Clinical Practice Guideline of

Acute Abdomen

Bambang Supriyo, dr. DTM&H, Sp.B,

FICS.FINACS
 Curriculum Vitae
Nama : dr. Bambang Supriyo, DTM&H, Sp.B, FICS.FINACS

TTL : Purworejo, 12 Agustus 1954

Alamat : Jl. Dr. Soetomo No. 30 Rt/Rw. 01/06 Kec. Slawi Kab. Tegal

Email : bambangsupriyo.54@gmail.com

HP : 087832010203

BACKGROUND PENDIDIKAN :
-Dokter umum (UGM 1982)

-DTM&H (Mahidoll University Bangkok 1985)

-Dokter spesialis bedah (UNDIP 1994)

RIWAYAT PENUGASAN / ORGANISASI :

-Kont. Garuda VIII Mesir – Israel / UNEF / PBB

-Ketua IDI Cabang Kabupaten Tegal

-Direktur RSUD dr. Soeselo Slawi

Yang Masih Diampuh Saat Ini :

-Ketua PESTI Provinsi Jawa Tengah

-Ketua KONI Kabupaten Tegal

-WANTIMCAB Veteran Republik Indonesia Kota/Kabupaten Tegal

-Ketua PABI Cabang LANGBERGAS

-DIRUT PT. Syafira Mulya Medika

-Dokter Bedah RS Hawari Essa

 ASPEK KLINIS
AKUT ABDOMEN

“The general rule can be laid down that the majority of

severe abdominal pains which ensue in patients who have
been previously fairy well, and which last as long as six
hours, are caused by conditions of surgical import.”
(Zachary Cope, 1881–1974)
 Contoh
kasus

Pasien laki laki 65 th dg nyeri perut seluruh lapang perut,

tidak bisa BAB dan tidak bisa kentut, GCS 15, T 120/70,
Nadi 90 x/menit
RR 20 x/mnt, suhu 37, saturasi O2 98%

Apa diagnosis pasien ini ?

 PENDAHULUA
N
• Kemajuan teknologi imaging
• Black box
• Anamnesis dan pemeriksaan fisik yang teliti
• 2 pertanyaan kritis : apa diagnosis dan
apakah perlu laparotomi emergensi ?

Assesment of acute abdominal symptoms,

Norton surgery, basic science and clinical evidence 2008
 Definisi
• Keadaan klinis akibat kegawatan di rongga
perut yang biasanya timbul mendadak dengan
nyeri sebagai keluhan utama. Sebagian
memerlukan terapi pembedahan.

• Abdomen akut berkisar antara 5 – 10 % dari

semua kasus emergency dari 5 – 10.000
pasien di United States. Penelitian lain
mendapatkan sekitar 25 %.
 Penyebab akut abdomen

The Problem
Most major textbooks contain a long list of possible causes for acute abdominal pain, often
enumerating 20–30 “most common” etiologies.
 Trik dan
tips
• Clinical pattern: • Therapy options:
1. abdominal pain with 1. surgery now
shock 2. surgery tomorrow
2. generalized peritonitis morning
3. localized peritonitis 3. conservative
4. bowel obstruction 4. discharge home
5. medical illness

Schein's Common Sense Emergency Abdominal Surgery 2nd Edition

“ Often the most difficult surgical
decision is when not to operate “
 1. Abdominal pain with shock
• Abdominal apoplexy: pale, diaphoretic, severe
abdominal pain, hipotensi

• Contoh : ruptur aneurisma aorta, Kehamilan

ektopik terganggu (KET)
• Mirip : severe acute pancreatitis, acute
mesenteric ischemic
 2. Generalized peritonitis
• Diffuse abdominal pain (sick &
toxic)
• Lies motionless
• Peritoneal sign (tenderness,
rebound tenderness, defans
musculer)
• Contoh : ulkus pepticum
perforasi, apendisitis perforasi,
colon perforasi
Apendisitis perforasi
 3. Localized peritonitis
• Apendisitis akut
• Kolesistitis akut
• Divertikulitis colon sigmoid
Apendisitis akut
 4. Bowel obstruction
• Small bowel obstruction
• Large bowel obstruction

• Contoh : Hernia incarserata, tumor

kolorektal, gallstone ileus, adhesion
intestinal
Bowel obstruction ec. adhesi
Bowel obstruction
Large bowel obstruction
 5. Medical illness
• Inferior acute myocard infark
• Diabetic ketoasidosis
• Basal pneumonia
• HIV (mimic an acute abdomen )
Diagnosis
AKUT ABDOMEN
 Assesment of acute abdominal

• Anamnesis dan pemeriksaan fisik yang teliti

• Imaging dan pemeriksaan penunjang

• 2 pertanyaan kritis : apa diagnosis dan apakah

perlu laparotomi emergensi ?

Norton surgery, basic science and clinical evidence 2008

 Principles of history-taking

• Identify the reason for consultation

• Identify the duration and evolution of the
problem
• Recognise the most likely organ or system
affected
• Recall the relevant leading questions
• Select the most likely pathology from a list of
differential diagnoses
Bailey & love, short practice of surgery,26th ed, 2012
 Classic presentations of abdominal pathology

• Obstructive and inflammatory pathology must be excluded in

patients with abdominal pain and altered bowel habit
• Closed-loop obstruction with tenderness in the right iliac fossa is
indicative of imminent caecal rupture
• Caecal cancer classically presents with anaemia
• Patients who have had previous abdominal surgery may have
adhesions
• Check carefully for small incarcerated hernias, particularly femoral,
in obese patients

Bailey & love, short practice of surgery,26th ed, 2012

 Nyeri abdomen
Saraf Reseptor Spesifikasi nyeri Lokasi Rangsangan

Visceral s. otonom Peritonium Sukar Sukar Tarikan,

visceralis dijelaskan ditunjuk regangan,
kontraksi
berlebih

Somatik s. tepi Peritonium Jelas, tajam, Dapat Rabaan,

parietalis menusuk ditunjuk tekanan
Referred Pain
Location
 Pemeriksaan
Fisik
Status generalis Keadaan umum
Tanda Vital : nadi, tekanan darah, pernafasan,
suhu

Status lokalis abdomen:

inspeksi, auskultasi, perkusi, palpasi, rectal
toucher
Pemeriksaan
Fisik
Pemeriksaan abdomen

•Inspeksi : datar/cembung, warna

kulit, gambaran & gerakan usus

•Auskultasi : bising usus

•Perkusi : nyeri ketok, pekak hepar

•Palpasi : nyeri tekan, nyeri lepas

defense muskuler , massa tumor
Common Cause Acute Abdomen
 Clinical features of
peritonitis
• Abdominal pain, worse on movement, coughing and deep
respiration
• Pyrexia (may be absent), Raised pulse rate
• Tenderness ± guarding/rigidity/rebound of abdominal
wall, Pain/tenderness on rectal/vaginal examination
• Absent or reduced bowel sound
• Systemic inflammatory response syndrome (SIRS),
multiorgan dysfunction syndrome (MODS) in later stages
 The Hippocratic facies in
terminal diffuse peritonitis

Bailey & love, short practice of surgery,26th ed, 2012

Classical position adopted to ease Cullen’s and Gray Turney’s sign of
pancreatic pain (patient with skin discolouration of flanks and
chronic pancreatitis) around umbilicus

Gray Turney’s sign

Cullen’s Sign

Bailey & love, short practice of surgery,26th ed, 2012

 Cardinal clinical features of
bowel acute
obstruction
• Abdominal pain
• Distension
• Vomiting
• Absolute constipation
 Features of bowel obstruction
In high small bowel In low small bowel
obstruction obstruction
• vomiting occurs early, is • pain is predominant with
profuse and causes rapid central distension.
dehydration. • Vomiting is delayed.
• Distension is minimal with • Multiple dilated small bowel
little evidence of dilated loops are see on
small bowel loops on radiography
abdominal radiography

Bailey & love, short practice of surgery,26th ed, 2012

 Features of bowel obstruction

In large bowel obstruction

• distension and pronounced.
• Pain is less severe
• vomiting and dehydration are later features.
• The colon proximal to the obstruction is distended
on abdominal radiography.
• The small bowel will be dilated if the ileocaecal
valve is incompetent

Bailey & love, short practice of surgery,26th ed, 2012

 Pemeriksaan
penunjang
Laboratorium
Darah lengkap
Biokimia darah : amylase, lipase, glukosa,
kreatinin, faal hepar
Urinalisa
Radiologi
Abdomen polos berbaring, tegak/dekubitus
Thorax
USG
CT scan abdomen
 Imaging apa yang dipilih ?
X-ray polos abdomen ? USG abdomen / CT scan abd ?
• Bowel obstruction • Cairan bebas : pus, darah
• Peritonitis / • Abses hepar, cholecystitis,
perforasi pancreatitis
hollow organ • Cancer colorectal
• Problem ginekologis
• Apendisitis
• Peritonitis dan Bowel
obstruction
 Imaging
X-ray polos abdomen CT scan abdomen
Kasus Perforasi
gaster (free air
appearance)
Alogaritma Akut Abdomen
 RESUME
• Diagnosis akut abdomen dapat ditegakkan
dengan :
1. Anamnesis dan pemeriksaan fisik yang teliti
2. Pemilihan tools diagnostik (imaging) yang tepat
TERIMA KASIH