DR. BAMBANG RISHARDANA, SP.

B FINACS
RSU KARSA HUSADA BATU
RS HASTA BRATA BAYANGKARA BATU
RS KHUSUS BEDAH HASTA HUSADA KEPANJEN
DOSEN FK UIN MALANG
DOSEN PEMBIMBING KLINIK BEDAH FK UNIV. MUHAMA
MALANG

PENDIDIKAN :
S1 FAKULTAS KEDOKTERAN UNIV. BRAWIJAYA MALANG
PROGRAM SPESIALIS BEDAH UNIV. BRAWIJAYA MALANG
PROGRAM FINACS PABI JAKARTA

PENGALAMAN KERJA DAN ORGANISASI :

DOKTER PUSKESMAS JUNREJO
DOKTER PERUSAHAAN JAMSOSTEK
KETUA AKREDITASI RSU KARSA HUSADA BATU
KOORDINATOR PELAYANAN MEDIS RSU KARSA HUSADA
KETUA KOMITE REKAM MEDIS RSU KARSA HUSADA BAT
KETUA KORDINATOR PENDIDIKAN KARSA HUSADA BAT
KETUA KOMITE PENELITIAN ETIK KESEHATAN KARSA H
BATU
dr. Bambang Rishardana SpB, FINACS
SOURCES

 Sarah L. Cartwright, MD and Mark P. Knudson, MD, MSPH,

Evaluation of Acute Abdominal Pain in Adults, Wake Forest University
School of Medicine, Winston-Salem, North Carolina
 Differential Diagnosis of Acute Abdominal Pain by Dr.Christopher
Mansbridge at www.OSCEstop.com 2015 acessed February 03, 2018
 Abdominal Pain Assesment and Diagnosis Powerpoint Presentation By
Lawrence R. Kosinski, MD, MBA, AGAF Managing Partner Illinois
Gastroenterology Group 745 Fletcher Drive Elgin, Illinois 60123
ACUTE ABDOMINAL PAIN
 Abdomen akut /acute abdominal /gawat perut adalah suatu keadaan
klinis akibat kegawatan di rongga perut, timbul mendadak, dengan nyeri
sebagai keluhan utama.Keadaan ini memerlukan penanggulangan segera

 Banyak penyakit menimbulkan gejala nyeri , namun belum

membutuhkan tindakan pembedahan. Hal ini memerlukan evaluasi
dengan metode dan pemeriksaan yang sangat berhati-hati

 Keterlambatan tindakan akan meningkatkan morbiditas dan mortalitas

 Sebagian besar dapat didiagnosis secara klinik tanpa mempergunakan
alat-alat canggih
MORBIDITAS DAN MORTALITAS
NYERI ABDOMEN AKUT

Obstruksi usus Gangguan keseimbangan cairan

Perforasi Saluran Cerna Peritonitis

Infeksi Sepsis Shock septik

Perdarahan Shock hipovolemik

Iskemi Perforasi Peritonitis

CONTOH KASUS
 Pria 40 tahun, nyeri perut kanan bawah, diberi analgetik spasmolitik,
keluhan berkurang
 Hari ke 4 nyeri hebat, panas badan tinggi, tanda-tanda peritonitis
 Menjalani operasi laparotomi appendektomi dengan tanda-tanda abses
appendiks
 Pasca bedah terjadi sepsis yang tidak berrespon dengan antibiotika dan
perawatan intensif
 Penderita meninggal setelah 20 hari perawatan di ICU
 Para dokter sering mempergunakan
obat-obatan yg tidak diketahui cara bekerjanya,
untuk penyakit yg tidak diketahuinya, dan ditujukan kepada pasien yg
sama sekali tidak dikenalnya
ABDOMINAL PAIN
Type of pain
Visceral
Stimuli
Parietal
Stretch
Reffered
Inflmation
Shifting
ischemia History S O KC RA TES
Side
Onsset
Kuality
Chronology
Aggravating Factors
Associated Symptoms
POSSIBLE DIAGNOSE
BASED
ON
LOCATION ?
Right Upper quadrant Epigastric Left Upper Quadrant
Cholecystitis, Cholelithiasis, Cholecystitis, cholelithiasis, Angina, Myocardial infarction,
Cholangitis cholangitis pericarditis
Colitis, Diverticulitis Myocardial infarction, pericarditis Esophagitis, gastritis, peptic ulcer
Liver Abcess, Hepatitis, liver mass
Esophagitis, gastritis, peptic ulcer Pancreatitis, pancreas mass
Pneumonia,
Pancreatitis, pancreas mass Nephrolithiasis, pyelonephritis
Nephrolithiasis, Pyelonephritis

Periumbilical
Early appendicitis
esophagitis, gastritis, peptic ulcer
small bowel mass or obstruction

Right Lower quadrant Suprapubic Left Lower Quadrant

Appendicitis, colitis, diverticulitis, Appendicitis, colitis, diverticulitis,
colitis, diverticulitis, IBD
IBD IBD
Ectopic Pegnancy, Ovarian mass, Ectopic Pegnancy, Fibroids, Ovarian Ectopic Pegnancy, Fibroids,
Torsion, PID mass, Torsion, PID Ovarian mass, Torsion, PID
Nephrolithiasis, Pyelonephritis Cystitis, Nephrolithiasis, Nephrolithiasis, Pyelonephritis
Pyelonephritis
ABDOMINAL PHYSICAL EXAM
1. Inspection
2. Auscultation
3. Palpation
4. Percussion
INSPECTION
 Distension
 Scars
 Venous Pattern
 Contour
 Jaundice
 Wound
ABDOMINAL DISTENSION

Think of the 6Fs

Fat
Fluid - Ascites
Flatus
Fetus - Pregnancy
Feces - Obstipation
Fatal Growths - Tumors
AUSCULTATION
 Bowel Sounds
 ƒ Normal
 ƒ Hyperactive: Obstruction or Colitis
 ƒ Hypoactive: Ileus
 ƒ Absent: Acute Abdomen
PALPATION
Light Palpation
 ƒBuild Confidence
 ƒStart away from the pain
 ƒTenderness
 Direct Tenderness
 Rebound Tenderness

Deep Palpation
 ƒ Organ Size
 ƒ Masses
PERCUSSION
 Organ size Density
 Types of Sounds
 ƒ Tympani to Dullness
 Ascites
LABORATORY EVALUATION
 CBC (Complete Blood Count)
 ƒ Anemia, leukocytosis, thrombocytopenia
 CMP ( Compehensive Metabolic Panel)
 Renal Function, Hepato bilier Function
 Amylase/Lipase
 Urinalysis
 Pregnancy Test
IMAGING
ULTRASOUND
Indications
 ƒ Evaluation of the Biliary Tree, Liver, Pancreas
 ƒ Pelvic Organs
Benefits
 ƒ Noninvasive
 ƒ No Radiation dose
 ƒ Patient Tolerance
Limitations
 ƒ Poor visualization of hollow GI organs
 ƒ Limited visualization in obese or distended patients
PLAIN X‐RAYS
Utility
 ƒ Gas Patterns
 ƒ Calcifications
Benefits
 ƒ Inexpensive
 ƒ Easy to do
 ƒ Noninvasive
Limitations
 ƒ Limited Detail of hollow organs
CT SCANNING

Indications
 ƒ Evaluation of Solid organs, ie: Liver, Pancreas,
 Requires IV Contrast
 ƒ Bowel Wall Evaluation
 Requires Oral Contrast
Benefits
 ƒ Easy to do
 ƒ Good Patient Compliance
Limitations
 ƒ Hollow organs not visualized in detail
 ƒ Immobile (Cannot be done at bedside)
ACUTE ABDOMINAL PAIN
GASTRITIS / PEPTIC ULCER
 Classical History
 Epigastric pain
 Related to meals (Peptic ulcer = during meals, duodenal ulcer = before meals /at
night)
 Risk factor e.g. Alcohol, NSAID, spicy food.
 Classic Examination Findings
 Tender epigastrium
 Soft abdomen
 Investigation Findings
 May be myocitiuc anemia
 Xray : exclude perforation
 Endoscopic : define cause and treatment
 Definitive Management
 PPI
 Antibiotic for Helicobacter pylori
 APPENDICITIS
 Classical History
 young patient
 periumbilical pain initially
 moves to RLQ
 Nausea, vomiting
 diarea
 Classic Examination Findings
 Tender RLQ
 Worse at McBurney's point
 Guarding/local peritonitis
 Rovsing's sign +, Psoas SIGN
 RT +
 Investigation Findings
 USG abdomen/pelvic if gynae diffeentials
 Definitive Management
 Appendicectomy
 PERITONITIS
 Classical History
 Severe generalized abdominal pain
 Classic Examination Findings
 Percussion tenderness
 Shock
 No Abdominal movement with respiration
 Rebound Tenderness
 Severe pain to light palpation
 RT Pain All Area
 Bowel Sound Absense
 Investigation Findings
 Errect X-ray : Air Under diaphragm
 CT scan : reveal cause
 Definitive Management
 Cito or Urgent Laparotomy & repair
 Organ
Pecah

Isi Organ
Material : Darah
• Feces
• Cairan lambung
• Pus

Abdomen
Akut

Iskemi Regangan
Strangulasi

Torsi
DERAJAT IRITASI PERITONEUM

 Oleh cairan yg berada abnormal dlm rongga peritoneum

Cairan Lambung
Isi Usus Halus
Crn Pankreas
Empedu

Nanah
Darah

Urine

Iritasi Ringan Berat

PYELONEPHRITIS
 Classical History
 Fever, chills, rigor
 Loin pain
 Urinay frequency and dysuria
 Classic Examination Findings
 Loin tenderness
 Renal angle tenderness
 Investigation Findings
 Leucocyt and nitrites at urine dip + culture
 Definitive Management
 Antibiotics e.g. Cipro or cephalosporin
GALLSTONES
 Investigation Findings
Diffeential Diagnose
 CT scan
Biliary colic (Cholelitiasis)
 abdominal USG
 Intermittent RUQ pain
 Exacerbated by fatty food
Cholecystitis
 Continous RUQ pain
 Definitive Management
 Murphy's sign +
CBD Stones (Choledocolitiasis) Billiary colic
analgesia
 Jaundice
OPT Cholecystectomy
 RUQ pain
Cholecystitis
Cholangitis
Antibiotics (cipro/cephalosporin)
 Jaundice Cholecystectomy
 Fever/rigors Trias Charcot CBD Stone
 RUQ pain Explore CBD
Cholangitis
 Syok (hipotesion) Reynolds IV antibiotics (cipro/tazocin)
 Confusion Pentats Treat cause
RENAL COLIC
 Classical History
 Spasm of loin to groin pain
 Nausea and vomiting
 Classic Examination Findings  Definitive Management
 Soft abdomen  Diclofenac analgesia
 May be renal angle tenderness  Smooth muscle relaxant (nifedipine/
 Investigation Findings tamsulosin)
 Antibiotics
 Microscopic Hematuria

Pelvic stone
KUB X-Ray
 <2 cm ESWL
 CT KUB
 >2 cm PCNL
Ureteric stone
 <5 mm conservative
 < 1cm ESWL
 > 1 cm Uteroscopy
 BOWEL OBSTRUCTION
 Classical History
 Vomiting
 Colic abdominal pain
 No bowel motion no flatus
 Evalution of iguinal
 Classic Examination Findings
 Distended, tender abdomen
 Tinkling bowel soun
 Investigation Findings
 Abd. X-Ray : Distended bowel loops
 CT abdomen : confirm & determine cause
 Definitive Management
 IV fluids
 NG tube + Cathetre
 Laparotomy
PICTURE
ECTOPIC PREGNANCY
 Classical History
 Severe unilateral pelvic pain
 May have spotting
 Shoilder tip pain
 Miss period of contraception
 Classic Examination Findings
 Tenderness RLQ/LLQ
 VT
 Anemia
 Investigation Findings
 Urine HCG +
 Serum HCG + trends
 Transvaginal USG
 Definitive Management
 Laparotomy
OVARIAN CYST
 Classical History
 Sudden unilateral pelvic pain
 May be light vaginal bleeding
 May be fever / vomiting
 Classic Examination Findings
 Tenderness RLQ/LLQ
 VT
 Adnexal tenderness + Mass
 Investigation Findings
 Transvaginal/Abdomen USG
 Definitive Management
 Laparoscopy or Laparotomy
PELVIC INFLAMATORY DISEASE (PID)
 Classical History
 Bilateral pelvic pain (gradual onset)
 Vaginal discharge
 Dyspareunia or dysminorrhoea
 May be post coital or intermenstrual bleeding
 Classic Examination Findings
 Suprapubic tenderness
 Vaginal discharge
 Cervitis
 Bilateral adnexal; tenderness
 Cervical excitation
 May be fever
 Investigation Findings
 Raised inflamatory markers
 Triple vaginal swabs
 Definitive Management
 Broad spectrum antibiotics
TERAPI UMUM SECARA SIMPEL SEBELUM INTERVENSI
BEDAH

 1. Diberikan cairan IV RL
 2. Puasa kan sampai dignosis karena masalah bedah disingkirkan
 3. NGT dan Kateter jika dicurigai adanya obstruksi, illeus, atau
perdarahan saluran cerna atas
 4. Jika ada kecurigaan infeksi, sepsis, perforasi dapat diberikan
antibiotik spektrum luas
 5. Resusitasi dan tranfusi jika anda curiga internal bleeding dgn
hemodinamik tdk stabil jika anda mempunyai stok darah
MATURNUWUN