sign Transient abdominal wall Peritoneal inflammation
rebound tenderness
Iliopsoas sign Elevation and extension Appendicitis with
of leg againts resistance retrocecal abcess
creates pain
Rovsing’s sign Pain at McBurney’s point Acute appendicitis
when compressing the
left lower abdomen
Ten Horn sign Pain caused ny gentle Acute appendicitis
traction of righttesticle
 Differential Diagnosis
• Rupture of a graafian • Perforated ulcer
folicle • Acute pancreatitis
• Rupture of a corpus • Acute diverticulitis
lutheum cyst • Strangulating intestinal
• Ruptured tubal pregnancy obstruction
• Endometriosis • Uretral calculus
• Twisted ovarian cyst • Pyelonehpritis
• Acute mesentric • Regional enteritis
lymphadenitis (Chron’s disease)
• Acute gastroenteritis • Acute cholecystitis
 Management
• Choice of therapy
– Appendictomy
– Antibiotics

• If the diagnosis is too late, perforation may

occur already and the mortality may
increase if it happens
APPENDECTOMY
 Complication of appendicitis
Intraperitoneal complications
• Early
– Appendix stump blowout-spillage of colonic contents
into the peritoneal cavity.
– Generalised peritonitis-perforated or gangrenous
appendix , virulent organisms, late presentation or
diagnosis
– 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
 Complication of appendicitis
Abdominal wall complications
• Early
– Superficial wound infection
– Deep wound infection
– Dehiscence
• Late
– Incisional hernia
 Peritonitis
• It is the inflammation of the peritoneum of
the abdomen
• Primaryly caused by nonintraabdominal
source
• Secondaryly caused by infections or
ruptures or traumas
 Conditions Leading to Secondary
Bacterial Peritonitis
Perforation of bowel Perforations or leaking of other organs
Trauma, blunt or penetrating Pancreas-pancreatitis
Inflammation Gall bladder-cholecystitis
Appendicitis Urinary bladder-trauma, rupture
Diverticulitis Liver-bile leak after biopsy
Peptic ulcer disease Fallopian tubes-salpingitis
Inflammatory bowel disease Bleeding into the peritoneal cavity
Iatrogenic Disruption of integrity of peritoneal cavity
Endoscopic perforation Trauma
Anastomotic Leaks Continuous ambulatory peritoneal dialysis
Catheter perforation (indwelling catheter )
Vascular Intraperitoneal chemotherapy
Embolus Perinephric abscess
Ischemia Iatrogenic-postoperative,
Obstructions foreign body
Adhesions
Strangulated Hernias
Volvulus
Intussusception
Neoplasms
Ingested foreign body
toothpick, fish bone
• 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 % )
 Conclusion
• Mr. Bond probably suffer from appendicitis
and peritonitis
 Suggestion
• Mr. Born should be observed to make a
firm diagnosis if he does have
appenditicitis and or peritonitis he should
take appropriate treatment
• He must eat more dietary fibers, drinks to
ensure a smooth defecation
 REFERENCES
• Price, Sylvia A., Wilson, Lorraine M.
Patofisiologi vol 1. Ed 6. Jakarta : EGC,
2006.
• Fauci, Braunwald, Kasper, dkk. Harrison’s
Principles of Internal Medicine vol II. Ed
17.United Stated : mcGraw-Hills, 2008.
• Sherwood, Lauralee. Physiology from
Cells to Systems. Ed 6. United Stated :
Thomson Higher Education, 2007.
• William wh,Myron jl, Judith ms,dkk.
Current Diagnosis And Treatment in
Pediatrics 18 th ed. New York: Lange
Medical Books; 2007.
• Fauci, Braunwald, Kasper, dkk. Harrison
Principal Internal Medicine 17th ed. New
York : Mc Graw Hill; 2008.