How Low Can You Endure

The Pain, Mr. Bond?

CASE 4A
GROUP 3
TUTOR : dr. CHRISMERRY SONG
BLOCK : GASTROINTESTINAL
FACULTY OF MEDICINE TARUMANAGARA UNIVERSITY
SEPT 16th, 2009
 NIM NAME
405070051 ERIK ADITYA CREW
405070056 RIODIAN S CREW
405070062 FORSALINA T CREW
405070063 ALINE C CREW
405070066 MAILAN J SECRETARY
405070128 SUSANTI L CREW
405070129 ANDRUW T LEADER
405070134 GRISELDA T CREW
405070148 HOSANA T CREW
405070153 DANIEL Z CREW
405070163 EMELIA W SCRIBER
405070164 ANNASTA P CREW
 CASE 4A
Mr. Bond, a 22-year old man is reffered by his GP to the
hospital with pain in the right lower quadrant. He says
that within the last month he felt egigastric pain or
sometimes the pain was located in the periumbical
region. He also felt nuseated for past 2 weeks and since
then he has vomited several times. Last night the pain
has begun to shift to its current location.
Exam:
VS: BP 100/70 mmHg, pulse 90bpm, temprature 38°C.
Tenderness and guarding over the right lower quadrant
are present.
 LEARNING OBJECTIVE
• Know and explain the unknown words
• Know and explain the quadrant and regio of
abdomen within the disease
• Know and explain chracteristic of the
abdominal pain
• Know and explain about acute abdomen
UNKNOWN WORD
 GUARDING
• The detection of increased abdominal muscle tone
during palpation
• To detect guarding  press gently but slowly and firmly
on the patient’s abdomen, using 2 hands works best
• Muscle spasm denotes guarding
• Asking patient to relax and breathe deeply  muscle
relax  Voluntary guarding
• If muscle remain rigid or tense  involuntary guarding ->
peritonitis
• Guarding may be localized or generalized
• Generalized intense guarding perforated duodenal
ulcer
Tenderness + guarding :
(alternate name : abdominal rigidity) stiffness of the wall of the
abdomen. Abdominal rigidity is often caused by a spasm of the
abdominal wall muscles after an injury. It may also be a sign that
the person has swelling inside the abdominal cavity. Serious
disease inside the abdomen can also cause abdominal rigidity.

Cause :
• Abdominal abscess - Meckel's diverticulum
• Acute appendicitis - Ovarian torsion (twisted Fallopian tube)
• Diverticular disease - Pelvic inflammatory disease
• Hepatitis - Peritonitis
• Incarcerated or strangulated hernia
ABDOMINAL REGIONS
• Abdominal pain is pain that is felt in the abdomen
LOCATION

EPIGASTRIUM PANCREATITIS, APPENDICITIS, DUODENUM ULCER, PEPTIC ULCER,

KOLESISTITIS, CA PANCREAS, MIOKARD INFARK

RIGHT KOLESISTITIS, HEPATITIS, PANCREATITIS, ABSES SUBFRENICUS,

HIPOKONDRIUM PNEUMONIA, INFARK MIOKARD

LEFT INFECTION VIRUS, PEPTIC ULCER, PNEUMONIA

HIPOKONDRIUM

PERIUMBILICALIS PANCREATITIS, CA PANCREAS, INTESTINAL OBSTRUCTION, AORTA

ANEURYSMA, APPENDICITIS

LUMBAL KIDNEY STONE, PIELONEFRITIS, CA COLON, ANSES PEINEFRIK

INGUINAL & APPENDICITIS AT RIGHT INGUINAL, DIVERTICULOSIS, SALPINGITIS,

SUPRAPUBIK SISTITIS, OVARIUM CYST
ACUTE ABDOMINAL
 DEFINITION
• Refers to any acute intra & extra abdominal
disease processes. Many cases require urgent
surgical management, although some can be
managed nonsurgically.
 ETIOLOGIC
• Parietal peritoneal inflammation
– Bacterial contamination : pelvic inflammatory
disease, perforated appendix
– Chemical irritation : perforated ulcer, pancreatitis
• Mechanical obstruction of hollow viscera :
– Obstruction of the small or large intestine
– Obstruction of the biliary tree
– Obstruction of the ureter
– Volvulus
– Hernia
 ETIOLOGIC
• Vascular disturbances :
– Embolism or thrombosis
– Vascular rupture
– Pressure or torsional occlusion
• Abdominal wall :
– Distortion or traction of mesentery
– Trauma or infection of muscles
• Neoplasm intraabdominal
• Congenital disease
 ETIOLOGY
(ACCORDING TO AGE)
Neonatal causes of Abdominal Infant causes of Abdominal Pain
Pain – Intussusception
– Infantile colic
– Colic – Bowel Obstructionn
– Milk Protein Allergy • Pyloric stenosis
– Gastroesophageal reflux • Incarcerated Herniaa
• Internal hernia
– Malrotation or Midgut volvulus • Omphalomesenteric band
– Necrotizing Enterocolitis • Hirschprung's Diseasee
– Battered Infant
– Hirschprung's Enterocolitis • Jejunum perforation
• Duodenal hematoma
– Gastroenteritis
– Constipation
– Urinary Tract Infection
 ETIOLOGY
(ACCORDING TO AGE)
Child causes of Abdominal Pain Adolescent
– Constipation – Appendicitis
– Lactose Intolerance – Gastroenteritis
– Lead Poisoning
– Constipation
– Helicobacte pylori
– Urinary Tract Infection – Gynecologic cause
– Pneumonia • Pregnancy (or Ectopic Pregnancy)
– Pancreatitis • Mittelschmerz
– Appendicitis • Dysmenorrhea
– Mesenteric Lymphadenitis • Pelvic Inflammatory Disease
– Gastroenteritis • Ovarian torsion
– Intussusception or Volvulus (children – Testicular Torsion
under age 6) – Drug and Alcohol use
– Abdominal trauma
– Sexual abuse
– Pharyngitis (e.g. Strep Throat)
– Sickle Cell Crisis – Gallbladder disease
– Henoch-Schonlein Purpura – Neoplasm
– Inflammatory Bowel Disease
 ETIOLOGY/CAUSES/DIFFERENTIAL
DIAGNOSIS OF ACUTE ABDOMEN
• Gastrointestinal • Urinary tract
– Appendisitis – Renal/ureteral stone
– Perforated peptic ulcer • Gynecologic
– Intestinal ischemia – Ectopic pregnancy
– Diverticulitis – Tuboovarian abscess
– Inflammatory bowel disease – Ovarian torsion
– Meckel’s diverticulitis – Uterine rupture
• Pancreaticobiliary tract, liver, – Ruptured ovarian cyst or follicle
spleen • Retroperitoneum
– Acute pancreatitis – Abdominal aortic aneurysm
– Calculous cholecystitis • Supradiaphragmatic
– Acalculous cholecystitis – Pneumothorax
– Acute cholangitis – Pulmonary embolus
– Hepatic abscess – Acute pericarditis
– Ruptured hepatic tumor – Empyema
– Splenic rupture
 PHYSICAL EXAMINATION
• Patient overall appearance
– Ability to communicate and habitus ?
– Lie quietly in bed or active move ?
– Lie on his or her side with knees and hips flexed?
– Appear dehydrated with dry mucous membranes?
• Patient lying quietly in bed, avoiding motion, and
complaining of abdominal pain -> serious intra-
abdominal disease
 PHYSICAL EXAMINATION
• Evaluation of the vital signs
– Low fever (37.2 ⁰ C – 37.8⁰ C)  diverculitis,
appendicitis, acute cholecystitis
– High fever (> 37.8⁰ C) pneumonia, urinary tract
infection, septic cholangitis, or gynecologic
infection
– Rapid heart rate and hypotension  complicated
disease with peritonitis
 PHYSICAL EXAMINATION
Inspection
• Scars
• Hernias
• Masses
• Abdominal wall defect
• Contour abdomen scaphoid, flat, distended
– Abdominal distention  intestinal obstruction,
ileus, or fluid including ascites, blood, or bile
– Peristaltic movement  intestine obstruction
– Contraction abdomen  perforation
 PHYSICAL EXAMINATION
Auscultation
• Bowel sounds ↑  obstruction of small
intestine, early acute pancreatitis
• Bowel sound ↓  chronic obstruction of
intestine, difuse peritonitis, ileus
 PHYSICAL EXAMINATION
Palpation
• Localized tenderness in :
– McBurney poin  appendicitis
– RUQ  inflamed gallbladder
– LLQ  diverticulitis
– Throughout abdomen  diffuse peritonitis
– Rebound tenderness  peritonitis
• Deep palpation can detect abdominal masses (Acute
cholecystitis, acute pancreatitis, abdominal aneurysm,
diverticulitis)
 PHYSICAL EXAMINATION
Percussion
• Hyperresonance or tympany  gaseous
distention of the intestine or stomach
• Resonance over the liver  free
intraabdominal gas
• Percussion pain which has the same located
with rebound tenderness  peritoneal
irritation
• Shiffting dullness +  fluid on peritoneal
 CHARACTERISTIC OF THE PAIN
• Visceral pain, comes from abdominal viscera, innervated by
autonomic nerve fibers and respond mainly to the sensation
of distention and muscular contraction. Typically vague, dull,
and nauseating.
• Somatic pain, comes from parietal peritonium, innervated by
somatic nerves, which respond to irritation from infectious,
chemical, or other inflammatory processes. Sharp and well
localized.
• Referred pain, perceived distant from its source and result
from convergence of nerve fibers at the spinal cord. Ex:
scapular pain due to biliary colic, groin pain due to renal colic,
shoulder pain due to blood or infection irritating the
diaphragm
 LABORATORY TESTING
• Intra-abdominal inflammation  WBC ↑
• Dehydration , vomitting, diarrhea, taking diuretic
medicine -> measure the concentrations of serum
sodium, potassium, blood urea nitrogen, creatinine,
glucose, chloride, and carbon dioxide.
• Pancreatitis, perforated duodenal ulcer  serum
amilase ↑
• Abdominal pain RUQ should have measurements of
serum bilirubin, alkaline phosphatase, and serum
transaminase
 DIAGNOSIS ACUTE ABDOMEN
• History:
– Acute appendicitis: periumbilical pain, low-grade fever, anorexia
with/without vomiting followed by movement of the pain into the
right lower quadrant McBurney’s point.
– Constipation: obstructive conditions, inflammatory disorders produce
ileus.
– Watery diarrhea: gastroenteritis,
– Bloody diarrhea: infectious colitis, inflammatory bowel disease,
mesenterial ischemia.
– Jaundice: hepatic and pancreaticobiliary disease, sepsis. Urinary
frequency, dysuria, hematuria, and suprapubic or flank pain : urologic
disease.
 DIAGNOSTIC IMAGING
• USG -> Liver, gallbladder, bile ducts, spleen,
pancreas, appendix, kidneys, ovaries, and
uterus. Also detect and charaterizes the
distribution of intra-abdominal fluid.
• Color doppler USG -> evaluation of intra-
abdominal adn retroperitoneal blood vessels.
• CT scan
• X-ray
 APPENDICITIS

Inflammation of the appendix

The appendix is a 3 to 6-cm long tube-like structure that projects from the junction of the
small and large intestines. No one knows what the function of the appendix is. However, once
the appendix becomes infected or inflamed, it must be removed.
 ETIOLOGY
• The primary pathogenic hallmark is obstruction of the lumen,
usually by fecalith (hardened stool typically formed around
vegetable fibers)
• Enlarge lymphoid follicles associated with viral infection (e.g
measles), worm (e.g ascaris, taenia, oxyuris), and tumors
(carcinoma or carcinoid) may also obstruct the lumen
• The other common is appendiceal ulceration
• The cause of the ulceration is unknown, but a viral origin
speculated. An infection by the yersinia enterocolitica is the
most recently speculated cause
• The increased intraluminal pressure may cause occlusion of
the appendicular end artery. When the condition is allowed
the progress, necrosis, gangrene, and perforation usually
result.
 RISK FACTORS
• Most cases of appendicitis occur between the
ages of 10 and 30 years.
• Having a family history of appendicitis may
increase a child's risk for the illness
• Having cystic fibrosis also seems to put a child
at higher risk.
 PATOPHYSIOLOGY
opening appendix 
cecum is blocked
peri-appendiceal
abscess
build-up of thick mucus Appendicitis
within the appendix or to
stool that enters the
appendix from the cecum infection spread
throughout the
abdomen
The mucus or stool
hardens, becomes
bacteria which normally are
rock-like (Fecalith), and
found within the appendix
blocks the opening
begin to invade (infect) the
wall of the appendix
the lymphatic tissue in
Rupture
the appendix may
swell and block the inflamation (respon of the
appendix body)
 SIGNS AND SYMPTOMS
• Aching pain that begins around your periumbilical and often shifts to your
lower right abdomen
• Pain that becomes sharper over several hours
• Tenderness that occurs when you apply pressure to your lower right
abdomen
• Sharp pain in your lower right abdomen that occurs when the area is
pressed on and then the pressure is quickly released (rebound
tenderness)
• Pain that worsens if you cough, walk or make other jarring movements
• Nausea
• Vomiting
• Loss of appetite
• Low-grade fever ( 37,2-37.8°C)
• Constipation
• Inability to pass gas
• Diarrhea
• Abdominal swelling
 PHYSICAL EXAMINATION
• Guarding : occurs when a person subconsciously tenses the abdominal
muscles during an examination
• Rebound tenderness
– by applying hand pressure to a patient’s abdomen and then letting go
– Pain felt upon the release of the pressure
• Rovsing’s sign
– by applying hand pressure to the lower left side of the abdomen
– Pain felt on the lower right side of the abdomen upon the release of
pressure on the left side
• Psoas sign
– The right psoas muscle runs over the pelvis near the appendix
– Pain felt if patient tries to lift the right thigh while lying down
• Obturator sign
– patient to lie down with the right leg bent at the knee
– Moving the bent knee left and right requires flexing the obturator
muscle and will cause abdominal pain if the appendix is inflamed
 Psoas
sign

Obturator
sign
 DIFFERENTIAL DIAGNOSES
• Meckel's diverticulitis.
– A Meckel's diverticulum :small outpouching of the small intestine which
usually is located in the right lower abdomen near the appendix
– The diverticulum may become inflamed or even perforate  surgically.
• Pelvic inflammatory disease.
– The right fallopian tube and ovary lie near the appendix
– Sexually active women may contract infectious diseases that involve the
tube and ovary.
– Usually, antibiotic therapy is sufficient treatment, and surgical removal of
the tube and ovary are not necessary.
• Inflammatory diseases of the right upper abdomen
– Fluids from the right upper abdomen may drain into the lower abdomen
where they stimulate inflammation and mimic appendicitis
– Such fluids come from a perforated duodenal ulcer, gallbladder disease,
or inflammatory diseases of the liver (liver abscess)
• Right-sided diverticulitis
– When a right-sided diverticulum ruptures it can provoke inflammation
they mimics appendicitis.
• Kidney diseases.
– The right kidney is close enough to the appendix that inflammatory
problems in the kidney-for example, an abscess-can mimic
appendicitis.
 LAB EXAMINATION
• CBC – WBC
– WBC count > 10,500 cells/mm3
– Neutrophilia greater than 75%
• CRP test 
• Urinalysis
• Abdominal x-ray
• CT scan of the abdomen:
– Very good test for diagnosing appendicitis
• Ultrasound of the abdomen
• MRI scan of the abdomen
– May be helpful in diagnosing acute appendicitis in the
pregnant female.
 • Clinical diagnostic scores
CHARACTERISTIC SCORE

M = Migration of pain to the

1
RLQ

A = Anorexia 1

N = Nausea and vomiting 1

T = Tenderness in RLQ 2

R = Rebound pain 1 SCORING :

• score of 3 or lower had a 3.6%
E = Elevated temperature 1
incidence of appendicitis
L = Leukocytosis 2 •scores of 4-6 had a 32%
S = Shift of WBC to the left 1
incidence of appendicitis
• scores of 7-10 had a 78%
Total 10 incidence of appendicitis.
 EMERGENCY DEPARTMENT CARE
• Treatment guidelines for patients with suspected acute appendicitis
– Patients with suspected appendicitis should not receive anything by mouth
– Administer parenteral analgesic and antiemetic as needed for patient comfort
– Consider ectopic pregnancy in women of childbearing age, and obtain a
qualitative beta–human chorionic gonadotropin (beta-hCG)
– Administer intravenous antibiotics to those with signs of septicemia and to
those who are to proceed to laparotomy
• Nonsurgical treatment of appendicitis
– Anecdotal reports describe the success of intravenous antibiotics in treating
acute appendicitis in patients without access to surgical intervention (eg,
submariners, individuals on ships at sea)
• Preoperative antibiotics
– decreasing postoperative wound infection rates
– Penicillin-allergic patients should avoid beta-lactamase type antibiotics and
cephalosporins (Carbapenems)
– Pregnant patients should receive pregnancy category A or B antibiotic
 TREATMENT
PHARMACOLOGY
• Antibiotik
– Metronidazole (flagyl)
– Gentamisin (Gentacidin, Garamycin)
– Cefotetan (Cefotan)
– Cefoxitin (Mefoxin)
– Meropenem (Merrem)
– Piperacillin dan tazobactam natrium (Zosyn)
– Ampicillin dan sulbactam (Unasyn)
• Analgesik
– Morfin sulfat (Astramorph, Duramorph, MS CONTIN, MSIR,
Oramorph)
APPENDICITIS TREATMENT: SURGERY
• Surgery to remove the appendix is called an
appendectomy
• The two types of appendectomy include:
– Open appendectomy:
• An incision is made in the right lower abdomen and the
appendix is removed through the incision.
– Laparoscopic appendectomy:
• A small incision is made in the umbilicus and the surgeon
uses a flexible fiberoptic scope to remove the appendix
through the small incision.
• The laparoscope cannot be used if the surgeon suspects
that the appendix has ruptured
 PROGNOSIS
• If your appendix is removed before it ruptures,
you will likely get well very soon after surgery.
If your appendix ruptures before surgery, you
will probably recover more slowly, and are
more likely to develop an abscess or other
complications.
APPENDICITIS
DURING
PREGNANCY
• As fetal gestation progresses,
making the diagnosis becomes
more difficult because the appendix
is pushed laterally and superiorly by
the expanding uterus.
• Researchers have shown that the
expanding uterus can progressively
displace the appendix into the
upper right quadrant by as much as
3 cm above McBurney's point (see
Figure 1)
• However, clinical studies have
shown that 84% of pregnant
women presenting with
appendicitis have pain in the right
lower quadrant, not the right upper
quadrant.
• As soon as acute appendicitis is suspected in a pregnant patient,
prompt surgical evaluation should be initiated.
• A delay in surgical intervention increases maternal and fetal
morbidity and mortality rates
• The rate of perforation uring pregnancy can be as high as 43%,
compared to 19% in the general population.
• The overall perforation rate appears to be highest in the third
trimester of pregnancy.
• Perforations in pregnancy often lead to serious complications,
including intraperitoneal infections and fetal death
• Laparoscopy is being performed on pregnant patients with
increasing frequency in many centers  In general, laparoscopy
is well tolerated by both mother and fetus during all three
trimesters of pregnancy.
 COMPLICATIONS DURING
PREGNANCY
• Gestational age  Complication rate
(Tracey and Fletcher,2000)

• Abortion , Fetal loss ~ 15% (1st trimester)

• Decreased birth weight
• Other surgical complication – wound infection, atelectasis etc.
INTESTINAL OBSTRUCTION
 DEFINITION
• Intestinal obstructions are a partial or
complete blockage of the small or large
intestine, resulting in failure of the contents of
the intestine to pass through the bowel
normally.
 ETIOLOGY
Mechanical obstructions Non-mechanical obstruction
• The bowel is physically • Called ileus or paralytic ileus,
blocked and its contents can occurs because peristalsis
stops.
not pass the point of the
• Peristalsis is the rhythmic
obstruction. contraction that moves
• This happens when the material through the bowel.
bowel twists on itself • Ileus is most often associated
(volvulus) or as the result of with an infection of the
peritoneum (the membrane
hernias, impacted feces, lining the abdomen). It is one
abnormal tissue growth, or of the major causes of bowel
the presence of foreign obstruction in infants and
bodies in the intestines. children.
 CAUSES OF INTESTINAL
OBSTRUCTION
Location Causes
Colon Tumors (usually in left colon), diverticulitis (usually
in sigmoid), volvulus of sigmoid or cecum, fecal
impaction, Hirschsprung's disease
Duodenum Cancer of the duodenum or head of pancreas, ulcer
(Adults) disease
Duodenum Atresia, volvulus, bands, annular pancreas
(Neonates)
Jejunum and ileum Hernias, adhesions (common), tumors, foreign body,
(Adults) Meckel's diverticulum, Crohn's disease (uncommon),
Ascaris infestation, midgut volvulus, intussusception
by tumor (rare)
Jejunum and Ileum Meconium ileus, volvulus of a malrotated gut,
(Neonates) atresia, intussusception
EXAMPLES OF CAUSES OF INTESTINAL
OBSTRUCTION

Obstruction due to Obstruction due to Obstruction due

adhesions mesenteric occlusion to hernia

Obstruction due to Obstruction due to Obstruction due to

intussusception tumor volvulus
PATOPHYSIOLOGY
 SYMPTOMS
Small bowel Large bowel
• Abdominal cramps centered around the
umbilicus or in the epigastrium,
• Increasing constipation leads to
• Vomiting obstipation and abdominal
• Obstipation (in patients with complete distention.
obstruction) • Vomiting may occur (usually
• Diarrhea (partial obstruction) several hours after onset of
• Severe, steady pain suggests that strangulation other symptoms) but is not
has occurred. In the absence of strangulation,
the abdomen is not tender common
• Hyperactive, high-pitched peristalsis with • Lower abdominal cramps
rushes coinciding with cramps is typical unproductive of feces occur
• Dilated loops of bowel are palpable sometimes.
• With infarction, the abdomen becomes tender
• No tenderness
• Auscultation reveals a silent abdomen or • The rectum is usually empty.
minimal peristalsis • A mass corresponding to the site
• Shock and oliguria (serious signs that indicate
either late simple obstruction or strangulation)
of an obstructing tumor may be
palpable.
 PHYSICAL EXAMINATION
• Hyperactive bowel to overcome the obstruction (early) 
Hypoactive bowel sounds
• Proper genitourinary and pelvic examinations are essential
• Look for the following during rectal examination:
– Gross or occult blood, which suggests late strangulation or
malignancy
– Masses, which suggest obturator hernia
• Check for symptoms commonly believed to be more
diagnostic of intestinal ischemia, including the following:
– Fever (temperature >100°F)
– Tachycardia (>100 beats/min)
– Peritoneal signs
 LAB EXAMINATIONS
• X-rays
• CT Scan
• MRI
• USG
• Sigmoidoscope
• CBC (Complete Blood Count)
• Electrolytes
• BUN (Blood Urea Nitrogen)
• Urinalysis
• Laboratory tests to exclude biliary or hepatic disease
– Phosphate level
– Creatine kinase level
– Liver panels
 TREATMENTS
• Non-Farmacologic :
– Nasogastric tube
– Rectal tube
– Intravenous fluids
– Repair the hernia to correct the obstruction
– Surgery  complete obstructions
• Farmacologic :
– Antibiotics : pre and post operation
 PROGNOSIS
• Most intestinal obstructions can be corrected with
prompt treatment and the affected child will recover
without complications.
• Untreated intestinal obstructions can be fatal,
however.
• The mortality rate for unsuccessfully treated infants
is 1–2 percent.
 COMPLICATIONS
• Dehydration  Kidney failure (severe
dehydration)
• Irregular heartbeat
• Shock
• Systemic infection from perforation of the
bowel
 PREVENTION
• Most cases of intestinal obstruction are not
preventable.
• Surgery to remove tumors or polyps in the
intestines helps prevent recurrences.
 CONCLUSION
• From the signs and symptoms, Mr. Bond
probably got an acute abdomen, appendicitis.
 SUGGESTION
• Mr. Bond must take the laboratory
examination.
• Mr. Bond suggest to eat a fiber foods, to avoid
a made of fecalith, that could be induce
appendicitis.
 REFERENCES
• Kumar V, Abbas A, Fausto N. Robbins and Cotran’s Pathologic Basis of
Disease. 7th ed. Philadelphia: Saunders, 2005
• Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors.
Harrison’s Principles Of Internal Medicine. 16th ed. New York: McGraw Hill,
2007
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