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Abdominal Pain
dr. Nurcahya Setyawan, SpB-KBD, FinaCS, FICS
Sub. Bagian Bedah Digestif
FK-UGM/RSUP dr. Sardjito, Yogyakarta
Definisi :
Terminology:
Pain ?
Sign or symptom ?
Signs
Tenderness
Rigidity
Masses
Altered bowel sounds
Evidence of malnutrition
Bleeding
Jaundice
Symptoms
D
D
Visceral Pain
D
Stimuli
Distention
Sensation
Corresponds
to the
embryologic origin of the
diseased organ (foregut,
midgut, hindgut)
t
midgut
hindgut
Somatic Pain
D
Stimuli
Sensation
Irritation of the
peritoneum
Sharp, localized pain
Easily described
Cardinal signs
Pain
Guarding
Rebound
Absent bowel sounds
Example: McBurneys point in late appendicitis
Referred Pain
Diaphragmatic irritation
Gastric pain
Liver and biliary pain
Colonic pain
Biliary colic
Pancreatic and renal pain
Uterine and rectal pain
Boerhaave's syndrome
Diverticulitis
Mallory-Weiss syndrome
Gastroenteritis
Acute gastritis
Mesenteric adenitis
Pancreatic disorders
Acute pancreatitis
Vascular disorders
Ruptured aortic and visceral aneurysms
Acute ischemic colitis
Mesenteric thrombosis
Peritoneal disorders
lntra-abdominal abscesses
Primary peritonitis
Tuberculous peritonitis
Retro-peritoneal disorders
Retro-peritoneal hemorrhage
Extra-Abdominal Causes
of the Acute Abdomen
D
D
D
D
D
Supra-diaphragmatic
Myocardial infarction
Pericarditis
Left lower lobe pneumonia
Pneumothorax
Pulmonary infarction
Drugs
Metabolic
Nervous System
D
D
D
Hematologic
D
D
Herpes Zoster
Tabes dorsalis
Nerve root compression
Endocrine
D
D
Diabetic ketoacidosis
Addisonian crisis
Laboratory tests or
other investigation are
usually needed
for diagnostic confirmation.
Question key
Physical examination key point
Laboratory investigation
Radiology investigation
Other investigation
Planning
Hemology
Electrolit & Serum creatinin
LFT
Amylase lipase
Pregnancy test
Urine analysis
Cervical culture
Radiology investigations :
Other investigations :
ECG
Paracentesis
Endoscopy
Arteriography
Planning:
Observation
Surgery / indication ?
The Quadrants
CLUES
Acute hepatitis
Right pyelonephritis
Retrocecal appendicitis
Differential Diagnosis:
LUQ and Epigastric Pain
CONDITION
CLUES
Splenic rupture
Fractured ribs
Pancreatitis
Pneumonia
CLUES
Acute appendicitis
Mesenteric adenitis
Crohns disease
Gynecologic causes
see next
CONDITION
CLUES
Ruptured follicle
Torsion of ovary
Ruptured ectopic
pregnancy
Pelvic inflammatory
disease
CLUES
Diverticular disease
Dysuria, frequency
Torsion of testis
CLUES
Gastroenteritis
Constipation
Inflammatory bowel
disease
Early appendicitis
Small bowel
obstruction
Ischemic bowel
Referred Pain
perforated ulcer
mesentric occlusion
ruptured aneurysm.
ruptured ectopic pregnancy
abdominal pain
Vomiting :
intestinal obstruction.
visceral reflex due to the pain
Haematemesis : gastritis or
peptic ulcer disease
Diarrhea :
Gastro enteritis
Ischemic colitis
Inflammatory bowel disease.
Missed period :
disturbed ectopic
pregnancy .
Tachycardia
Hypotension
Fever
Posture
Jaundice
2. Lungs:
Evidence of consolidation.
Friction rub.
Effusion.
3. Heart:
Arrhythmias.
Valvular lesion.
Heart failure.
4. Abdomen:
a. Inspection:
: obstruction, ileus, ascites.
Distension
b. Palpation:
Tenderness & rigidity
Organomegaly.
c. Percussion:
:
Tympany
Shifting dullness :
Absent
: ileus.
Hyper peristaltic
: gastroenteritis.
e. Other sign:
Psoas sign.
Obturator sign
Rovsings sign
Acute
appendicitis
5. Rectum
Mass
Lateral tenderness.
6. Female genitalia
Adnexal masses :
Pelvic inflammatory
diseases
ectopic pregnancy
ovarian abscess cyst
neoplasm
Value :
Preoperative assessment.
Hemology
Electrolit & Serum creatinin
LFT
Amylase lipase
Pregnancy test
Urine analysis
Cervical culture
1. Hemology :
Bowel obstruction :
hypokalemia,
azotemia and
alkalosis
4- Amylase / lipase :
Elevated in cases of acute pancreatitis.
In up to 30% of patients with acute pancreatitis,
amylase may be normal.
S. amylase is also elevated in cases of
5 Pregnancy test
6. Urine analysis for haematuria and/or
pyuria.
7. Cervical culture PID.
Radiology investigations :
Radiology investigation :
1 Erect and supine abdominal films: looking for :
Air-fluid levels
Aortic calcification.
Ectopic pregnancy.
Barium studies.
I.V.P
Other investigations :
ECG
Paracentesis
Endoscopy
Arteriography
Other investigation
ECG: in patients with acute upper abdominal pain
to rule out acute myocardial infarction or
pericarditis.
paracentesis.
Endoscopic studies: upper or lower G.I endoscopy
or ERCP.
Arteriography in cases of suspected acute
mesenteric artery ischemia.
Management / plan :
Physical findings
Involuntary
spreading.
guarding
or rigidity,
especially
Tender abdominal or
or hypotension.
if
Radiologic findings
Endoscopic findings
Pneumoperitoneum
Gross or progressive bowel distension
Free extravasation of contrast material
Space-occupying lesion on
CT scan with fever
Mesenteric occlusion on angiography
Paracentesis findings
Management / plan :
observation: include
Referral (when ?)
Algorithm.
Algorithm.
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When to Refer
to :
Urologist
Gynecologist
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