Acute Abdomen

ACUTE ABDOMEN

ACUTE ABDOMENPembimbing: dr. Suryadi S, Sp.B

Oleh: Ilham Saputra (06-005)

1INTRODUKSISuatu keadaan apapun, tiba-tiba, spontan, gangguan nontraumatik dengan manifestasi utama di daerah perut dan operasi yang mendesak mungkin diperlukan. Nyeri perut adalah salah satu alasan yang paling sering untuk kunjungan ke kantor dokter dan unit gawat darurat dan merupakan penyebab utama untuk masuk rumah sakit di Amerika Serikat. 2INTRODUKSI (2)Beratnya nyeri tidak selalu berkorelasi dengan situasi.Tidak semua pasien dengan akut abdomen memerlukan intervensi bedah. Anamnesis dan pemeriksaan fisik akan mengungkap penyebab rasa sakit perut untuk memutusan pengobatan awal.3EPIDEMIOLOGI Dalam populasi Barat antara 5 dan 10 pasien dirawat di bangsal bedah setiap hari dengan sakit akut abdomen.Satu atau dua lagi akan mengeluh gejala akut abdomen setelah kecelakaan. Apendiksitis lebih sering terjadi pada kaum muda, sedangkan penyakit bilier, gangguan pencernaan, iskemia dan infark usus, dan divertikulitis lebih sering terjadi pada pasien usia lanjut.(2)4Table 1 Causes of acute abdominal pain seen in hospitals in the developed world (after de Dombal, 1991)Percentage of casesNon-specific abdominal pain34Acute appendicitis28Acute cholecystitis10Small-bowel obstruction 4Acute gynaecological disease 4Acute pancreatitis 3Renal colic 3Perforated peptic ulcer 2Cancer 2Diverticular disease 1Miscellaneous 95ETIOLOGI Nonsurgical Causes of Acute AbdomenEndocrine and Metabolic CausesUremiaDiabetic crisisAddisonian crisisAcute intermittent porphyriaHereditary Mediterranean feverToxins and DrugsLead poisoningOther heavy metal poisoningNarcotic withdrawalBlack widow spider poisoningHematologic CausesSickle cell crisisAcute leukemiaOther blood dyscrasias6ETIOLOGI (2)HemorrhageSolid organ traumaLeaking or ruptured arterial aneurysmRuptured ectopic pregnancyBleeding gastrointestinal diverticulumArteriovenous malformation of GITIntestinal ulcerationAortoduodenal fistula after aortic vascular graftHemorrhagic pancreatitisMallory-Weiss syndromeSpontaneous rupture of spleenSurgical Acute Abdominal Conditions7Surgical Acute Abdominal ConditionsInfectionAppendicitisCholecystitisMeckel's diverticulitisHepatic abscessDiverticular abscessPsoas abscessPerforationPerforated gastrointestinal ulcerPerforated gastrointestinal cancerBoerhaave's syndromePerforated diverticulum8Surgical Acute Abdominal ConditionsObstructionAdhesion related small or large bowel obstructionSigmoid volvulusCecal volvulusIncarcerated herniasInflammatory bowel diseaseGastrointestinal malignancyIntussusceptionIschemiaBuerger's diseaseMesenteric thrombosis or embolismOvarian torsionIschemic colitisTesticular torsionStrangulated hernias9ANATOMI DAN EMBRIOLOGI

HindgutForegutHeart tubePericardial cavityBEndodermEctodermConnectingStalk

Angiogeniccell clusterAllantoisAmniotic cavityA

CloacalmembraneLung budCDYolk sacRemnant Of The

Buccopharyngeal membraneVitelline ductLiver budMidgutHeart tubeAllantoisBuccopharyngealmembrane10

11REGION ABDOMINAL

12PATOFISIOLOGISensasi visceral dimediasi terutama oleh serat C aferen terletak di dinding usus berongga dan dalam organ padat. Nyeri viseral menimbulkan distensi, oleh peradangan atau iskemia neuron merangsang reseptor, atau dengan keterlibatan langsung dari saraf-saraf. Sensasi yang dirasakan terpusat umumnya lambat di awal.Karena itu, ketegangan meningkat dinding karena distensi lumen atau kuat kontraksi otot polos (kolik) menghasilkan menyebar, rasa sakit mendalam dirasakan di midepigastrium, daerah periumbilical, perut bagian bawah, atau daerah panggul. Nyeri visceral yang paling sering merasa di garis tengah karena sensorik bilateral ke sumsum tulang belakang.

13Sebaliknya, nyeri parietal dimediasi oleh kedua C dan A delta serat saraf, yang terakhir bertanggung jawab untuk transmisi lebih akut, sensasi yang lebih tajam, lebih baik sakit lokal.Langsung iritasi peritoneum parietalis diinervasi (terutama di bagian anterior dan bagian atas) dengan nanah, empedu, urin, atau sekresi pencernaan menyebabkan sakit lebih tepat lokal.Distribusi nyeri kutan parietalis sesuai dengan daerah T6-L1. Nyeri parietal lebih mudah terlokalisasi dari nyeri viseral karena serat-serat aferen somatik diarahkan untuk hanya satu sisi dari sistem saraf. Sakit perut parietal secara konvensional digambarkan sebagai terjadi di salah satu dari empat kuadran perut atau di daerah perut epigastrium atau pusat.

14GEJALA DAN TANDA KLINIS Anoreksia, Mual dan muntah, Sembelit, atau diareJaundice15ANAMNESISAgeTime and mode of onset of painDuration of symptomsCharacter of painLocation of pain and site(s) of radiationAssociated symptoms and their relation to painNausea or anorexiaVomitingDiarrhea or constipationMenstrual history16PEMERIKSAAN FISIK

General observationsGeneral appearanceAttitude in bedVital signs, including temperatureChestAuscultationAbdomenInspection (distention, localized swelling, hernia)Percussion (tympany or dullness, tenderness, referred tenderness)Palpation (muscle rigidity, tenderness, [rebound pain], hyperesthesia)[Auscultation]PelvisRectal examination (tenderness, presence of stool, occult blood, mass)Bimanual examination (cervical motion tenderness, adnexal masses)Obturator signBack and flanksPercussion (costovertebral angle tenderness)Iliopsoas sign17Table 4. Physical Findings in Various Causes of Acute Abdomen.(5)ConditionHelpful SignsPerforated viscusScaphoid, tense abdomen; diminished bowel sounds (late); loss of liver dullness; guarding or rigidity.PeritonitisMotionless; absent bowel sounds (late); cough and rebound tenderness; guarding or rigidity.Inflamed mass or abscessTender mass (abdominal, rectal, or pelvic); bump tenderness; special signs (Murphy, psoas, or obturator).Intestinal obstructionDistention; visible peristalsis (late); hyperperistalsis (early) or quiet abdomen (late); diffuse pain without rebound tenderness; hernia or rectal mass (some).Paralytic ileusDistention; minimal bowel sounds; no localized tenderness.Ischemic or strangulated bowelNot distended (until late); bowel sounds variable; severe pain but little tenderness; rectal bleeding (some).BleedingPallor, shock; distention; pulsatile (aneurysm) or tender (eg, ectopic pregnancy) mass; rectal bleeding (some).18SIGNDESCRIPTIONDIAGNOSIS/CONDITIONAaron signPain or pressure in epigastrium or anterior chest with persistent firm pressure applied to McBurney's pointAcute appendicitisBassler signSharp pain created by compressing appendix between abdominal wall and iliacusChronic appendicitisBlumberg's signTransient abdominal wall rebound tendernessPeritoneal inflammation19Carnett's signLoss of abdominal tenderness when abdominal wall muscles are contractedIntra-abdominal source of abdominal painChandelier signExtreme lower abdominal and pelvic pain with movement of cervixPelvic inflammatory diseaseCharcot's signIntermittent right upper abdominal pain, jaundice, and feverCholedocholithiasis20Claybrook signAccentuation of breath and cardiac sounds through abdominal wallRuptured abdominal viscusCourvoisier's signPalpable gallbladder in presence of painless jaundicePeriampullary tumorCruveilhier signVaricose veins at umbilicus (caput medusae)Portal hypertensionCullen's signPeriumbilical bruisingHemoperitoneum21Danforth signShoulder pain on inspirationHemoperitoneumFothergill's signAbdominal wall mass that does not cross midline and remains palpable when rectus contractedRectus muscle hematomasGrey Turner's signLocal areas of discoloration around umbilicus and flanksAcute hemorrhagic pancreatitisIliopsoas signElevation and extension of leg against resistance creates painAppendicitis with retrocecal abscess22Kehr's signLeft shoulder pain when supine and pressure placed on left upper abdomenHemoperitoneum (especially from splenic origin)Mannkopf's signIncreased pulse when painful abdomen palpatedAbsent if malingeringMurphy's signPain caused by inspiration while applying pressure to right upper abdomenAcute cholecystitis23Obturator signFlexion and external rotation of right thigh while supine creates hypogastric painPelvic abscess or inflammatory mass in pelvisRansohoff signYellow discoloration of umbilical regionRuptured common bile ductRovsing's signPain at McBurney's point when compressing the left lower abdomenAcute appendicitisTen Horn signPain caused by gentle traction of right testicleAcute appendicitis24PEMERIKSAAN PENUNJANG ImmediateSame Day1Next Day1BloodHematocrit, white blood cell count, urea, creatinine, crossmatching,1 arterial gases.1Clotting studies, amylase, liver function tests.Specific tests.UrineMicroscopy, dipstick testing, culture.1Specific tests.StoolOccult blood.Warm smear, culture.25Radiography and ultrasoundChest, abdomen.Ultrasonography or CT scan, angiography, water-soluble upper gastrointestinal series, HIDA scan.Repeat abdominal films; barium enema or small bowel follow-through, intravenous urogram, and percutaneous transhepatic cholangiography; liver-spleen, gallium, and technetium scans.EndoscopyProctosigmoidoscopy, upper endoscopy.ERCP, colonoscopy, laparoscopy.OtherParacentesis, culdocentesis.26DIAGNOSISRIGHT UPPER QUADRANT PAINLEFT UPPER QUADRANT PAINBiliary colic/cholecystitisSplenic ruptureCholangitisSplenic infarctionHepatic abscessSplenomegalyHepatitis (toxic or viral)Ruptured splenic artery aneurysmPerihepatitis (Fitzhugh-Curtis syndrome)GastritisHepatic congestionPerforated gastric ulcer (phlegmonous gastritis)Budd-Chiari syndromeJejunal diverticulitisHepatic tumor (primary or secondary)PancreatitisAppendicitisDiverticulitis (splenic flexure)Perforated peptic ulcerPerinephritisPerinephritisPneumonia (left lower lobe)Pneumonia (right lower lobe)Pulmonary infarctionPleuritisPulmonary infarctionPericarditisPleuritisMyocardial ischemiaMyocardial ischemiaEmpyemaEmpyemaRib fractureRib fractureHerpes zosterHerpes zoster27RIGHT LOWER QUADRANT PAINLEFT LOWER QUADRANT PAINAppendicitisDiverticulitisAcute enterocolitis (viral or bacterial)AppendicitisPerforated colon cancerCrohn's disease (ileitis)Intestinal obstructionForeign body perforationCrohn's colitisRight-sided diverticulitisIschemic colitisCecal diverticulitisRuptured iliac artery aneurysmMeckel's diverticulitisRuptured ovarian cyst (including Mittelschmerz)Torsion of appendix epiploicaOvarian torsionMesenteric adenitisEndometriosisIntestinal obstructionSalpingitis (pelvic inflammatory disease)Perforated peptic ulcerEctopic pregnancyPancreatitisRenal or ureteral calculiRuptured ovarian cyst (including Mittelschmerz)PyelonephritisOvarian torsionPsoas abscessEndometriosisSeminal vesiculitisSalpingitis (pelvic inflammatory disease)Rectus sheath hematomaEctopic pregnancyHerpes zosterCholecystitisRuptured iliac artery aneurysmRenal or ureteral calculiPyelonephritisPsoas abscessSeminal vesiculitisRectus sheath hematomaHerpes zoster28PENATALAKSANAAN Table 6. Medical Causes of an Acute Abdomen for which Surgery Is Not Indicated.Endocrine and metabolic disordersInfections and inflammatory disordersUremiaTabes dorsalisDiabetic crisisHerpes zosterAddisonian crisisAcute rheumatic feverAcute intermittent porphyriaHenoch-Schnlein purpuraAcute hyperlipoproteinemiaSystemic lupus erythematosusHereditary Mediterranean feverPolyarteritis nodosaHematologic disordersReferred painSickle cell crisisThoracic regionAcute leukemiaMyocardial infarctionOther dyscrasiasAcute pericarditisToxins and drugsPneumoniaLead and other heavy metal poisoningPleurisyNarcotic withdrawalPulmonary embolusBlack widow spider poisoningPneumothoraxEmpyemaHip and back29Table 7. Indications for Urgent Operation in Patients with an Acute Abdomen.Physical findingsInvoluntary guarding or rigidity, especially if spreadingIncreasing or severe localized tendernessTense or progressive distentionTender abdominal or rectal mass with high fever or hypotensionRectal bleeding with shock or acidosisEquivocal abdominal findings along with septicemia (high fever, marked or rising leukocytosis, mental changes, or increasing glucose intolerance in a diabetic patient)Bleeding (unexplained shock or acidosis, falling hematocrit)Suspected ischemia (acidosis, fever, tachycardia)Deterioration on conservative treatmentRadiologic findingsPneumoperitoneumGross or progressive bowel distentionFree extravasation of contrast materialSpace-occupying lesion on scan, with feverMesenteric occlusion on angiographyEndoscopic findingsPerforated or uncontrollably bleeding lesionParacentesis findingsBlood, bile, pus, bowel contents, or urine30PREOPERATIFUrin output dari 0,5 mL /jam/kg Tekanan darah sistolik paling sedikit 100 mm Hg Denyut nadi dari 100 denyut / menit atau kurang, Sebuah kelainan elektrolit umum membutuhkan koreksi hipokalemia. Asidosis preoperative dapat menanggapi hal penuh cairan dan infus IV bikarbonat. Namun, kebanyakan pasien harus memiliki darah crossmatched dan tersedia di operasi.31REFERENCESBritton Julian. Oxford Textbook of Surgery (E-book). 2nd Ed. UK. Oxford University Press; 2002. Chapter 34.1, The Acute Abdomen.Postier Russell G,Squires Ronald A. Townsend: Sabiston Textbook of Surgery (E-book). 18th ed. 2007. Saunders. Elsevier. Chapter 45, Acute Abdomen.T.W Sadler. Langmans Medical Embryology (E-book). 9th ed, Chapter 13, Digestive System. P. 285-319.Matthews Jeffrey B, Hodin Richard A. Greenfield's Surgery: Scientific Principles And Practice (E-book). 4th ed. Lippincott Williams & Wilkins; 2006. Chapter 74, Acute Abdomen and Appendix.Doherty M.Gerard. Current Surgical Diagnosis & Treatment (E-book). 12th ed. San Fransisco. The McGraw-Hill Companies; 2006. Chapter 21, The Acute Abdomen.White Michael J. White, Counselman Francis L. Troubleshooting Acute Abdominal Pain (Internet). 2011 (Dikutip pada 17 Maret 2011). Tersedia dalam http://www.emedmag.com/html/pre/cov/covers/011502.asp 32