ACUTE ABDOMENOTJE HUDAJAFK UKM2007

ACUTE ABDOMENANY NON-TRAUMATIC DISORDER OF ACUTE ONSET IN WHICH THE SYMPTOMS ARE PREDOMINATLY ABDOMINAL AND FOR WHICH IN SOME CASE URGENT SURGERY MAY BE INDICATED. PROMPT DIAGNOSIS IST ESSENTIAL A CAREFUL HISTORY AND EXAMINATIONS WILL INDICATE THE CAUSE OF MOST ACUTE ABDOMEN

ACUTE ABDOMENIN PRACTICE IT REPRESENTS A SPECTRUM OF PROBLEMS RANGING FROM SUDDEN ONSET OF SEVERE ABDOMINAL PAIN WITH LIFE-THREATENING UNDERLAYING CAUSE TO MINOR ABDOMINAL SYMPTOMS OF LENGTHY DURATION

ACUTE ABDOMENTHE SEVERE CAUSES WHICH NEED URGENT SURGERY (e.g. RUPTERED AORTIC ANEURYSM, PERFORATED DIVERTICULITIS)SEVERE ANDOMINAL PAIN THAT DOES NOT NEED REQUIERE SURGERY (BILIARY COLIC, URETERIC COLIC, PANCREATITIS)CONDITIONS WHICH DO NOT NEED URGENT INVESTIGATIONS AND TREATMENT (GASTROENTERITIS, CONSTIPATION)

HISTORYAGE.MESENTERIC ADENITIS IN CHILDREN, DIVERTICULITIS IN THE OLDER PATIENTPAIN. - TIME AND MODE OF ONSET, e.g. SUDDEN, GRADUAL- CHARACTER : DULL, VAGUE, CRAMPING, SHARP, BURNING- SEVERITY

HISTORYPAIN- CONSTANCY. COUNTINUOUS PAIN, INTERMITTENT OF INTESTINAL COLIC- LOCATION. WHERE DID IT START, HAS IT MOVED?- RADIATION : LOIN TO GROIN IN UTERIC COLIC- EFFECT OF RESPIRATION : MOVEMENT, FOOD, DEFAECATION, MICTURITION, MENSTRUATION

HISTORYVOMITING. - DID VOMITING PRECEDE THE PAIN- FREQUENCY - CHARACTER, e.g. BILE, FAECULENT, BLOOD, COFFE GROUNDSDEFAECATION. - ABSOLUTE CONSTIPATION WITH COLICKY ABDOMINAL PAIN, DISTENSION AND VOMITING (SUGGESTS INTESTINAL OBSTRUCTION)- DIARRHOEA.: FREQUENCY, CONSISTENCY OF STOOL, BLOOD, MUCUS, PUS

HISTORYFEVER. ANY RIGORSPAST HISTORY.- PAST SURGERY, e.g. ADHESIONS MAY CAUSE INTESTINAL OBSTRUCTION- RECENT TRAUMA, e.g. DELAYED RUPTURE OF SPLEEN- MENSTRUAL HISTORY, e.g. ECTOPIC PREGNANCY, MITTELSCHMERZ

EXAMINATIONSGENERAL - IS THE PATIENT LYING COMFORTABLY?- IS THE PATIENT LYING STILL BUT IN PAIN? - IS THE PATIENT WRITHING IN AGONY, e.g. URETERIC OR BILLIARY COLIC? - IS THE PATIENT FLUSHED SUGGESTING PYREXIA?PULSE, TEMPERATURE, RESPIRATIONCERVICAL LYMPHADENOPATHY (MESENTERIC ADENITIS)CHEST (REFFERED PAIN FROM LOBAR PNEUMONIA)

EXAMINATIONS OF THE ABDOMENINSPECTION. FROM ARCUS COSTARUM GENITAL. MOVES OF RESPIRATION, SCAR, DISTENDED, DARMKONTUR, DARMSTEIFUNG, PAIN ON COUGHING, HERNIAL ORIFICES (GROIN, SCROTUM), ANY OBVIOUS MASSES, e.g. PULSALTILE MASS TO SUGGEST AORTIC ANEURYSMAUSCULTATION. TAKE YOUR TIME (30-6O S), INTESTINAL OBSTRUCTION : HIGH-PITCHED TINKLING BOWEL SOUNDS (METALIC SOUND), BORBORYGMUS

EXAMINATIONS OF THE ABDOMENPERCUSSION.- TYMPANIC NOTE WITH DISTENTION DUE TO INTESTINAL OBSTRUCTION- DULLNESS OVER BLADDER DUE TO ACUTE RETENTION - PAIN BY PERITONITIS, CAVE : DONT DO THE OTHER EXAMINATIONS

EXAMINATIONS OF THE ABDOMENPALPATION- PATIENT RELAXED, LYING FLAT, WITH ARMS BY SIDE- BE GENTLE AND START AS FAR FROM THE PAINFUL SITE AS POSSIBLE - CHECK FOR GUARDING AND RIGIDITY.- REBOUND TENDERNESS IS UNPLEASENT FOR PATIENT AND IS RARELY HELPFUL- CHECK THE HERNIAL ORIFICES- CHECK FOR MASSES, e.g. APPENDIX MASS, PULSATILE EXPANSILE MASS OF AORTIC ANEURYSM

RECTAL EXAMINATIONAS IMPORTANT AS THE ABDOMINAL EXAMINATIONIN THE LEFT LATERAL POSITIONINSERT THE FINGER POSTERIORLY INTO THE SACRAL HOLLOWMOVE THE FINGER AROUND IN THE ARC OF A CIRCLE UNTIL IT IMPINGES ON THE PERITONEUM OF THE RETROVESICAL OR RETROUTERINE POUCH

RECTAL EXAMINATIONIF THE PATIENT HAS PAIN, THIS IS A SIGN OF PERITONITIS IN THE MOST DEPENDENT PART OF THE PELVISTHE CORRECT ANNOTATION OF A POSITIVE RECTAL EXAMINATION SHOULD BE TENDER ANTERIORLYTENDER HIGH UP IN THE RIGHT IS INAPPROPIATE

RECTAL EXAMINATIONTHERE SEEMS TO BE A MISCONCEPTION AMONG MEDICAL STUDENTS THAT YOU FEELING THE AREA OF THE APPENDIX. YOU ARE FEELING FOR TENDERNESS DUE TO INFLAMMATION OF THE PELVIC PERITONEUM CAUSED BY INFECTED EXUDATES DRAINING TO THE MOST DEPENDENT PART OF THE PELVIS, i.e. THE RETROVESICAL OR RETROUTERINE POUCH

REMEMBERSITE OF ABDOMINAL PAIN IN RELATION TO ANATOMYe.g. RUQ : HEPAR, GALL BLADDER, BILIARY TREEWHAT IS MOST COMMONS IN THE SITE OF ABDOMINAL PAINe.g. RLQ : APPENDICITISEXAMINATIONS : - BE GENTLE AND START FROM NON INVASIVE EXAMINATION (IN TEXT BOOK : INSPECTION, PALPATION, PERCUSSION, AUSCULTATION) - START AS FAR FROM THE PAINFUL SITE AS POSSIBLE

PROF.SAEGESSER A DIRTY FINGER IS BETTER THAN A BAD REPUTATION THEREFOREDONT FORGET TO DO THE RECTAL EXAMINATION

INVESTIGATIONSWCC (WHITE CELL COUNT) RAISED WITH A NEUTROPHIL LEUKOCYTOSISUREA, ELECTROLYTESLIVER FUNCTION TESTSAMYLASE, HIGH AMYLASE (PANCREATITIS) MILDLY RAISED AMYLASE (PERFORATED VISCUS, INTESTINALOBSTRUCTION/ISCHAEMIA)

INVESTIGATIONSCHEST X RAY. - EXCLUDE REFFERED LESIONS - GAS UNDER DIAPHRAGM (FREE AIR)ABDOMINAL X RAY. DISTENDED BOWEL WITH AIR/FLUID LEVELS, GALLSTONES, CALCIFICIED AORTA (ANEURYSM), AIR IN BILIARY TREEPLAIN X RAY (KIDNEY URETER BLADDER/ BNO)INTRA VENOUS UROGRAPHY (IVU, IVP)ANGIOGRAPHY : HAEMORRHAGE, EMBOLUS, THROMBOSIS

INVESTIGATIONSULTRA SOUND SCANCOMPUTERIZED TOMOGRAPHYMAGNETIC RESONANCE IMAGINGENDOSCOPYLAPAROSCOPICELECTROCARDIOGRAM ( MI )

CAUSES OF ACUTE ABDOMENGUT- ACUTE APPENDICITIS- INTESTINAL OBSTRUCTION- PERFORATED PEPTIC ULCER- ACUTE EXECERBATION OF PEPTIC ULCER- MESENTERIC ADENITIS- DIVERTICULITIS- MECKELS DIVERTICULITIS

CAUSES OF ACUTE ABDOMENLIVER AND BILIARY TRACT- CHOLECYSTITIS- CHOLANGITIS- HEPATITIS- BILIARY COLICURINARY TRACT- CYSTITIS- ACUTE PYELONEPHRITIS- URETERIC COLIC- ACUTE RETENTION

CAUSES OF ACUTE ABDOMENGYNAECOLOGICAL- RUPTERED ECTOPIC PREGNANCY- TORSION OF OVARIAN CYST- RUPTERED OVARIAN CYST- SALPINGITIS- SEVERE DYSMENORRHOEA- MITTELSCHMERZ- ENDOMETRIOSIS

CAUSES OF ACUTE ABDOMENVASCULAR- RUPTERED AORTIC ANEURYSM- MESENTERIC EMBOLUS- MESENTERIC VENOUS THROMBOSIS- ISCHAEMIC COLITIS- ACUTE AORTIC DISSECTION

CAUSES OF ACUTE ABDOMENPERITONEUM- PRIMARY PERITONITIS- SECONDARY PERITONITISABDOMINAL WALLRECTUS SHEATH HAEMATOMARETROPERITONEALHAEMORRHAGE, e.g. ANTICOAGULANTS

SITE OF ABDOMINAL PAIN IN RELATION TO SUSPECTED PATHOLOGY

WHOLE ABDOMEN- GENERALIZIED PERITONITIS- MESENTERIC INFARCTIONRIGHT UPPER QUARDAN- ACUTE CHOLECYSTITIS- CHOLANGITIS - HEPATITIS- PEPTIC ULCERATION

SITE OF ABDOMINAL PAINLEFT UPPER QUARDAN- PEPTIC ULCERATION- PANCREATITIS- SPLENIC INFARCTRIGHT LOWER QUARDAN- APPENDICITIS- OVARIAN CYST- ECTOPIC PREGNANCY- PELVIC INFLAMMATORY DISEASE

SITE OF ABDOMINAL PAINRIGHT LOWER QUARDAN- URETERIC COLIC- RECTUS SHEATH HAEMATOMA- RIGHT-SIDED LOBAR PNEUMONIALEFT LOWER QUARDAN- SIGMOID DEVERTICULAR DISEASE- OVARIAN CYST- ECTOPIC PREGNANCY- PELVIC INFLAMMATORY DISEASE

SITE OF ABDOMINAL PAINLEFT LOWER QUARDAN- URETERIC COLIC- RECTUS SHEATH HAEMATOMA- LEFT-SIDED LOBAR PNEUMONIARADIATING PAIN- BACK : PEPTIC ULCER, PANCREATITIS, ACUTE AORTIC DISEASE- GROIN : URETERIC COLIC, TESTICULAR TORSION

MEDICAL CAUSES OF ACUTE ABDOMINAL PAINOCCASIONALLY, CERTAIN MEDICAL CONDITIONS MAY CAUSE ACUTE ABDOMINAL PAINREFERRED PAIN : MI, DEGENERATIVE DISEASE OF THORACIC SPINE, HERPES ZOSTER, LOBAR PNEUMONIA, PLEURISY, HAEMATOLOGICAL : THIS MAY BE DUE TO SICKLE CELL CRISIS

MEDICAL CAUSESINFECTIVE AND INFLAMMATORY :TABES DORSALIS, HENOCH-SCHNLEIN PURPURAENDOCRINE AND METABOLIC :URAEMIA, HYPERCALCAEMIA, DIABETIC KETOACIDOSIS, ADDISONS DISEASE, ACUTE INTERMITTENT PORPHYRIA

TREATMENTRELIEVE PAIN.CAVE : ANALGETICS AND ANTIBIOTICS COULD UNDER COVER THE SYMPTOMSINTRAVENOUS FLUIDS AND NASOGASTRIC SUCTIONCATHETERIZIEDBROAD-SPECTRUM ANTIBIOTICS IF PERTONITIS OR SEPSISSURGERY IF INDICATED

INDICATIONS FOR SURGERYLOCALIZED PERITONEAL IRRITATION WITH GUARDING OR RIGIDITYSPREADING TENDERNESSTENSE OR PROGRESSIVE DISTENSIONGENERALIZED PERITONITISSHOCK WITH BLEEDING OR SEPSISFREE GAS ON RADIOGRAPHMESENTERIC OCCLUSION ON ANGIOGRAPHYBLOOD, PILE, PUS OR BOWEL CONTENTS ON PARACENTESIS