1. The document discusses the diagnosis and management of acute abdominal pain, outlining various potential causes and approaches. 2. It emphasizes the importance of the initial 20 seconds for determining if a patient is very ill, ill, or reasonably well to guide initial management and need for consultation. Very ill or ill patients require emergency treatment or surgery. 3. A case study is presented of a 67-year-old man with abdominal pain initially diagnosed with cholecystitis but who deteriorated with perforated appendicitis found at later laparotomy, highlighting how initial diagnoses can change.

1. Diagnosa dan Managemen
Nyeri Abdomen Acut
dr Djoko Judojoko Sp. B
PIT VI IDI KOTA BOGOR
November 2013

2. INTRODUKSI
• Dari 1000 kasus AAP
– Non Spesifik Abdominal Pain 34%
– Acut appendicitis 28%
– Obstruksi usus 4%
– Perforasi GI Tract 3%
– Pancreacitis 3%
– Difercucitis 2%
– Lain lain 13%

3. INTRODUKSI
• Nyeri Abdomen Acut 20-40%
pengunjung IGD
• 50-60% Inaccurate Initial Diagnosis

4. Abdominal Pain
• Viceral Pain
• Parietal Pain
• Referred Pain

5. Viceral Pain
– Distensi, Inflamasi, dan ischemia
– Localisasi
• Forgut – Epigastrium
• Midgut Umbilicus
• Hindgut Hipogastric

6. Parietal Pain
– Dinding Abdomen
– Sesuai Dermatome
Referred Pain

7. Generalized AP
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•
•
•
•
Perforation
AAA
Acute pancreatitis
DM
Bilateral pleurisy

8. Central AP
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•
•
•
•
•
Early appendicitis
SBO
Acute gastritis
Acute pancreatitis
Ruptured AAA
Mesenteric
thrombosis

9. Epigastric pain
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•
•
•
DU / GU
Oesophagitis
Acute pancreatitis
AAA

10. RUQ pain
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•
•
•
•
Gallbladder disease
DU
Acute pancreatitis
Pneumonia
Subphrenic abscess

11. LUQ pain
•
•
•
•
GU
Pneumonia
Acute pancreatitis
Spontaneous splenic
rupture
• Acute perinephritis
• Subphrenic abscess

12. Suprapubic pain
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•
•
•
•
•
Acute urinary retention
UTIs
Cystitis
PID
Ectopic pregnancy
Diverticulitis

13. RIF pain
•
•
•
•
•
•
•
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•
Acute appendicitis
Mesenteric adenitis (young)
Perf DU
Diverticulitis
PID
Salpingitis
Ureteric colic
Meckel’s diverticulum
Ectopic pregnancy
Crohn’s disease
Biliary colic (low-lying gall
bladder)

14. Loin pain
•
•
•
•
Muscle strain
UTIs
Renal stones
Pyelonephritis

15. LIF pain
•
•
•
•
•
•
•
Diverticulitis
Constipation
IBS
PID
Rectal Ca
UC
Ectopic pregnancy

16. Key Point Anamnesa
•
•
•
•
•
•
Site
Nature & character
Duration
Intensity
Precipitating & relieving factors
Associated symptoms

17. Riwayat Penyakit Lalu
•
•
•
•
•
•
Riwayat Abdominal pain
MCU
Operasi
Penyakit Cronis
Immuno supresif
Medication (NSAID)

18. Pemeriksaan Fisik
• Observasi sangat penting
• Observasi
– Bongkok ke depan: Chronic Pancreatitis
– Jaundiced: obstruksi CBD
– Dehidrasi:
• Peritonitis,
• Obstruksi Usus Halus

19. Pemeriksaan Fisik
• Pemeriksaan Fisik Abdomen
– Inspeksi
• Scapoid / Datar --- Ulcus Pepticum
• Despended :
– obstruksi Usus
– Acites
• Darm Countur dan Darm Steifung
– Obstruksi Usus

20. Pemeriksaan Fisik
• Palpasi
– Cek hernia
– Defance musculer
– Rebound Tedernes
– Nyeri tekan

21. • Nyeri Abdomen
– Local right illiac fossa
• Appendicitis acut
• Salpingitis acut
– Lowgrade poorly localiced
• Obstruksi usus
– Nyeri hebat seluruh perut
• Mesenteric ischemia
• Acut pancreatitis
– Nyeri pinggang / low backpain
• Peri nephric abcees
• Retrocaecal appendicitis

22. Pemeriksaan Fisik
• Auscultasi
– Bising usus / peristaltik
– Minimal dua menit untuk (negatif)
– Peristaltik meningkat – obstruksi
– Bruit di epigastrik - AAA

23. Pemeriksaan Fisik
• Colok Dubur
– Nyeri
– Indurasi
– Masa
– Darah dan lendir

24. Pemeriksaan Fisik
• Colok Vagina
– Darah
– Discharge
– Nyeri goyang portio
– Nyeri / masa abnesa
– Ukuran uterus

25. Manegemen Awal
Nyeri Abdomen Acut
• 20 detik pertama diagnosis hanya tiga
– Very ill (mengancam jiwa)
– ill (perlu tindakan segera)
– Reasonably well (elektif)

26. • Very ill
– Mengancam jiwa / going to die
– Cari bantuan
• Perawat resusitasi
• Sesama dokter jaga
• Senior Konsultan diberi tahu

27. • ill (perlu tindakan segera)
– Stabil dalam beberapa jam
– Investigasi segera (urgent)
– Initial diagnosis
– Initial management

28. Reasonably well (elektif)
– Investigasi seperlunya
– Formulat diagnosis
– Terapi simtomatik
– Rujuk poli spesialis elektif

29. Initial Management
ABCDE
Resusitasi dan analgetik (Opioid iv)
Full monitoring (urin output)
Minta bantuan senior (cito)

30. Initial Lab Investigasi
-
Darah rutin
Amylase (pancreatitis)
Ureum, creatinim dan lft
BLT, CLT, PT, APTT
(Acut pancreatitis, sepsis, DIC)
-
GDS
AGD
ECG
Cardiag enzim
Urinalisa (Murah dan simple)
Tes kehamilan

31. CT Scaning
- No significant advantage in DD of AAP
- Delay of necessary treatment
- Routing use not justified
Fast
(Fucus assesment with sonografy for trauma)
- Nilai diagnostik untuk trauma tinggi

32. Laparoscopy Diagnostik
- Early diagnostik laparoskopi may result non
spesifik abdominal pain
- Acurat
- Prompt
- Efficient management of AAP
- Reduces the rate of unnesessary laparatomi
- Increases the diagnosis accuracy
- May be a key to soving the diagnostik dilema of
NSAP

33. Suggesions
- Hal penting untuk dinilai dari AAP
-
Initial diagnostic
Pilihan pemeriksaan pembantu yang tepat
Initial treatment yang tepat
Persingkat length of stay
Cost effectiveness

34. Studi Kasus
Identitas Kasus :
- Laki-laki
- Umur 67 tahun
Tanggal
Klinis
16 Okt 2013
S : Ulu hati nyeri
O : Nyeri tekan ulu hati
B U (+)
A : W.D. / Dispepsi
Kolik Abdomen
P : Alganax
Rebamid
Trolac
Fastro
Jolocid
1x1
3x1
3x1
2x1
1x1
Laboratorium
Lekosit 14000
Radiologi

35. Tanggal
17 Okt 2013
Klinis
Laboratorium
Radiologi
S : Mengeluh sakit sekali
USG :
O : T = 110 / 70
N = 80 S = 36
RR = 20
- Hepar normal
- KE dinding
menebal sedikit
- SLUDGE
- Kesan
cholecystitis
A : W.D. / Dispepsi
Kolik Abdomen
P : Teruskan
18 Okt 2013
S : Sakit + + +
O : USG cholecystitis
dengan sludge
A : Dispepsi Kolik
Abdomen ec
cholecystitis
P : Urdafalk 3 x 1
MST 10 2 x1
HB = 11,2
HT = 34
L = 12000

36. Tanggal
19 Okt 2013
Klinis
Laboratorium
S : Sakit perut +++
Demam +, Batuk
Thoraxfoto :
- Cor normal
- CTR 55%
- Pulmo effusi
pleura kiri
- Sudut
costophrenicus
tumpul
O:
- Nyeri tekan ulu hati
- C/P dalam batas
normal
A:
Dispepsi Kolik Abdomen
ec cholecystitis
P : Terapi lanjutkan
20 Okt 2013
S : status quo ante
Radiologi
- Natrium 133
- Calium 4.0
- CL 107

37. Tanggal
21 Okt 2013
Klinis
S:
- Ku Lemah
- Diare +
O:
- Ku lemah Cm
- T = 120 / 70, N = 84,
S = 36, RR = 20
-C/P tak
- Abdomen nyeri tekan +
- Akral hangat
A:
- Dispepsi Kolik
Abdomen ec
Cholecystitis
- GEA
P:
- Lodia
- Terapi lain teruskan
Laboratorium
- Lekosit 8900
- LED 82
Radiologi

38. Tanggal
22 Okt 2013
Klinis
S:
-Demam naik turun
(catatan perawat)
- BAB cair
- Kedua kaki bengkak
O:
- Ku Lemah
- T = 110 / 70, N = 88,
S = 36, RR = 20
A:
-Dispepsi Kolik
Abdomen ec
cholecystitis
- GEA
P:
- Cek Elektrolit
- Cek Albumin
- Lain2 teruskan
Laboratorium
- Albumin 2.2
- N a = 130
Radiologi

39. Tanggal
23 Okt 2013
Jam 18:15
Klinis
S:
- Perut Kembung
- Nyeri seluruh perut
- Demam (+)
O:
- Ku Lemah Cm
- T = 130 / 70, N = 88
S = 38,3, RR = 20
- C/P tak
- Abdomen kembung
(destended)
- Defance musc (+)
- Hepar/Lien sulit diraba
- Edman (–)
A:
- suspect ileus paralitik
- DD obstruksi
- Dispepsi Kolik
Abdomen ec cholecystitis
dengan SLUDGE
Laboratorium
Jam 19:10
- HB = 11
- L = 19800
- NA = 130
Radiologi
Abdomen 3
posisi, hasil
adalah :
- Preperitonial fat
menebal
- Air fluid level (+)
- Free air (-)

40. Tanggal
23 Okt 2013
Jam 18:15
Klinis
A:
- GEA
- Hipo Albumin
P:
- Konsul SPB
- Puasa
- NGT dekompresi
- Abdomen 3 posisi
- Albuminar 100 25%
- DPL
- Elektrolit ulang
Laboratorium
Radiologi

41. Tanggal
23 Okt 2013
Jam 20:43
Klinis
Laboratorium
Radiologi
S : Sakit seluruh perut
Jam 23:32
Usg :
O:
- Keadaan umum
kesakitan
- T = 110 / 70, N = 88
S = 36, RR = 20
-C/P tak
- HB = 10,5
- HT = 31
- L = 20800
- T = 421
- Cholelithiasis
- Abdomen 3
posisi
- Air fluid level (+)
- Preperitoneal fat
menebal
- Kesan peritonitis
umum
Abdomen
- Destended
- Peritonitis (+)
- Bu (-)
- Nyeri tekan (+)
- Nyeri lepas (+)
- Defance Musc (+)
A:
- Peritonitis umum
- APP perforasi
- Cholecystitis ruptur

42. Tanggal
23 Okt 2013
Jam 20:43
Klinis
P:
- Infus teruskan
- Puasa
- NGT kateter tampung
ukur
- Anjuran ekplorasi
- Laparatomi cito
-Terapi tambah
- Trichodasol 1 x 1,5 gr
Laboratorium
Radiologi

43. O.S. dilakukan Laparotomi
3 hari kemudian
karena masih pikir-pikir

44. Hasil Laparotomi ?

45. Take home messages :
1. Initial diagnosis :
- Very ill (mengancam jiwa)
- ill (perlu tindakan segera)
- Reasonably well (elektif)
2. Very ill dan ill -> konsul Spb
Reasonably well -> konsul poliklinik bedah
3. DD
- Infeksi intra abdomen
- Obstruksi GI tract
- Bleeding intra abdomen
- Ischemia organ intra abdomen

46. Thank You