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radiographic founding on pneumoperitoneum
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See pneumoperitoneum
- 1. Pneumoperitoneum By : Rafi Mahandaru / 2013
- 2. By : Rafi Mahandaru / 212 Pneumoperitoneum
- 3. Background Pneumoperitoneum is a common medical problem in a recent year As the surgical treatment increase Usually unnoticed by practitioner due to insidious symptom Severe case can lead to unwanted complication Diagnosis can be done by GP Once diagnostic proof, severe case confirm immediate treatment should achieved by the patient
- 5. Physiological Aspects Intra Abdominal Pressure (5-7mmHg) (BMI, Position, Diseases) Abdominal Perfusion Pressure (0-7mmHg APP = MAP - IAP
- 6. Etiology Ruptur viskus berongga (yaitu perforasi ulkus peptikum, necrotizing enterocolitis, megakolon toksik, penyakit usus inflamasi) Faktor iatrogenik (yaitu pembedahan perut terakhir, trauma abdomen, perforasi endoskopi, dialisis peritoneal, paracentesis) Infeksi rongga peritoneum dengan organisme membentuk gas dan atau pecahnya abses yang berdekatan
- 7. Etiology Perforated viscus organ ( 41% ) Residual Air (37 %) Peptic ulcer (16%) Diverticulitis (16%) Trauma (14%)
- 8. Non surgical Retained post operative air (25 – 60 %) Peritoneal dialysis and catheter placement (0,3 – 25 %)
- 9. Another Source Pneumoperitonium Dengan Peritonitis Perforated viskus Necrotizing enterocolitis Infark usus Cedera perut Tanpa peritonitis Thorax Abdomen pelvis
- 10. DP ABDOMEN
- 11. THORAX
- 12. ABDOMEN
- 13. PELVIS
- 14. CLINICAL SIGN Perforation : - Intense abdominal pain - Abdominal fullness - Shoulder pain - Acute distress dsypnea - Abdominal tension - Tenderness - Tympanic and rigid - Rectal Prolapse ??? - Crepitus - Hypovolemic Shock immediate
- 15. Depen on the Causes and size : Benign may be asymptomatic Vague abdominal pain Viscus organ rupture : Peritonitis sign Onset Depend on organ Immediate laparotomy
- 17. PATOGENESIS •CO2 absorbed •Hypercapnea •Pulmonary vasoconstriction •ANS tachycardia •Depressive effect on miocardium •Cardiac index decrease 30% during 30 minutes initiation of pneumoperitoneum •Decrease cardiac output (CO) hemodynamic disturbances Decrease urine output Increase Aldosteron Decrease Creatinin clearance Elevated liver enzym Decrease portal Venous flow
- 18. DIAGNOSIS Purpose Entrapment of free air in the peritoneal cavity is the key Holistic history taking and Physical Examination the most important Already mentioned above !!! Radiological Confirming Thorax X-Ray erect Best Right or Left Lateral Decubitus is allright ! USG, CT and MRI
- 19. X- Ray Semilunar Shadow gambaran udara (radiolusen) berupa daerah berbentuk bulan sabit (Semilunar Shadow) diantara diafragma kanan dan hepar atau diafragma kiri dan
- 20. Decubitus Abdomen Sign Terdapat udara bebas diantara dinding abdomen dengan hepar (panah putih). Ada cairan bebas di rongga peritoneum (panah hitam).
- 21. Anterior Subhepatic Space Free Air Linear Shape Triangular Shape Geograpichal Sign Density difference defining
- 22. Doges Cap Sign Morison Pouch Hepato-Renal Recesses
- 23. Anterior View of Hepatic Surface
- 24. Foot Ball Sign >1000 ml air collected abdominal decompression Here Comes the MASSIVE ones
- 25. Gas-Relief Sign, Rigler Sign or Double Wall Sign memvisualisasikan dinding terluar lingkaran usus disebabkan udara di luar lingkaran usus dan udara normal intralumen
- 26. Urachus Sign udara tampak melapisi urachus. Urachus tampak seperti garis tipis linier di tengah bagian bawah abdomen yang berjalan dari kubah vesika urinaria ke arah kepala. Dasar urachus tampak sedikit lebih tebal daripada apeks.
- 27. Telltale Triangle Sign menggambarkan daerah segitiga udara diantara 2 lingkaran usus dengan dinding abdomen
- 28. Try To Guess ??? Rigler’s Sign Foot Ball sign Foot ball sign Falciform ligament’s sign
- 29. CT - Scan Standard Radiological examination Not necessarily needed Benefit : Detect, intraluminal free air Not depend on position and technique What X-Ray can’t shows and if it not specific Disadvantage : High cost Can’t locate perforation Beside the intraluminal fluid is not specific for pneumoperitoneum
- 30. Differential Chilaiditi’s syndrome (interposition hepatodiapragmatica, subphrenic displacement of the colon, pseudopneumoperitoneum) Basal Lung Atelectasis (colapsed alveoli – linear form, pneumonia, COPD, TBC ) Subphrenic abcess (acute pancreatitis, peritonitis) Peritonitis
- 31. Management When ur patient has proven for pneumoperitoneum - - Find the Underlying Causes Unstable means Delay Stabilize A , B , C Management Abdominal decompression Stable Confirm
- 32. Diagnostic confirm immediate < 20 % can be managed by non- surgical approach In patients with small amount of intraperitoneal air Without sign of peritonitis Patients should receive • intravenous fluid •Absolute bowel rest •Intravenous broad spestrum antibiotic •Get better on two days > 50%
- 33. Symptomatic patient with proof of peritonitis Laparotomy (standard surgical management)
- 34. Conclusion Pneumoperitoneum akumulasi udara pada rongga peritonel Penyebab terbanyak adalah ruptur Hollow Viscus Abdominal Organ karena berbagai sebab Diagnosis dapat dibuat dengan anamnesis dan pemeriksaan fisik yang teliti Diagnosis radiologi (X-ray, CT-scan, USG, MRI) sebagai konfirmasi sangat penting dalam mendiagnosis Penanganan yang cermat dan tepat waktu meliputi stabilisasi hemodinamik dan penemuan penyakit terkait sangat penting untuk mengurangi mortalitas dan morbiditas pasien
- 35. Refferences ME ,Breen, Dorfman M, Chan SB. 2008. Pneumoperitoneum Without Peritonitis: A Case Report.Am J Emerg Med, 26:841. e1-2 Churchill , James D Begg . 2006. Abdominal X-rays Made Easy 2nd Edition. Elsevier Khan, Ali Nawaz. 2011. Pneumoperitoneum Imaging : A Journal Diunduh dari http://emedicine.medscape.com, pada 8 Oktober 2012 Daly, Barry D, J. Ashley Guthrie and Neville F. Cause of Pneumoperitoneum: A Case Report. United Kingdom Mansjoer , Arif,dkk. 2000.Bedah Digestif. Kapita Selekta Kedokteran Jilid 2 Edisi Ketiga (pp 240-252). Jakarta: Balai Penerbit FKUI. Dan L. Longo, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, J. Larry Jameson, Joseph Loscalzo, Eds. 2008. Harrison’s Principle of Internal Medicine 17th Edition. USA : The McGraw-Hill Companies. CH, Lee. 2010. Imaging Pneumoperitoneum : A Journal Diunduh dari http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/pneumoperitone um.htm pada 8 Oktober 2012 Weerakkody , Yuranga dan Jeremy Jones.Pneumoperitoneum. Diunduh dari http://radiopaedia.org/articles/pneumoperitoneum pada 8 Oktober 2012 Silberberg , Phillip. 2006. Pneumoperitoneum. Kentucky, USA. Derveaux ,K., F Penninckx. 2007. Crash Courses of Pneumoperitoneum. University Leuven Belgia
- 36. Thanx..,
Editor's Notes
- Intra-abdominal pressure (IAP) is defined as the steady-state pressure contained within the abdominal cavity (1). The normal value of IAP ranges from 0 mmHg to 7 mmHg and depends on both the elasticity of the abdominal wall and abdominal capacity. Several pathologies result in IAP increases, including abdominal trauma with intra- or extra-peritoneal bleeding, ascites, intra-abdominal tumours, intestinal injury, ileus, pancreatitis and surgical ‘packing’. Moreover, increases in IAP may be observed after massive fluid resuscitation, poly-transfusion, hypothermia and severe coagulation disorders. IAP values higher than 12 mmHg represent intra-abdominal hypertension (IAH), and a significant IAP elevation reduces the microcirculatory blood flow in most organs of the abdominal cavity. The abdominal blood flow pressure is known as the abdominal perfusion pressure (APP) and can be calculated as the difference between mean arterial pressure (MAP) and IAP (ie, APP = MAP – IAP) (1,2). Therefore, the changes in APP are strongly dependent on changes in MAP and IAPMAP2D + S / 3
- Chilaiditi syndromeinterposition of the bowel (usually hepatic flexure of the colon/transverse colon) between the liver and the (right) hemidiaphragm.Subphrenic abscessSubphrenic abscesses are localised collections of pus, usually underneath the right or left hemi- diaphragm.There is a accumulation of infected fluid between the diaphragm, the liver and the spleen.linear atelectasis at the base of the lungsAtelectasis is the collapse of part or closure of alveoli resulting in reduced or absent gas exchange.Linear atelectasis is collapsed areas of the lung that have a horizontal appearance.When linear atelectasis at the base of the lungs it mimics pneumoperitoneum in chest x ray.