Curriculum

Vitae
dr. Raya Henri Batubara, Sp.BKBD
Tempat / Tanggal Lahir : Pematang Siantar, 18 4
1971
Alamat : Pondok Bambu, Jakarta Timur
Jabatan : Dokter Bedah
Institusi : Bedah RSUD Kota Bekasi
HP : 0811-1071804
Riwayat Pendidikan

FK USU Medan
Sp Bedah FK - UI
Sp Bedah Konsultan Bedah
Digesif FK UI
Riwayat Pekerjaan
Dokter PTT PKM Cirimen Lebak (1997-2000)
Dokter Umum PKM Bantar Gebang & Aren Jaya Bekasi
(2001-2003)
Dokter Bedah RSUD Kota Bekasi (2011-sekarang)
Riwayat Organisasi

IDI Kota Bekasi

PABI
IKABDI
IKABI
ACUTE ABDOMEN FOR
PRIMARY PHYSICIAN
Which one of both has an acute abdomen?

Scheins Common Sense Emergency Abdominal Surgery 3rd ed

Definition
acute abdomen refers to abdominal pain of
short duration that requires a decision regarding whether
an urgent intervention is necessary

Be defined generally as an intraabdominal process

causing severe pain and often requiring surgical
intervention
It is a condition that requires a fairly immediate judgment
or decision as to management
 Visceral Parietal Referred

Nyeri dirasa
Tumpul Lebih intense jauh dari
Sulit dilokalisir Bisa dilokalisir sumber nyeri
Epigastrium
Periumbilikal
Suprapubik Iritasi Nyeri bahu
Berkeringat Diaphragma

Gelisah
Muntah
 Streching
Distention of peritoneum

Cutting Cancer

Tearing
Crushing
Burning

Peritoneal Ischemia
Inflamation

Bacterial Chemical
.
Type of Onset

Sudden - rupture of viscous,

Gradual- mesenteric thrombosis
cholecystitis, appendicitis
 Quality
Dull - initial epigastric pain of appendicitis
Sharp - renal or biliary colic or obstruction of gut
Aching - pelvic inflammatory disease
Lancinating - acute pancreatitis
Tearing - dissecting aneurysm
Intensity

Severe - rupture of viscous or blood in the

peritoneal cavity
Moderate - RLQ appendiceal
Mild peptic ulcer, without perforation
Temporal Features
continuous - acute pancreatitis
pulsatile - abdominal aneurysm
colicky - lumen obstruction, intermittent severe pain with
pain-free intervals
frequency & duration transient pain of short duration which
does not recur is usually insignificant. The longer the
duration the more likely a surgical condition
Acute Abdomen
Symptoms & sign

Grey-Turner, Cullen sign

Grey-
Murphy sign
GI Obstruction
Free a/Pneumoperitoneum
Free fluids
Increasing Bowel sound
common causes of abdominal pain

Acta Medica Indonesiana 2012;44(4):344-50

 Important Clue ! ! !

Instead of consider the 50 or so most likely causes of acute

abdominal pain from the list
tries to identify a clinical pattern and to decide on a course of
action from a limited menu of management options
Clinical Pattern
1. Abdominal pain and shock
P
2. Generalized peritonitis R
I
3. Localized peritonitis O
4. Intestinal obstruction R
I
5. Medical illness T
Y
 Abdominal Pain and Shock

Ruptured abdominal aortic aneurysm (AAA)

the only management option is immediate surgerynow

Intestinal Obstruction
Acute Mesenteric Ischemia
Severe Acute Pancreatitis
Due to fluid loss into the third space
Generalized Peritonitis
Perforated Peptic ulcer

Colonic or smal bowel perforation

Perforated Diverticulitis

Caution !!! - Medical condition mimicking diffuse peritonitis

- Acute Pancreatitis
- Spontaneous Bacterial Peritonitis
- Abdominal Tuberculosis
Localized Peritonitis
Acute Appendicitis most common in adult

Acute Cholecystitis assess severity

Acute Diverticulitis simple or complicated ?

Differential Diagnosis:
- Gynecologic / Obstetric Emergencies
- Ureteral Colic
Intestinal Obstruction
The clinical pattern of intestinal obstruction consists of
central, colicky abdominal pain, distension, constipation,
and vomiting

Classical pitfalls :

Hernias never forget to look for it

Simple bowel obstruction be ware of a more
complex causes (e.g. tumor, invagination)
Inguinal Hernias
Signs of Strangulation 3T
Tension Tenderness Temperature
Risk of bowel necrosis
Non-operative treatment (taxis) is unjustified,
except in early strangulation in infants
Supportive Investigation
Other Imaging Technique
Plain abd X `rays
USG
CT Scan

Other Diagnostic Tools

Diagnostic Peritoneal Lavage
Endoscopy
Laparoscopy
Certain tests when associated with
characteristic clinical features
Markedly elevated serum amylase levels acute
pancreatitis
Free air under diaphragm in an upright x-ray film
perforation of a hollow viscous - usually a duodenal
ulcer
Distended loops of small bowel above the level of
obstruction in small bowel obstruction with absence
of gas below by x-ray.
First Aid

Primary Survey ABCs

Ensure optimal oxygen delivery

Early identification of SEPSIS or even worse,

septic shock

No Analgesic until diagnosis is made ?

Obtain Informed Consent

Management Options

Immediate operation (Surgery Now)

Preoperative preparation and operation
(Surgery tomorrow morning
Conservative treatment (active observation, IV
fluids, antibiotics, etc.)
Discharge home
Surgical interventions
Severe contaminated peritonitis
Strangulated GI Obstruction
GI obstruction + Respiratory distress
Perforation
Abdominal shot gun wound
Penetrated Abdominal wound
Massive GI bleeding
ABDOMINAL COMPARTMENT SYND.
(ACS)
Key for the best outcome
Operate only when necessary and do the minimum
possible

Do not delay a necessary operation and do the

maximum when indicated

When in Doubt.. There is No Doubt..

Do Something !!!
Surgeon Exploratory Laparotomy ?
ED Physician Consult !!!
Role of ED Physician

First Aid and Early Consultation

+
Intervene when necessary
- Immediately lethal problems
- too sick patients
- Remote areas
Immediately Lethal Problems
Intra Abdominal Pressure (Abdominal Compartment
Synd.)
Primary Injury/disease of abdomino-pelvic region,
surgical
Secondary Sepsis, capillary leak, burns, medical
Recurrent ACS develops despite surgical intervention
Strangulated Hernia

EARLY
INTERVENTION
!!!
too sick patients
Severe sepsis Septic Shock
Comorbidities, especially in elderly
Cardio-Pulmonary
Metabolic
Kidney Failure LEADS

TO

Increased Mortality
What to do as
ED physician ?
Strangulated inguinal hernias
Viability of the strangulated bowel segments
Key points : release of inguinal ring
Can even be done under Local Anesthesia
In too sick patients or remote area where surgical
consult is not readily available
Local anesthesia for inguinal hernia surgery
Ann Surg 1994;220(6): 735-7

Recognition and Release of

these structure

Making of the skin wheal anddeepsubcutaneousinjection.

Subfascialinfiltration
Summary
Acute abdomen is a surgical emergency

Early recognition of specific clinical pattern is essential in

the diagnosis of acute abdomen

ED physicians play an important role in the primary

management, early surgical consult / referral or even
intervention in selected cases
Thank you