Clinical Examination

of Acute Abdomen
11/12/2014

Acute Abdomen (acute abdominal pain)

Condition which requires immediate treatment (FD

Moore, 1977): Surgery? When to perform?

(Buku Ajar Ilmu Bedah, 1997): Clinical condition

which arises from acute critical condition in the

abdominal cavity, and usually manifests as pain.
Acute abdominal pain: Chief complaint: acute pain

(Nyhus, Vitello, Condon, 1995)

Why is it important?
Patient with acute abdomen:

Sudden onset
Unknown etiology (not clear)
Need immediate diagnosis & treatment

Prevent morbidity & mortality

Morbidity & Mortality

obstruction

fluid imbalance

Perforated viscus

Peritonitis

infection

Shock

Bleeding

Sepsis

hypovolemic Shock

ischaemia Perforation

Peritonitis

Acute abdominal pain

Most can be diagnosed clinically
Require accurate and focused history taking
Need meticulous & rationale physical examination
Appropriate special investigations

The
Diagnostic
Process

HISTORY
Patient perception of symptoms
Patient description of symptoms
Physician perception
Physician interpretation of symptoms

LABORATORY
FINDINGS

SYNTHESIS
RECORDING

DECISION

PHYSICAL
EXAM

History taking
60 - 80% of accurate diagnosis arises from good &

meticulous history taking

Physical diagnosis confirms accurate diagnosis
10 - 15% of accurate diagnosis arise from laboratory

& radiological examinations

History taking:
May confirm :
Suspected

diagnosis
Possible etiology
Disease stages/ complications
Differential diagnosis

History Taking
Introduction
Greet the patient, and develop a warm and
helpful environment
Introduce yourself to the patient

Patient Identity
Ask the patient politely concerning his/her:

name
age
Record the gender:
Male
Female
Ask the marital status of the patient
(especially for female)

Acute abdominal pain in specific groups

In children

Acute appendicitis

In the elderly

Perforated tumors
Bowel obstruction due to tumors

During pregnancy

Complicated Ectopic pregnancy

Chief complaint:

Ask the patient regarding why the patient comes to you.

Onset
Site at onset
Radiation
Type

PAIN

Progression
Duration

Site at present
Severity

Aggravating /relieving factors

Site of pain

Upper abdominal pain

Peptic or gastric ulcer
Acute Cholecystitis, Acute Cholangitis

Pancreatitis
Early Appendicitis
Hepatitis or liver abscess
Extra abdominal:

Inferior Pleuritis, lobar pneumonia, pneumothorax

Pericarditis, Myocardial infarction, angina
Pyelonephritis, renal colic

Central abdominal pain

Early appendicitis
Bowel obstruction, strangulated

Pancreatitis
Gastroenteritis
Mesenterial Emboli /Thrombosis
Dissecting aortic aneurism
Mesenteric adenitis
Early sigmoid diverticulitis

Lower abdominal pain

Colonic Gangrene/Obstruction
Appendicitis

Mesenteric adenitis
Diverticulitis
Ruptured tubo-ovarial abscess
Tuboovarial Torsion
Ectopic gestation

Onset of pain
Sudden onset

Onset of pain
Gradual pain

Type of
pain

Visceral pain &

Parietal pain

Type and severity of pain

A

A. Toothache
C. Colicky pain of inflammed hollow organs

Type and severity of pain

Intermittent colicky pain of obstructed hollow organ at

early stage.

Type and severity of pain

Progressive & Continous colicky pain due to

strangulated bowel obstruction (ischemic stage)

Other related symptoms:

Ask the patient concerning related/concomitant symptoms of
Gastro-intestinal function:

Nausea
Vomiting
Loss of appetite
Faintness
Previous indigestion (habitual)

Other related symptoms:

Jaundice
Bowel habit:
constipation?
Diarrhoea?
Colour

of the stool?
Presence or absence of blood and mucus
(slime)

Other related symptoms:

Urinary function:
Micturition: amount of urine, lower abdominal
discomfort, colour of urine
Gynaecological function ( female)

Menstrual function
Delayed or miss period
Abnormal bleeding or discharge (colour, quantity)

Previous history of :
similar pain

abdominal surgery
Major illness: incl. fever, abdominal injury.
Drugs

Allergies

PHYSICAL EXAMINATION
Preparation

Check all the equipment required and have a good

light:
Examination couch
Stethoscope
Explain the procedure and its goals to the
patient.
Wash your hands with antiseptic soap.
Dry and warm your hands with tissues.

Implementation:
A General Examination
General

appearance:Consciousness
Mood: distressed? Anxious?
Immobile
Move cautiously
Colour: Pallor? Flushing? Jaundice?
Cyanosis?

Implementation:
Examine the vital signs:
Temperature
Pulse

rate
Blood Pressure
Respiratory rate

Implementation:
Perform other systems examination, including

cardio-pulmonary system.
Ask the patient politely to expose his/her

abdomen.

Abdominal Examination: Inspection

Inspect the movement:

Respiratory movement
Visible bowel peristaltics

Is there any scars on the skin of the abdomen?

Is there any abdominal distention?

Flatus ? , Fluid ? , Fetus?

Abdominal Examination: Inspection

Is there any rashes and discolouration?

Cullens sign
Gray Turners sign
Ecchymosis of the abdominal wall
Is there any masses:
Tumors?
Hernial sites?
Masses with pulsation?

Cullen Sign

Gray-Turner sign

Abdominal Examination: Palpation

Ask the patient to locate the site of maximum

pain with the tip of a finger.

Using the palmar surface of your fingers,

gently palpate the abdomen, starting from a

site farthest from the area of maximum pain,
move gradually towards it.

While palpating, look to the face expression

of the patient, and look for any signs of :

Tenderness
Rebound tenderness
Muscle guarding
Rigidity
Murphys sign

While palpating, look to the face expression

of the patient, and look for any signs of :
Swelling

or masses
Rovsings sign
Expansile pulsation
Hernial orifices
Scrotum in male

Expansile pulsation

Specific signs:
Rovsings sign
Obturator sign

Psoas sign

Abdominal Examination : Percussion

Place the palmar aspect of your left hand on the

abdomen, and gently percus its dorsal aspect with

the tip of the middle finger of the right hand,
moving all around the abdominal region:
Is it tymphanitic?
Is it Dull ?
Is there any shifting dullness?
Site of liver dullness ? and is it disappeared ?

Auscultation
Using stethoscope, and place it gently on the

abdomen, listen to the bowel sounds and bruit at

least for one minute:
Absent?
High pitched and hyperactive?
Metallic sound?
Vascular bruit?

Digital Rectal Examination

Put on surgical hand

gloves and ask the

patient to expose
his/her buttock and
anus, and place the
patient in lithotomy
position.Apply
lubricating jelly on to
the right index finger.

Digital Rectal Examination

Gently insert your right index finger into the anus, move

toward the anal canal slowly, and evaluate the followings:

Anal margin: piles?
Mucosal surface of the anal canal and the ampulla
(collaps?)
Sites of any pain elicited
Masses or swelling: consistency, location, surface, fixity
to the surroundings.
Bowel contents: consistency of faeces? Mucus? Blood?

 Perform bimanual palpation in female patient to

examine the uterus, pelvic cavity and adnexa.

Write up

Write up all significant findings in the medical

record. Conclude your diagnosis and differential
diagnosis, and order any necessary special
investigations

Extra
peritoneal
causes of
acute
abdomen
Cardiothorax
Urology
Vascular
E.t.c

Acute peritonitis

Patology

Mild
Gastric juice

Bowel bontent

Pancreatic juice

pus

bile

Urine

blood

Degree of peritoneal irritation

(Lowenfels, 1975)

Severe

Signs of intrabdominal sepsis

Fever, nausea, vomiting, tachicardia, tachipneu

Abdominal pain
Peritoneal signs
Signs of dehydration
Leucositosis
Shock, Multiple organ failure

Tips
> 6 hours: surgical related diseases !!!

Limited movement: peritonitis / ischaemia

persistent pain on morphine : ischaemia

Sense of Crisis
Repeated exams : important

Perforated duodenal
ulcer

GI bleeding

Pancreatitis

Acute appendicitis

Intusucseption

sigmoid volvulus

Mesenteric
thrombosis

Mechanical
Intestinal
obstruction

Obstetrics & gynecological causes

Obstetrics
Ectopic gestation
Abdominal pregnancy
Rupture of the uterus
Mola Destruen

gynecology
Ruptured ovarial cyst
Ovarial Torsion, Myoma
Ruptured abscess
Perforated Uterus

Ruptured
organ

Content
Pus

Blood

Materials :
sebum
meconeum

Acute
abdomen

Abdominal
pain in
Obgyn

ischaemia

distention
Strangulation

torsion

A Good Diagnostician

is not Born,
but is Developed