CASE PERSONAL

I.

II.

IDENTITY OF PATIENT
Name

: An.A

Age

: 9 years

Sex

: Male

Religion

: Islam

Job

: Student

Address

: Pegagan lor, Kapetakan-Cirebon

ANAMNESIS (AUTOANAMNESIS AND ALLOANAMNESIS)

The main complaint: stomach pains

Additional complaint: nausea, vomiting, diarrhea,

History of present illness:

A 9-year-olds came to the hospital emergency room on Monday Arjawinangun date
07/02/2012, the patient complained of abdominal pain since the day of Friday afternoon
29/6/201, stomach feels bloated suddenly after coming home from school, and urine of
patients admitted from the day the amount of diarrhea Friday morning until Sunday
morning.Patients do not eat spicy food before and did not snack at random.In addition,

patients also experienced a high fever since Thursday morning, patients were nausea and
vomiting when eating and drinking.The patient vomited in a day more than 5 x and
vomit green to victimization.Before entering the hospital, the patient can not flatus since
Saturday 06/30/2012.The patient had never previously treated. Defecate smoothly
currently still a little liquid, waste water small current.

Past Medical History:

Paien never experienced pain like it is today
The patient had no history of previous trauma
The patient had no history of previous illness magh
Patients had no previous history of urinary stones
Patients no history of previous oprasi
Patients also do not have a previous hernia riwat
Family History of Disease:
There was no family history of disease

III.

PHYSICAL EXAMINATION
Status Generalis
General condition
Consiousness
Vital signs

Head
Eyes

Neck
Thorax
Cast

: Look sick is moderate

: Compost mentis
:
Blood Pressure
: 90/60 mmHg
Pulse rate
: 96 x / minute
Respiration rate
: 26 x / minute
Temperature
: 36.8 C
: Normocephal.
:
Conjunctiva anemis : (- / -)
Sclera jaundice
: (- / -)
Light reflex director : (+ / +)
: palpable enlargement of lymph nodules (-), palpable
enlargement of the thyroid (-)

: Inspection : ictus Cordis (-)

Palpation
: Cordis palpable ictus
Percution
: limits in normal
Auskultation : Heart sound I-II, Additional heart sound (-)

Pulmo

: Inspection
Palpation
Percution
Auskultation

Abdomen

Extremities

IV.

: movement of right and left hemithorax are symmetrical

at static and dynamic state
: vocal and tactile fremitus right and left hemithorax are
symmetric
: resonant at whole hemithorax, word of CVA pain (-)
: vesicular + / + N, crackles - / -, wheezing - / -

: Inspection : flat, cicatrix (-), hiperemis (-)

Palpation
: tender (+) in all quadrants, defans muscular (+)
Percussion : hypertymphany at other regions of the
abdomen
Auscultation : bowel sound (-), tenderness (+) in all quadrants
: Upper
Below

: Jaundice - / -, Edema - / -, Cyanosis - / : Jaundice - / -, Edema - / -, Cyanosis - / -

EXAMINATION SUPPORT
Blood Laboratory:
- WBC: 19.0 X 10 UL
- GRA: 17.1 X 10 UL
- GRA%: 89.9%
- LYM%: 392 000%
Imaging examination:
Plain photo abdomen:
- Normal Preperitoneal
- Psoas normal linea
- Contours of both kidneys is not clear
- Excessive air seemed to fill small caliber bowell boweldengan further enlarged and
thickened wall of the air seemed to fill at least part of the more distal
- Appear multiple fluid level in the water and LLD ereck photo
- No visible free water on the second image on the photo subdiafragma erect and LLD
ImpressioObstructive
- ileus where the high
- There does not appear peritonitis or pneumoperitonium

VI .

DIFFERENTIAL DIAGNOSIS
Cleaner layout obstructive ileus
Acute appendicitis
Hernia incarcerate
Gastroenteritis

Acute cholecystitis
Acute Cystitis

VII. WORKING DIAGNOSIS

Cleaner layout obstructive ileus
VIII. MANAGEMENT

Medical:
IVFD RL 20 GTT
Lapixim 2x1
Antrain 2x1
2x1 amp IV ketorolac
2x1 amp IV ranitidine
Cebaktam 2x 1
Operative:
Laparotomy
IX.

Prognosis
- Quo ad Vitam: ad dubia bonam
- Quo functionam ad: ad dubia night

CHAPTER I
Acute abdomen is a condition that occurs suddenly arise where the main
symptoms are abdominal pain and can be life threatening and its reduction surgery is
usually required.This incidence of acute abdomen is often found in medical
environments.
General management of patients with acute abdominal pain do not be an easy
matter because it is a challenge for a physician to diagnose the cause of acute
abdomen.Decision for surgery should be enforced as any delays can cause
complications that result m eningginya morbidity and mortality.
The accuracy of diagnosis and mitigation depends on the ability to determine a
good analysis of the data anamnesis, physical examination and investigations are
obtained. Thorough knowledge of anatomy and physiology of the abdomen and its
contents play an important role in getting rid of the many possibilities that could be
the cause of acute abdominal pain.
When the patient entered the severe abdominal pain, the doctor must have a
mindset to make differential diagnosis. The importance of narrowing the differential
diagnosis to be a top choice because of the need for making the determination of when
a patient needs surgery.A major Cuan on the abdominal pain is very severe abdominal
pain, which appears in a previously healthy patients and lasted at least for 24 hours
and sometimes require surgery.

CHAPTER II
REVIEW REFERENCES
ACUTE ABDOMINAL
2.1.

Definitions
Acute abdomen are generally defined as intraabdominal processes that occur that cause
great pain and arise suddenly, which can rapidly deteriorate and life-threatening and require
surgery.
A situation that requires quick decisions or judgments for their management. The term
acute abdominal pain show a state of sudden and severe abdominal lasting less than 24 hours.
This is a situation that requires rapid and specific diagnosis. Its management usually require
surgery.
2.2.
Etiology
Circumstances-circumstances that can cause acute abdomen can be divided into 6 major
categories of:
1. Inflammatory
Inflammatory category can be divided into two parts, namely bacterial and chemical.
Common examples of bacterial such as acute appendicitis, diverticulitis, and some cases
inflammtory Pelvic Disease.Examples of chemicals include perforation, peptic ulcer
disease which causes stomach acid content of peritoneal reaction.
2. Mechanical Examples of such circumstances cause me kanik obstruction.C ontohnya
inkarserata hernia, adhesions, intussusepsi, intestinal malrotation with volvulus,
congenital atresia or stenosis of the intestine.Common causes of mechanical bowel
obstruction is a Ca Colon.

3. Neoplasms
4. Vascular
Vascular disorders that cause acute abdominal thrombosis or embolism example is A.
mesenteric. When blood flow stops, tissue necrosis occur, with bowel gangrene that
occurs in the intestine.
5. Congenital Defects
A congenital defect may involve surgery anytime soon since the time of birth (eg,
duodenal atresia, omphalocele or hernia diaphragmatica) until many years later as in
chronic intestinal malrotation.
6. Trauma
Causes of traumatic acute abdomen varies from stab wounds and blunt abdominal
gunshot wound to the circumstances leading to rupture of the spleen. History of trauma
should be clear. 1

2.3.

Diagnosis
Pain, anorexia, nausea, vomiting and fever rupakan me a typical manifestation of
acute abdominal disorders.Vital signs on physical examination tenderness multitude
'defense musculair' and changes in intestinal peristalsis.However, the critical distinction
between an acute abdomen and not the non-acute, but the abdominal surgery cramoplasty
and abdomen.Identification of abdominal surgery depends upon the use of three basic
diagnostic components: anamnesis, physical examination and ancillary tests.
2.3.1. Anamnesis

Onset

Since when is being felt?

How long does the pain last?

Painful

Does the pain occur suddenly or gradually?

Where is the initial location of pain, and where the current location of
pain?

Does the pain change location?

Whether the pain spreads to other locations?

What kind of pain that is felt?

What can reduce the pain?

What worsens the pain?

Throw up

When it starts throwing up?

How the relationship between vomiting and pain?

How often the patient vomiting?

What is spit?

Past medical history

Have experienced similar pain?

Defecation

Is there a change in bowel habit?

When Chapter last & what kind?

History of Menstruation

Other symptoms of

Appetite, swallowing
circumference, fever

disorders,

Symptoms of Acute Abdomen

Painful

Location of pain,
The onset and progression of pain,
This type of pain
Characteristics

weight

loss,

increased

waist

That reduce and exacerbate

Location of pain: abdominal pain upper

Gastric or duodenal ulcer

Cholecystitis, cholangitis

Pancreatitis

Appendicitis (early)

Hepatitis or Liver Abscesses

Extra abdomen:
o
Pleurisy, Pneumonia lobaris inferior, Pneumothorax
o
Pericarditis, Myocardial infarction, angina
o
Pyelonephritis, renal Colik
Abdominal pain was:

Disturbances (early)
Small bowel obstruction or gangrene
Pancreatitis
Gastroenteritis
Mesenteric embolism / thrombosis
Aortic dissection
Adenitis mesenteric
Sigmoid diverticulitis (early)

Abdomen pain below:

Colon obstruction or gangrene

Interference
Adenitis mesenterik
Diverticulitis
Pyosalphinx a ruptured abscess
Tortio tubo-ovarian
Ectopic Pregnancy

The onset and progression of pain

generalized extreme pain

dangerous hollow organ perforation, ruptured

aneurysm, ectopic pregnancy or an abscess.

accompanied by systemic symptoms: tachycardia, sweating, tachypnea, and

shock.
mild pain so severe that develops within 1-2 hours to:

Acute cholecystitis,

Acute pancreatitis,

Intestinal strangulation,

Mesenteric infarction,

Colik kidney or ureter,

Small bowel obstruction where the high

Pain is gradual:

Acute appendicitis

Hernia inkarserata

Pancreatitis

Small bowel obstruction where the low

Large bowel obstruction

Uncomplicated peptic ulcer,

Genitourinary system and gynecological disorders.

This type of pain

Visceral pain

visceral pain stimulation of the organ or structure in the abdominal cavity.

Pull / stretch / contraction of excessive muscle pain

ischemia

Can not accurately indicate the location of pain

Foregut: stomach, duodenum, hepatobilier system, pancreas pain in the

pit of the stomach or epigastrium

Midgut: the small intestine and colon to the mid transverse Colon pain
around the umbilicus.

Hindgut: the mid-transverse colon to the Colon Sigmoid Colon pain in

lower abdomen
Somatic pain

Stimulation of the parts supplied by the peripheral nerve.

Pain like being stabbed or slashed and patients can pinpoint its location with a finger.

Pain moved

Evolve according to the pathology.

Pain in the beginning, its location can be different from the location of pain at the time of
patient treatment.

Referred pain / referral

A segment of innervation serves> 1 area

Pain in areas away from the location of organs that have stimulus

Organ or structure
The center of the diaphragm

Nerve
N. phrenic

Level
Innervation
C 3-5

 Edge of the diaphragm, stomach,

Pancreas, gallbladder, small intestine
Appendix, Colon proximal, pelvic organ
Distal colon, rectum, kidney, ureter, testis
Bladder, rektosigmoid

Plexus seliakus

Th 6-9

Plexus mesenterikus
N. caudal splanchnic
Hypogastric plexus

10-11 years
Th 11 - L1
S2 - S4

Types of pain:
Characteristics of pain
Continuous pain
stimulation of the parietal peritoneum
perceived as constantly ongoing inflammatory reactions such as
Colic Pain
visceral pain due to spasm of the smooth muscle of hollow organs and organ barriers to
the passage in TSB
Trias colic: kumatan abdominal pain, nausea, vomiting, involuntary movement.
Circumstances which aggravate and mitigate the Comfortable position

lying motionless on the peritonitis

walking with bent Appendicitis,

patient is lying down with legs bent that stimulate inflammation M. psoas
(Appendicitis, Psoas Abscesses)

Pain that increases during breathing: pain Pleuritis, Peritonitis, peritoneal Abscesses, abdominal
distension due to intestinal obstruction, cholecystitis Characteristics of vomiting

not accompanied by bile: Stenosis of the pylorus.

repeatedly mingled with gall: beginning proximal small bowel obstruction.

the distal small bowel obstruction and bowel obstruction, vomiting that occurs preceded by
prolonged nausea, vomiting eventually accompanied faeces.

The vomiting

very severe and persistent: strangulation of the small intestine or acute pancreatitis.

occur at the peak of pain: renal colic or intestinal colic.

In the acute vomiting usually occur after abdominal pain, while in

gastroenteritis, vomiting, pain arising started.

Constipation

large bowel obstruction can be bowel and flatulen at all,

obstruction in the small intestine can not cause constipation.

Diarrhea

Diarrhea accompanied by blood ulcerative colitis, Crohn's disease, basilar or amoeba

dysentery.

CHAPTER abdominal pain accompanied with mucus and blood intussusepsi.

Jaundice tract abnormalities in hepatobilier

Hematokezia or hematemesis gastroduodenal lesions

hematuria urethral colic, cystitis

Pielitis dysuria, the presence of stones, acute hydronephrosis, pelvic Abscesses on urinary
vesicles, which irritate the appendix Abscesses right ureter.

KET menstruation and Endometriosis.

Leukorrhea PID and dysmenorrhea

General observation

colicky pain lots of move

parietal pain (appendicitis, peritonitis) silent

SYSTEMIC SYMPTOMS
Fever
Abdomen

Inspection

abdominal distension.
distended abdomen with a scar adhesion op intestine.
peristalsis which appears in the abdominal wall bowel obstruction.

Auscultation

accompanied by increased bowel sounds colic or intestinal obstruction

in the early phase of pancreatitis pd.

decreased bowel sounds bowel obstruction or advanced stages of

diffuse peritonitis.

Palpation

abdominal tenderness irritation / inflammation of the peritoneum below

off pain irritation / inflammation of the peritoneum

deffence muscular stimulation varies, the type of irritant

Laboratory

Low Hb hidden bleeding.

leukocytosis infection.

hypovolemic shock. examination of electrolytes, urea and creatinine

Blood Gas Analysis hypotension, generalized peritonitis, pancreatitis, and sepsis to

anticipate the occurrence of acidosis

Increased serum amylase pancreatitis

hepatobilier abnormalities of liver function tests (serum bilirubin, alkaline

phosphatase, SGOT, SGPT, albumin and globulin)

X-ray

air shadow in the abdominal cavity.

free air under the diaphragm hollow organ perforation

water fluid level intestinal obstruction

Obliteration of the shadow M. psoas bleeding from the kidney injury, Pyomiositis
M.psoas, Abscesses M.psoas, or retroperitoneal Abscesses.

Opaque shadow along the urinary tract canalikuli and urinary tract stones.

Acute appendicitis: inflammation of the appendix Appendix vermikularis or that occur in

acute

bacterial infections

Appendix lumen obstruction was a factor precipitating factors

Constipation increase pressure

intracaecal functional blockage of the appendix and
the increasing growth of normal flora bacteria Colon

Mild fever 37.5 -38.50 C, when the high temperature is likely that the perforation
occurred.

Bloating in patients with perforation

Protrusion on the lower right abdominal mass or Abscesses form peripendikuler

tenderness and pain off at McBurney's point

Rovsing sign (+)

Blumberg sign (+)

Digital rectal

To find the location of the appendix tested psoas and obturator test

Physical examination

Mild fever 37.5 -38.5

occurred.

Bloating in patients with perforation

Protrusion on the lower right abdominal mass or Abscesses form peripendikuler

tenderness and pain off at McBurney's point

Rovsing sign (+)

Blumberg sign (+)

Digital rectal

To find the location of the appendix tested psoas and obturator test

number of leukocytes binding to help make a diagnosis

Ultrasound can improve the accuracy of diagnosis

C, when the high temperature is likely that the perforation

Approximately 10% of patients with acute abdominal pain was very old and very young.P
Asien over age 65 have twice the incidence of surgical disease (30%) as a cause of pain in the
abdomen compared to patients under the age of 65 years.In the adult age group, women more
often suffer from abdominal pain than men, but men who display symptoms of disease incidence
have surgery higher.Genitourinarius system common cause of abdominal pain in women. In
order of presentation of the more rare, because genitourinarius common in women include pelvic
inflammatory disease, urinary tract infections, dysmenorrhea, and the ectopic pregnancy.
The pain is clearly a major complaint in patients of acute abdomen, it is important to know
the origin, location, propagation, and the nature of the pain. There are three types of onset of
abdominal pain: ekplosif (suddenly), quickly and slowly.
Patients who were suddenly seized with agonizing pain explosive, eg hollow viscus rupture
into the cavity free peritonealis or 'vascular accident' sustained.Derived from renal colic and
biliary tract can be start suddenly, but rarely cause pain so severe, so that helpless
patients.Patients with pain and a quick start quick bad mem akuta may suffer pancreatitis, trom
bosis mesenterica or intestinal strangulation.Patients with pain may slowly begin to suffer
inflammation of the peritoneum (peritonitis), as seen in appendicitis or diverticulitis.
Severity of pain is characterized as torture, severe, dull or like colic. Excruciating pain not
respond to narcotics illustrates a vascular lesion such as an acute abdominal aneurysm ruptures
minalis or bowel infarction.Small bowel infarction patients suffering from pain beyond typical
physical description and the proportion of laboratories. Severe pain easily controlled by
medication but is typical of peritonitis caused by a ruptured viscus or pankreatiti s akuta.Dull

pain, equivocal difficult localized, describes a process of inflammation and is an early sign of
appendicitis.Colicky pain and cramps marked as encouragement ('rush') describes gastroenteritis.
Pain due to mechanical obstruction of the small intestine is also colic, but it has a rhythmic
pattern with a pain-free intervals alternating with severe colic. Peristaltic encouragement could
be heard during severe colicky peristaltic impulse that accompanies gastroenteritis was not
necessary coordination with colicky pain.
Clinical picture is very important, related to the location of the distribution of pain in
the affected organs.The place of abdominal pain reflects the type of nerve stimulation and
embryology of the organ of origin. Perception of abdominal pain, visceral pain is the beginning
and then become somatic.Peritoneum and abdominal viscera viscera are innervated by sensory
nerves from T5 - L3. The flow of nerves leading to the viscera is very little the pain was so vague
that it is difficult to determine the location of the pain.
The sensation of pain that is difficult to be localized in the abdomen is mediated
through the autonomic nervous system associated with intra-abdominal viscera viscera is
called pain. The cause of visceral pain is tension in the muscle fibers caused by a strain of the
wall, muscle spasm or strain of the organ capsule. Strong peristaltic contractions occur to prevent
obstruction. The pain associated with obstruction it feels great and cramping can occur but are
intermittent, with the interval without pain called colic. Ischemic cause of muscle pain due to
visceral gut peristalsis and loss of ability to be paused's tension.The cause of ischemic visceral
pain most often occurs due to intestinal strangulation in a hernia or volvulus. A rare cause of
acute mesenteric thrombosis ohnya cont.
Peritoneum parietale restricts abdominal diaphragm surfaces have sensory innervation of
the somatic nervous dar T6-L1.When the parietal peritoneum e irritated, somatic pain
arises.Somatic pain is localized and there is spasm in the muscles and are innervated from the
original source of the pain. Examples of pain and muscle spasm in RLQ is usually associated
with inflammation caused by appendicitis in the RLQ parietal peritoneum. Sign of abdominal
pain in peptic ulcer perforation is comprehensive due to the diffusion of the acid in the peritoneal
space causing severe irritation of the parietal peritoneum at all.
Referred pain is pain that occurs in other places of origin of the pain which are supplied
from the same neural segment.Visceral pain is divided into three locations in the
abdomen.Localization of the pain suggests organ affected. Epigastric pain associated with organ
supplied by the T6-T8, stomach, duodenum, pancreas, liver and biliary tract and the parietal
peritoneum is associated.Perimubilical pain associated with the innervation of the T9-T10 and
including the small intestine, appendix, and the upper ureter.Hipogastric pain associated with the
innervation of the T11-T12, Colon, bladder, lower ureters and the uterus.
Charts which supply the sensory innervation of visceral organs 6
Organ
Neural pathways
Sensory level
Liver, spleen, and the center of N. phrenicus
C3-C5
the diaphragm
Peripheral diaphragm, stomach, Celiac
plexus
and
N T6 - T9
pancreas, gall bladder and small splanchnicus
intestine
Appendix, colon, and organs in Mesenterica plexus and N. T10 - T11
the pelvis
splanchnicus

Sigmoideum colon, rectum, N. splanchnicus the lowest

kidney, ureter and testicular
Bladder and rectosigmoid
Plexus hipogastrika

T11-L1
S2-S4

Pain 'flank' and the angle costrovertebralis pain associated with kidney or ureter stones or
with pyeloneph ritis.Kidney pain can also be accompanied by pain in the ipsilateral testis.
Diaphragm irritation can cause pain in the distribution of C4. So that the process of
inflammation of the liver or spleen, or a collection of fluid per forata subdiaphragma ulcer can
turn into shoulder pain.
2.3.2.
Physical examination
When patients present with abdominal pain, then the proper and thorough history is an
important basis for diagnosis., But the decision on whether surgery or not, made on the basis
of physical examination should be done carefully and systematically. \
6 Physical examination measures included:
(1) inspection,
(2) auscultation,
(3) percussion
(4) palpation,
(S) examination of the rectum / genital
(6) examination of specific signs
Inspection
The position of the patient.
In the severe colic patient can not lie down quietly.
Patients with peritonitis lying quietly with his knees bent even though there is great
pain.
Patients with facial expressions
Frequency and respiratory movements
Tensions m.rectus abdominis
"Darmsteifung" (peristaltic movement seen in the abdomen)
Auscultation
On auscultation should be noted peristaltiknya sound. Peristalsis can be increased,
berkuran g or disappear altogether in the presence or suspected acute abdomen.Peristalsis is
said to be lost if there is no sound after peritoneal we listened for a few-minutes. Did not
mean there is no peristaltic paralytic ileus caused by diffuse peritoneal irritation.While
hiperperistaltik usually found in three forms:
a. The constant presence of borborygmi and hard enough, and can vary in intensity, but no
particular pattern. Was found in acute gastroenteritis or intestinal disorders caused by the
disruption of food. This peristaltic rhythm is not certain and the variations in intensity occur
without changes in discomfort in the abdomen.
b. Less common but much more important is the sound caused by rhythmic contractions of
intestinum.It is found in the acute mechanical obstruction. In this situation, abdominal colic,
silent between the two periods into which borborygmi sound then gradually increased in

intensity: this borborygmi rises to the top of the loudest sound (crescendo), to then gradually
disappeared until only a very weak sound.Patients aware of the incidence of seizures with
pain that waxes and wanes along with the activity of Peris taltik.If someone has pern ah hear
the rhythmic peristaltic crescendo on acute mechanical obstruction, he will not be able to
either diagnose it.
c. Partiil a chronic obstruction in the lower small intestine and also in the healing phase of a
diffuse peritonitis, high sound like the echo can be heard because of the periodic
contractions: da ri intestine being stretched by the fluid in the cavity of the gut.Here there is
no regular rhythm on peristaliknya. Can be with or without symptoms of abdominal cramps.
A noise is heard in episgastrium be an important sign of chronic intestinal ischemia.Bruit
(noise) on the left or right of the midline of the abdomen may indicate a blockage of the vasa
da mean renal blood.The discovery of a noise is very important in assessments of abdominal
pain pence vague and repetitive.
Percussion
Percussion is done subtly useful for determining the area of pain. This also often reveal the
presence of the unexpected overcast condition that is with the pain; this indicates the
existence of an unknown mass shifts intestinum. Any sign of shifting dullness (deaf switch)
can be a feature of the regulation intra-abdominal anger after a trauma to the abdomen.It
should be carefully investigated the extent of the liver and vesica urinary deaf.
Palpation
First of all, the patient asked to cough. If there is an acute inflammation of the
peritoneum, the cough is usually going to cause pain great is limited to areas of
inflammation.Examination of the ca ra cause pain with cough is very useful; patient in asking
for shows with her fingertips right place where pain arises earlier.In this way a place can be
localized inflammation without holding previous palpation. So the examiner can avoid so as
not to touch this area to other parts of the abdominal examination were done.
The discovery of a spasm, and distinguish between intentional kejan g (by her own) with
spontaneous seizures.It should be noted that not hurt. First of all examiners must be in good
hands warm. Musculus rectus abdominis second seizure may be palpable in this way. A place
that feels pain with cough were examined after the examination was finished we all do.
I check my abdominal spasm.Entire sections of the left hand, placed on the abdomen
in the quadrants of the most distant from the pain and tenderness: this should be done as
gently as possible in a long time to ensure that patients not really in pain.To Then the
patient was told to breathe in, while the fingers of his left examiner musculus rectus
abdominis intersect with, pressed gently with the examiner's right hand.At the time when
there expirasi voluntary spasm of the musculus rectus will always be felt under his hand: is
the involuntary spasm or spasm which really will not be palpable. Muscle will be felt stiff,
dense, tense as a building board. No need here push hands too deep in the abdomen so that
the stiffness is palpable, and the examiner should not cause pain.

Abdominal palpation the wrong way.

Large stiffness in both musculus rectus showed a diffuse peritoneal irritation.Whereas
segmental spasm in a m. Rectus (spasmus limited to one quadrant) found in the early
peritonitis.But because there is no room to spread rnembatasi peritoneal fluid to one side of
the abdomen, then the stiffness along which extensive in one of the musculus rectus paralysis
flass id musculus rectus entirely on the other can not occur as a result of peritonitis or
peritoneal irritation.Extensive unilateral rigidity (extensively) origin of the re reflex.It is
sometimes found in the acute renal pain but its mechanism is poorly understood.
Palpation of the two recti muscles simultaneously useful in assessing the breadth and
nature of abdominal tension.
Determination of the pain hit. Appropriate area with tenderness in the abdomen, can be
determined with certainty by palpation a smooth way with a finger.Acute appendicitis or
acute cho lecystitis normally demarcated on the organ that unless there was te complications
of diffuse peritonitis.This examination can only be done right with careful and gentle
palpation with one finger.Do not check the entire surface with our hands: for in this way we
can not determine the extent and precise localization. Examination with light percussion of
the abdomen can be done to determine the localization of tenderness.

Determination of the pain hit. Appropriate area with tenderness in the abdomen, can be
determined with certainty by palpation a smooth way with a finger

Abdominal palpation should be followed by examination in the alley ping, and the lower
angle costovertebralis cavum thoracis.Use was the only one finger to check these areas
carefully.Strong palpation with one finger on the bottom spatium intercostale will sometimes
cause pain that is sometimes easy to be confused with abnormalities in the diaphragm. On
examination pain in the costovertebral region, the examiner uses one finger touched tuk un
Columna vertebral area between the twelfth and the costa.The pain in this area ren
pathognomonis to the inflammatory process, whereas a sense of tenderness over the lateral
in-costa costa or on the edge of the waist may be a sign of a variety of circumstances.

In examining the angle tenderness on the finger probe costovertebralis appropriately be placed in
the 12th costa and vertebral muscles.
The discovery of a mass. Examiner has determined where ri nye press earlier without
causing pain to the sufferer.Also been determined is the spasm of the muscles of the
abdominal wall and how wide. After this try to do more in the abdominal palpation. If there
is stiffness of the muscles of the abdominal wall, palpation will not be able to do. But
although there is no stiffness we still difficult to palpate the tools or mass in the abdomen
when there is pain in patients. However, with a very gentle palpation without hurting the
patient so that the resulting stiffness is deliberate, an experienced clinician can find explicitly
the limits of such tender mass vesica strained fellea appendicitis or an abscess.
We need to invent a palpation the acute abdomen for a second time been giving
morphine or in the operating room after dinarkose.If you always abide by this rule the masses
that had been known to often be overlooked. Also, this method allows the assessment of a
much more te pat on the properties of known mass.
Pulsus fingered.The nature and frequency of the pulse is a sign of the pen ting of the
severity of acute abdominal disease.Pulsus a slow, regular full and would not rule out the
possibility of a severe peritoneal infection, but showed that patients responded well. His
pulse was elevated medium, fast, irregular, were the characteristics of progressive abdominal

in ile.This is one sign that had worried about, although minimal abdominal findings.Pulsus
very fast and usually there is little information on peritonitis.
After the abdominal examination is done, the inguinofemoral and externa genitalia organs
to be carefully examined, so do not ignore the incarcerata hernia strangulation.
During this inspection should also feel the femoral artery, because the absence or not
symmetrical pulsation of this artery (right and left), in circumstances where there is severe
abdominal pain can be one sign of abdominal aortic aneurysm dissectans.
Pelvic examination and rectum 9.1
This was done pa ling end, but should never be forgotten.Abnormalities in the
Douglas cavity more easily we are touched with lithotomi position than the lateral position.
Palpas i on the rectum and Douglas cavity we should do it systematically; in this way the
exact location of pain can be determined and this can be a meaningful description of the
diagnosis.Also prostate and seminal vesicul a note because of inflammation in these tools to
mpunyai symptoms such as acute abdomen.In women, uterine artery pulsation can be found
growing which is a sign of pregnancy or crepitus in the broad ligament that occurs in gas
bacillus cellulitis after a septic abortion.Correct diagnosis and sometimes salvation of souls
sometimes people can depend on things such details.Examination of the pelvis and rectum
that is repeated once more after the narcotics are held, if there is reason to show pelvic
lesions.
Examination - Special examination 6.9
a.Painful cough.
b.Rebound tenderness (tenderness off).
The pain caused by strong pressure on the abdomen at a distance from the infla masi we
suspect, then we release the pressure suddenly.Tat when the abdominal wall back to its
original position, the pain occurs in pressure and tem pat inflamasinya own
place.Freelance tenderness in disclose to the other side, which is the side of the lesion,
is a useful ancillary evidence that there is a limited acute peritoneal irritation in the area
of pain.With the same meaningless pain and cough were more reliable because it is
tender out there, although there is no pain cough.
Out that there is tenderness everywhere showed diffuse irritation of peri toneal.No need
to do checks on peritonitis in Fusa clear, because this action would aggravate the pain
of the patient.In cases of doubt, especially sufferers of thick fat with muscle and a thick
omentum, "rebound phenomen" very valuable to determine the extent of inflammatory
processes.
c. Iliopsoas test.
Patients are asked memfleksikan articulatio coxae against the prisoners that we
provide.If there is inflammation that is located close to m. Psoas, with an examination
before the patient will feel pain.Disorders in low-grade can be determined by ordered
panderita lying on the opposite side and busi mengexten thigh in a position exposed to a
large extent.

Iliopsoas test
d. Obturator test.
Here the legs folded up 90 and then held endorotasi and exorotasi.Hipogastrium pain
can be caused if there is inflammation of the mass that is located in contact with
m.obturator internus. This may be positive if there is appendicitis or pelvic fluid or
blood accumulation in the pelvis.

Obturator test
Ding din fist percussion on the anterior thorax.The positive results found in a variety of
circumstances including acute hepatitis.This sign is also positive if there is acute
cholecystitis.

Percussion with the palm of the hand (fist) on the anterior wall of the lower thorax.Intensity can be
controlled with good punches and allow un tuk perform this maneuver with the softness of
manner.Patients will feel a sharp flash of pain in circumstances where there is an acute inflammatory
process in the diaphragm or the liver on the right side or around the spleen and stomach on the left
side.
e. Contralateral tenderness. Sometimes difficult to distinguish pe intrathoracal disease
that causes abdominal pain with rigidity or acute inflammatory processes in the upper
abdominal quadrant.Pressure on opposite sides of a rather deep toward the affected
side'll give rikan pain that this intraabdominal process, is that the process is on the
diaphragm will not give pain.
f. Inspiratory arrest (Murphy). This characteristic of acute cholecystitis. Patients with a
long breath at the time where we have put the pressure on the abdominal wall in an area
roughly fellea vesica. If the liver is down then the vesica fellea will be felt by the
fingers and the patient will feel a great pain with breathing due to stop soon. Can po h
epatitis sitip on acute hepatic failure, due to acute heart kegagaian.
g.Umbilical discoloration (cullen). Skin color is bluish umbilicus may be if there is a
broad hemoperitoneurn. This is usually an indication of a ruptured ectopic pregnancy.
But this sign is also positive in every situation in which the blood is ba many in the
cavum peritonii.But the "Cullen" is negative does not mean the absence of
intraperitoneal bleeding. 9

2.3.3. Examination Support

2.3.3.1. Laboratory
A complete blood count and serum electrolytes routinely performed in patients suffering
from abdominal pain to.Intra-abdominal inflammation may increase the elevation of leukocytes
although it is not always true. Even more important than the initial blood count is a tendency
towards a progressive increase in leukocyte count, which shows the progression Vitas process
of inflammation or sepsis.Leftward shift in the peripheral blood smear is another strong
indication for the state of inflammation compared with leukocyte count.
If the patient is dehydrated, a history of vomiting and diarrhea or if they are taking
medications such as diuretics that can increase the amount of serum electrolytes, such as the
concentration of serum sodium, potassium, blood urea nitrogen, creatinine, glucose, chloride,
and carbon dioxide.In addition, laboratory tests can detect diabetes, kidney failure, or other
systemic diseases. Examination of serum amylase and lipase may help to evaluate upper
abdominal pain due to pancreatitis. Although the accompanying increase in serum amylase
pancreatitis but can also accompany other diseases such as duodenal ulcer perforation and
intestinal obstruction.Patients with right upper abdominal pain should be examined bilirubin,
alkaline phosfatase, and serum transaminases due to the possibility of obstructive jaundice or
acute hepatitis.
Examination of her urine and provide important clinical information useful.Urinalysis can
detect possible urinary tract infection, hematuria, proteinuria, or hemoconcentration.Women of

childbearing age suffer from acute abdominal or hypotension should check the concentration of
serum or urine human chorionic gonadotropin.
2.3.3.2 Examination of X-Ray
Films obtained in a series of abdominal akuta traditionally terlazim confirmation
tests are required in these patients. Plain is still useful in some diseases.X-ray can detect
pneumoperitoneum is better than other radiographic examinations. Examination of the
thorax images upright can find out the presence of air 1 cm from the diaphragm into the
peritoneal cavity. For some patients who can not stand examination of the abdomen with a
lateral decubitus position can also find out pneumoperitoneum.
Radiographs with the patient tilted to the left can detect 5-10 ml of air under the
lateral abdominal wall. Free air in the peritoneal cavity showed a perforation of the
digestive tract. Perforated duodenal ulcers usually cause air to enter the peritoneal cavity.
Approximately 75% of patients with duodenal ulcer perforation radiographically showed a
pneumoperitoneum.Perforation of the stomach and colon can cause extensive
pneumoperitoneum. Number pneumoperitoneum also depends on the length of the
perforation and leakage.Plain abdomen may show a broad picture of pneumoperitoneum.
Movie picture shows the difference serous and mucous lining of the bowel wall that is
located on the surface of the free air serosa. Hidropneumoperitoneum extensive water
appears as a picture of fluid level. Supine position may indicate a collection of air between
the abdominal wall that does not appear in the intestine.
Plain may also show abnormal calcification. Approximately 10% and 90% of
gallstones contain calcium kidney stones that provide a sufficient radioopak.Appendicolith
mengkalsifikasi and radiographically can be seen in 5% of patients with appendicitis.
Calcific pancreatitis is characterized by chronic pancreatitis appears on the plain, and
vascular calcification can assist the evaluation of abdominal aortic aneurysms, aneurysm
areteri visceral, vascular and visceral atherosclerosis.
Plain abdominal supine and upright positions may indicate gastric obstruction;
small bowel obstruction proximal, middle, and distal; and colon obstruction.
2. 3.3.3.Ultrasonography
Ultrasound examination is useful in patients with acute abdominal pain because it can
provide a quick evaluation, safe, inexpensive on the liver, gallbladder, bile ducts, spleen,
pancreas, appendix, kidney, ovary, and uterus.Transabdominal and intravaginal ultrasound
can help to evaluate the ovaries, adnexa and uterus. Ultrasound can also detect the
distribution of intra-abdominal fluid. Colour Doppler ultrasound evaluation of the blood
vessels to help intra-abdominal and retroperitoneal.Aortic and visceral artery aneurysms,
venous thrombosis, fistula arterioles venosus, and other vascular abnormalities with
ultrasound can dievalua's.Unfortunately, in patients with acute abdominal air usually found in
large quantities at a disturbing picture of abdominal sonographic abdominal organs but bone,
fat does not interfere with air and CT-Scan image.Therefore, CT-Scan a major examination of
the acute abdomen.
2.3.3.4. CT-Scan
CT-Scan examination immediately to the abdomen is now commonly performed.This
examination proved to be very useful for evaluating abdominal complaints in patients who

have clear indications for laparotomy or oskopi hungry.CT-scan is very useful in identifying
free intraperitoneal air is very small and the location of areas of inflammation that require
immediate surgery (appendicitis, abscess tubovarian) or delay surgery (diverticulitis,
pancreatitis, hepatic abscess).
2.4

.Differential Diagnosis

In Gastrointestinal Disorders:
o
Nonspecific abdominal pain
o
Appendicitis
o
Small bowel obstruction and colon
o
Peptic ulcer perforation
o
Hernia incarcerata
o
Intestinal perforation
o
Meckel's diverticulum
o
Boerhaave's syndrome
o
Diverticulitis
o
Inflammatory bowel disorders
o
Mallory-Weiss syndrome
o
Gastroenteritis
o
Acute Gastritis
o
Adenitis mesenterica
o
Parasitic infections
Abnormalities in liver, spleen and biliary tract
o
Acute cholecystitis
o
Acute cholangitis
o
Hepatic abscess
o
Ruptured liver tumor
o
Spontaneous rupture of the spleen
o
Myocardial splenicus
o
Biliary colic
o
Acute hepatitis
Abnormalities of the pancreas
o
Acute pancreatitis
Abnormalities of the urinary tract
o
Ureter or renal colic
o
Acute pyelonephritis
o
Acute Cystitis
o
Myocardial Renalis
Gynaecologic
o
Ruptured ectopic pregnancy
o
Ovary Tumor
o
Ruptured ovarian follicular cysts
o
Acute salpingitis
o
Dysmenorrhea
o
Endometriosis

Vascular abnormalities
o
Ruptured aneurysm of the aorta and visceral
o
Acute colitis iskhemik
o
Mesenterica thrombosis
Abnormalities of peritoneal
o
Intra-abdominal abscess
o
Primary peritonitis
o
Peritonitis tuberculosa
Retroperitoneal disorders
Peritoneal hemorrhage

2.4.1 distinguishing signs on upper abdominal pain

Acute
Acute
Pepti
appendiciti cholecysti c
s
tis
ulcer
perfo
ration
Age
Usually <40 > 40 years 30-50
years
years
Gender

Painful

Men
Women

= Women,
obese

Rare
in
wome
n
Epigastric;
Great;
60radiating to radiating
70%
RLQ;
in to the back have a
line with the and
histor
distribution shoulders; y of
reduced
ulcers
with
;
antispasm sudde
odics
n
onset;
pain is

Acute
Pancreati
tis

Pneumonia
and
Pleurisy

Coronary
occlusion

30-50
years

All ages

> 40 years

Especially
in women

Men
Women

TBA
sudden
onset after
eating
a
lot; severe
and
constant
pain;
radiating
to the back

In the upper
abdomen,
not
localized;
commuted
with
respiratory
muscle
splinting

= Man

Puncture;
spread
to
the shoulder
and left arm

contin
uous;
Throw up

Appearan
ce

Temperat
ure of

No, but it
always
happens
with
anorexia
No pain to
peritonitis

A lot of Not a Always

vomiting
lot of
vomiti
ng
Looked
tired
because
pain

Looks
in
pain;
not
move
her
belly;
lookin
g
shock
ed
subno
rmal

99 - 100F; 99-102 F
can
be
higher after
perforation
Malaise
Localized in Localized Diffus
RLQ
in
the e.
RUQ
many
in the
upper
abdo
men,
kakau
as a
board,
no
sound
perist
altic
Laborator Leukocytosi Leukocyto Leuko
y
s
sis
cytosi
s
X-Ray
There is no May
Free
point
indicate
air at
stones or 85% 4
gall
hours
bladder is after
not visible onset

Not
available

Reflex

Looks in Was
pain,
restless;
looked
respiratory
shocked
grunting
when
necrosis

Dyspnea;
cyanosis;
nervous at
all;
sweating;
subnormal
blood
pressure

Subnormal
at onset;
subsequen
tly varied
Epigastric;
rebound;
decreased
peristaltic
sounds

100-103 F

Normal to
subnormal

Epigastric;
not settled,
no
restrictions
on
the
movement
of
abdominal
breathing

The upper
part
of
abdomen;
but
are
subject to
change and
do not settle

Increased
serum
amylase
"Sentinel
Loop"
small
intestine

Very
Leukocytosi
leukocytosis s, the ECG
is helpful
Thorax X- There's no
Ray done
point.

Distinguishing signs on the lower abdominal pain

Appendicitis Ureteric
Salpingitis
acuta
obstruction
acuta
Age
Usually <40 <40 years
<40 years
years
Gender Men
= Men
= Woman
Women
Women
Painful
Epigastric;
Weight, such Dull;
pain
move
to as punctured; remained at
RLQ;
starting from LQ; attacks
constant with the
lumbar of recurrent
exacerbations area; spread severe pain:
to
the back
pain;
scrotum;
dysuria
dysuria;
frequency
Menstru No change or
ation
menorrhagia

Ectopic
Pregnancy
<40 years

Diverticulit
is
> 40 years

Woman

Man

Sharp stabbing Cramps,

(usually
not pain LLP;
diagnosed until diarrhea
rupture occurs)

No
menstruation;
15-25%
irregular
Normal

Tempera 90-100
F Normal
99-102 F
99-101 F
ture of
before
perforation
Malaise Localized in Costovetebral Bilateral LQ; Unilateral LQ; LLQ;
RLQ;
; not in the suprapubic;
repeated
recurrent
repeated
abdomen
repeated
mass + / -,
distension +
/Rectal
Discomfort
Discomfort in Discomfort of and
on the right
the
being on the
pelvic
movement of movement of
examina
the
cervix; the cervix; out
tion
spending
blood
purulent
(blackish
brown)
Laborat Normal
Hematuria;
Vaginal
or AschheimLeukocytosi
ory
sediment;
leukocytosis - cervical fluid Zondek
be s
leukocytosis
culture
positive or not;
positive for puncture cul de
gonococcus; sac contained
sediment
blood
slightly
increased

X-Ray

Not useful

95% saw a Not helpful

stone;
Pyelogram
IV can help

Not helpful

Does
not
help though
barium X
rays
can
show
diverticulosi
s

2.5 Management of Acute Abdomen

2.5.1. Management in general 12
1. Fasting
2. Gastric decompression by NGT installation
3. Rehydration with infusion
4. Installation of Catheter
5. Laboratory examination:
- Routine Blood
- Amylase, Lipase
- Na, K
- U, Creatinine
- GDS
6. Roentgen
Photo 2 positions: - BNO BNO Upright and flat, or
- LLD and BNO Flat
Photo 3 positions: Upright BNO, LLD, BNO Flat

2.5.2. Management of acute abdomen based on severity and clinical symptoms

Priority

Mechanism

Clinical picture

Management

I.

II.

Pain, collapse, shock

(Catastrophic)
as
ulcer
perforation,
ruptured
ectopic
pregnancy,
acute
pancreatitis,
mesenterica
thrombosis, ruptured
aneurysms,
and
others.
Pain (intermittent),
colic such as acute
intestinal obstruction,
obstruction of biliary
colic, colic uereter.

Perforation,
hemorrhage,
thrombosis,
necrosis

Sudden severe pain,

shock or stages such
as shock, feelings of
discomfort in the
abdomen,
tense,
severe
systemic
reactions,
silent
abdomen

Immediate resuscitation
and supportive action,
surgery immediately if
there are indications

Obstruction of a
weak muscular
organ (smooth
muscle),
strangulation
may impending
or existing
Irritation
by
bacterial,
chemical,
ischemic faktos

Recurrent cramping Enforce diagnosis if

pain,
vomiting, possible, correction of
distention, abdominal the balance of systemic,
noisy,
systemic immediate surgery if
reactions are mild to indicated
severe,-Ray can be
used
iii. Pain,
discomfort,
Pain is variable, Clinical diagnosis is
inflammation such as
usually
increases, usually
possible,
acute
appendicitis,
localized discomfort, immediately on the
acute cholecystitis,
then
diffuse
to appendicitis operation,
acute diverticulitis,
rupture,
muscle time to prepare for all
acute salpingitis
spasms, usually there the therapy (fluids,
is a mass, systemic antibiotics, surgery)
reactions of moderate
to severe.
2.5.3. Specific causes of acute abdominal disease by category of severity and the
need for
Operation
Non Operating
Catastrophe
Rupture of a spontaneous weak Acute Pancreatitis
(Priority I)
organ or trauma (peptic ulcer Coronary thrombosis
disease, ectopic pregnancy) with Dissecting aneurysm (with rapid
severe bleeding.
diagnosis and circumstances that
Rupture of solid organs, especially allow the operation can be done)
trauma (spleen, liver, kidneys)
Acute
vascular
occlusions
(mesenteric damage, obstruction
stragulasi)
Severe bleeding, peptic ulcer,
varicose esophagus.
Colic (Priority Acute intestinal obstruction
II)
Appendicitis acuta (colic
fecolith the lumen)

Biliary
colic,
renal
colic,
from gastroenteritis, fecal impaction

Inflammation
(Priority III)

Acute appendicitis
Acute cholecystitis
Acute diverticulitis

Adenitis mesenterica
Regional enteritis
Pelvic Inflammatory Disease
Ruptured
ovarian
follicle
(Mttelschemrz)
Urinary tract infection
Pneumonia and pleurisy

2.6. Peritonitis
2.6.1. Definitions
Peritonitis is the inflammation that occurs in some or all of the peritoneum.Peritonitis is
the most common cause of death in the acute abdomen.Infectious organisms that can reach the
peritoneum through the following ways:
1. Through the injuries of the abdominal wall
2. Through the bloodstream.
3. Of visceral abdominal (common causes)
4. Through the diaphragm (very rare) or lymphatic spread (very rare).
Commonest organism was pneumococcus from the blood, which can lead to a state of primary
peritonitis. The organism can achieve pe ritoneum of viscera through (1) Rupture of viscera (2)
through the damaged wall viscera.In women there is an additional pathway through an infected
fallopian tube. Sometimes - sometimes there is a local abscess originating from extra or
intraperitoneal from the diseased organ, which eventually will break, so go to the peritoneal
cavity and cause peritonitis.
2.6.2. Etiology
1. Perforation
2. Gangrene
-

Appendix vermiformis
Gastric or duodenal ulcer
Typhoid or tuberculosis ulcers of the small intestine
Diverticulum in the colon
Of the gallbladder or bile duct
Intussusepsi
Volvulus

3. The spread of infection

Pyosalpinx
Infected uterus
Pyonephrosis
4. Rupture of
Liver abscess

Splenic abscess
Another rare form of peritonitis may occur from the entry of the bile or urine into the peritoneal
cavity.
2.6.3. Symptoms & Signs
Symptoms of peritonitis varies depending on the section and extensive peritoneal affected,
source of infection and onset.
Symptoms include:
1. Severe pain in abdomen
2. Throw up
3. Nausea
4. Fever
On physical examination found:
Inspection:
The person is sick, agitated, his face pale
Position the patient does not move / be afraid to move because the pain
Abdomen was tense
Rapid and shallow breathing
Auscultation:
Bowel sounds decreased / missing
Percussion:
Percussion pain
Tuberculosa peritonitis there is a phenomenon on the chess board
Palpation:
Pain Press
Pain off
Stomach feels like a board
Defense Musculair
Rectal toucher:
Pain in the whole circle
2.6.4. Examination Support
1. Laboratory
Routine blood, leukocytosis was found
Examination of peritoneal fluid (to see the erythrocytes, leukocytes and
bacteria, when the cause is trauma)
2. X-Ray Inspection
There is free water in the peritoneal cavity in an upright position and LLD
BNO
There is free water in the sub diaphragm in Thorax AP photo - Lateral
2.6.5. Management of
1. Fasting
2. NGT decompression with the installation of
3. Rehydration with infusion
4. Administration of oxygen

5. Catheter
6. Provision of broad spectrum antibiotics intravenously
7. Operation

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