akut abdomen,kuliah atma gi final

7/25/2019 Akut Abdomen,Kuliah Atma GI Final

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PLAIN ABDOMINAL FILMSPLAIN ABDOMINAL FILMS

The supine abdominal film

The erect chest film The horizontal-ray abdominal film:

- Erect

- Left lateral decubitus


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33

The supine abdomen filmThe supine abdomen film

Include the diaphram ! the hernial orifices

"sses:- The preperitoneal fat line: #lurrin of the preperitoneal fat line e$$ inflammatory

- The psoas outlines:

%bliteration of psoas outlines e$$ fluid&inflammatorye'udate

- (istribution of as

- The calibre of bo)el :

*: +alibre of small bo)el is 2$, cm ! colon is , cm$- The thicened of bo)el )all

- (isplacement of bo)el by soft-tissue masses$

- +alculus


4/101

*ormal .as /attern*ormal .as /attern

0tomach

"l)ays

0mall #o)el T)o or three loops of non-distended

bo)el

*ormal diameter 2$, cm

Lare #o)el

In rectum or simoid almost al)ays


5/101

Gas in

stomach

Gas in a few

loops of

small bowel

Gas in

ectum o

si!moid

Nomal Gas Patten


6/101

*ormal luid Le4els*ormal luid Le4els

0tomach

"l)ays 5e'cept supine film6

0mall #o)el T)o or three le4els possible

Lare #o)el

*one normally


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"ect Abdomen

Alwa#s

ai$fluid le%el

in stomach

A fewai$fluid

le%els in

small bowel


8/101

Lare 4s$ 0mall #o)elLare 4s$ 0mall #o)el

Lare #o)el

/eripheral

7austral marins don8t

e'tend from )all to )all

0mall #o)el

+entral

9al4ulae e'tend acrosslumen


9/101

The eect chest filmThe eect chest film

The erect chest film can assess:

0mall pneumoperitoneum$

+hest conditions may mimic an acute

abdomen$

"cute abdominal conditions may be

complicated by chest patholoy;

e$$ pleural effusion fre


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1=1=

The eect chest filmThe eect chest film

Erect

The patients should be in position for

1= min before the film is taen$ Radiological findings:

- free as beneath the diaphram

- chest abnormality


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1111

The hoi&ontal'a# abdominal filmThe hoi&ontal'a# abdominal film Erect ! left lateral decubitus$

The patients should be in position for

1= min before the film is taen$

Radiological findings:

fluid le4els ! free as


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1212

A()T" ABDOM"NA()T" ABDOM"N

/erforation Intestinal obstruction

/aralytic ileus

"cute colitis Intraperitoneal fluid

Inflammatory conditions

+alcification associated )ith acuteabdominal conditions


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"bnormal .as /atterns"bnormal .as /atterns

unctional Ileus

Localized 50entinel Loops6

.eneralized adynamic ileus >echanical %bstruction

0#%

L#%


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%ne or t)o persistently dilated loopsof

lare or small bo)el

.as in rectum or simoid

Localized IleusLocalized Ileus?ey eatures?ey eatures


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Sentinel Loops$Locali&ed ileus

Supine Pone


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Panceatitis)lce

Di%eticulitis

(holec#stitis

Appendicitis

)lce

)eteal calculus

Sentinel Loops


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Localized IleusLocalized Ileus/itfalls/itfalls

>ay resemble early

mechanical 0#%

+linical course

.et follo)-up


19/101

.asin dilated small bo)eland lare

bo)el to rectum #o)el )all Thicenin

Lon air-fluid le4els

%nly post-op patients ha4e eneralizedileus

.eneralized Ileus.eneralized Ileus?ey eatures?ey eatures


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Geneali&ed Ad#namic Ileus

Supine "ect


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2121

Ileus Paaliti*Ileus Paaliti*


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Is It "n Ileus@Is It "n Ileus@

Is the patient immediately post-op@

"re the bo)el sounds absent or

hypoacti4e@ If Ano;B then it isnCt an ileus


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>echanical 0#%>echanical 0#%?ey eatures?ey eatures

(ilated small bo)el

#o)el )all Thicenin

Little as in colon; especially rectum

?ey: disproportionate dilatation of 0#


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SBO


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>echanical 0#%>echanical 0#%+auses+auses

"dhesions

7erniaD

9ol4ulus .allstone ileusD

Intussusception

> h i l 0#%


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>echanical 0#%>echanical 0#%/itfalls/itfalls

Early 0#% may

resemble localized

ileus


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>echanical L#%>echanical L#%?ey eatures?ey eatures

(ilated colon to point of obstruction

>ultiple air fluid le4el0tep Ladder

A7errin #one appearancesB

Little or no air in rectum&simoid

Little or no as in small bo)el;

Ileocecal 4al4e remains competent


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22Gambaan Step LaddeGambaan Step Ladde


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22

Ileus Obstu*siIleus Obstu*si


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La!e Bowel Obstuction

Supine Pone


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>echanical L#%>echanical L#%+auses+auses

Tumor

9ol4ulus

7ernia

(i4erticulitis

Intussusception


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>echanical L#%>echanical L#%/itfalls/itfalls

Incompetent ileocecal 4al4e

Lare bo)el decompresses into small

bo)el >ay loo lie 0#%

ollo)-up


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(acinoma of Si!moid + La!e Bowel Decompessed into Small Bowel

Pone

Supine


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35/101

Ai in

bilia#

teeSBO

Gallstone Gallstone Ileus


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Si!moid ,ol%ulus


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"-taluminal AiFee Intapeitoneal Ai


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0ins of ree "ir0ins of ree "ir

"ir beneath diaphram

#oth sides of bo)el )all

alciform liament sin


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(escent

si!n

Fee Intapeitoneal Ai


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Ai on both sides of

bowel wall . /i!le0sSi!n


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Football si!n


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ree "irree "ir+auses+auses

Fupture of a hollo) 4iscus

/erforated ulcer /erforated di4erticulitis

/erforated carcinoma

Trauma or instrumentation

/ost-op ,G days

*%T perforated appendi'


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"-tapeitoneal Ai


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HHHH

P"/FO/ATIONP"/FO/ATION

11 PN")MOP"/ITON")MPN")MOP"/ITON")M

Fe


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H,H,

0mall pneumoperitoneum0mall pneumoperitoneum


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HKHK

/neumoperitoneum/neumoperitoneum


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HGHG

/neumoperitoneum/neumoperitoneum


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HH

INT"STINAL OBST/)(TIONINT"STINAL OBST/)(TION

(ilated loops of bo)el pro'imally )ithnon-dilated&collapsed bo)el distal to thepresumed point of obstruction$

Gastic Dilatation:Etiology:- >echanical astric outlet obstruction

- /aralytic ileus- .astric 4ol4ulus- "ir s)allo)in


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HH

Gastic DilatationGastic Dilatation


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,=,=

Small'Bowel Obstuction+Small'Bowel Obstuction+

EtiologyEtiology:: - "dhesions due to pre4ious surery - "dhesions due to pre4ious surery

- 0tranulated hernias - 0tranulated hernias - 9ol4ulus- 9ol4ulus

- .allstone ileus - .allstone ileus

- Intussusception - Intussusception

- *eoplastic; etc$ - *eoplastic; etc$


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,1,1

Radiological appearancesRadiological appearances::

MM /lain film/lain filmchanes appear after 3-, hchanes appear after 3-, h

5mared after 12 h6 5complete obstruction6$ 5mared after 12 h6 5complete obstruction6$

MM 0upine film0upine film:: -- 0mall-bo)el dilatation )ith accumulation0mall-bo)el dilatation )ith accumulation

of both as ! fluid$of both as ! fluid$

- " reduction in calibre of the lare bo)el$ - " reduction in calibre of the lare bo)el$


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,2,2

0mall-#o)el %bstruction0mall-#o)el %bstruction

due to adhesiondue to adhesion

>ultiple dilated loops of small bo)el >ultiple fluid le4els on erect film

0 ll # l %b t ti0mall #o)el %bstruction


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,3,3


due to allstone ileusdue to allstone ileus

>ultiple dilated loops of small

bo)el are seen$ " band of as in

the riht hypochondrium lies

)ithin the common bile duct$

0 %0 ll # l %b t ti


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,H,H


due to Intussusceptiondue to Intussusception

" crescent of air at the ape' of an intussusception


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,,,,

MM Erect filmErect film:: - >ultiple fluid le4els 5 - >ultiple fluid le4els 5Stepladder patternStepladder pattern66$$

- N - N0trin of beads0trin of beadsCC sinsin

small bubbles of as may be trapped small bubbles of as may be trapped

in ro)s bet)een the 4al4ulae conni4entes$ in ro)s bet)een the 4al4ulae conni4entes$


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,K,K

Stepladder patternStepladder patternin mechanicalin mechanical

obstruction of the small bo)elobstruction of the small bo)el


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,G,G

0mall-#o)el %bstruction:0mall-#o)el %bstruction:

0trin of beads sin0trin of beads sin


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,,

MM OltrasoundOltrasound::

- (ilated fluid-filled loops of small-bo)el- (ilated fluid-filled loops of small-bo)el

obstruction$ obstruction$

- "ssessment of the peristaltic acti4ity$ - "ssessment of the peristaltic acti4ity$


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,,

MM +T+T::

D +T should be performed )hene4erD +T should be performed )hene4erthere is a history of pre4ious abd$ there is a history of pre4ious abd$

malinancy$ malinancy$

DD Radiological appearancesRadiological appearances::

- #o)el calibre chane - #o)el calibre chane

- luid-filled loops - luid-filled loops

- The le4el of obstruction - The le4el of obstruction - /eritoneal adhesions- /eritoneal adhesions


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K=K=

LA/G"'BO2"L OBST/)(TIONLA/G"'BO2"L OBST/)(TION

Etiology:

- *eoplastic 5benin ! malinant6

- 9ol4ulus 5caecal ! simoid6; etc$

Radiological appearances:

(epends on the state of competence

of the ileocaecal 4al4e:

L"F.E #%PEL %#0TFO+TI%*L"F.E #%PEL %#0TFO+TI%*


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K1K1

L"F.E-#%PEL %#0TFO+TI%*L"F.E-#%PEL %#0TFO+TI%*

due to 0imoid 9ol4ulusdue to 0imoid 9ol4ulus

The huely dilated ahaustral loop

of simoid can be seen risin out

of the pel4is in the shape of an

in4erted O$ 7austrated ascendin

! descendin colon separate from

the 4ol4ed simoid loop$


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K2K2

L"F.E-#%PEL %#0TFO+TI%*L"F.E-#%PEL %#0TFO+TI%*

due to +aecal 9ol4ulusdue to +aecal 9ol4ulus(istended caecum )ith its

haustral marins is lyin lo) in

the central abdomen$ There is no

sinificant small-bo)eldistention$

PA/AL3TI( IL")SPA/AL3TI( IL")S


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K3K3

PA/AL3TI( IL")SPA/AL3TI( IL")SGeneralised paralytic ileusGeneralisedparalytic ileus::

EtiologyEtiology:: - /eritonitis- /eritonitis

- /ost-operati4e- /ost-operati4e

- 7ypoalaemia- 7ypoalaemia

- .eneral debility or infection- .eneral debility or infection- (rus: morphine- (rus: morphine

- +onesti4e cardiac failure; renal colic; etc$- +onesti4e cardiac failure; renal colic; etc$

Radiological appearancesRadiological appearances:: - #oth small ! lare-bo)el dilatation - #oth small ! lare-bo)el dilatation - 7orizontal-ray films: multiple fluid le4els - 7orizontal-ray films: multiple fluid le4els


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KHKH

PA/AL3TI( IL")SPA/AL3TI( IL")S

There is eneralised

dilatation of both

small ! lare bo)el$


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K,K,

Localised ileusLocalised ileus::

EtiologyEtiology:: - Local inflammatory processes: - Local inflammatory processes:

pancreatitis; cholecystitis; appendicitis; salpinitis pancreatitis; cholecystitis; appendicitis; salpinitis

- Trauma: - Trauma:

spine; ribs; hip; retroperitoneum spine; ribs; hip; retroperitoneum - Fenal colic; etc$ - Fenal colic; etc$

Radiological appearancesRadiological appearances::

- *on specific 5>imic small&lare-bo)el obstruction6$- *on specific 5>imic small&lare-bo)el obstruction6$

- (ilatation of one&t)o adQacent loops of bo)el$- (ilatation of one&t)o adQacent loops of bo)el$


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KKKK

To-ic me!acolonTo-ic me!acolon

" fulminatin form of colitis )ith transmural inflammation;

e'tensi4e ! deep ulceration ! neuromuscular

deeneration$

In4ol4e the trans4erse colon

Fo$ indins:

>ucosal islands 5pseudopolyps6 ! dilatation 5 cm6

+ommon complication:

/erforation in the simoid ! peritonitis


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KGKG

To'ic meacolonTo'ic meacolon


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KK

INFLAMMATO/3 (ONDITIONSINFLAMMATO/3 (ONDITIONS

"ppendicitis

"cute cholecystitis

Emphysematous cholecystitis "cute pancreatitis

" di i i


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KK

"ppendicitis"ppendicitis

Signs of acute appendicitis: -"ppendi' calculus 5=$,-Kcm6

- Localised paralytic ileus in FLR

- 0entinel loop-dilated atonic ileum containina fluid le4el

- Pidenin of the preperitoneal fat line

- #lurrin of the preperitoneal fat line - #lurrin of the riht psoas outline-unreliable

contS


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G=G=

AppendicitisAppendicitis

- 0coliosis conca4e to the riht

- (ilated caecum

- Fiht lo)er


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G1G1

0mall bo)el obstruction due to0mall bo)el obstruction due to

"ppendi' abscess"ppendi' abscess

"ppendi' abscess causin

small-bo)el obstruction$

" small as bubble )hich lies

)ithin the abscess is seen in

the riht iliac fossa$


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G2G2

Ultrasound signsUltrasound signsof acute appendicitisof acuteappendicitis::-- #lind-endin tubular structure at the point#lind-endin tubular structure at the point

of tenderness: of tenderness:

*on-compressible *on-compressible

(iameter(iameter G mmG mm *o peristalsis *o peristalsis

- "ppendicolith castin acoustic shado) - "ppendicolith castin acoustic shado)

- 0urroundin fluid&abscess - 0urroundin fluid&abscess


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G3G3

Acute appendicitisAcute appendicitis


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GHGH

"cute appendicitis"cute appendicitis

"cute appendicitis )ith appendicolith$ "bscess formation ! appendicolith$


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G,G,

Acute cholec#stitisAcute cholec#stitis

/lain abdominal film:

- .allstones seen in 2=U

- (uodenal ileus

- Ileus of hepatic fle'ure of colon - Fiht hypochondrial mass due to enlared

allbladder

- .as )ithin the biliary system - *ormal plain films in t)o-thirds of cases

Olt d i

i


76/101

GKGK

Oltrasound imainOltrasound imain::

- " circumferential halo of lo) echoenicity- " circumferential halo of lo) echoenicity

)ith thicenin of the allbladder )all)ith thicenin of the allbladder )all5 5V-1=mm6 in fastin state$V-1=mm6 in fastin state$

- Indistinct contour to the allbladder )all- Indistinct contour to the allbladder )all

- luid around the fundus of the allbladder- luid around the fundus of the allbladder

- .allstones castin acoustic shado)- .allstones castin acoustic shado) - " distended allbladder 5a stone obstructin- " distended allbladder 5a stone obstructin

the cystic duct6 the cystic duct6

- Echoenic sediment in the lumen- Echoenic sediment in the lumen - /ositi4e sonoraphic >urphy sin- /ositi4e sonoraphic >urphy sin


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GGGG

Acute cholec#stitisAcute cholec#stitis


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GG

+7F%*I+ +7%LE+W0TITI0+7F%*I+ +7%LE+W0TITI0

Oltrasound imain:

- " contracted allbladder

- 0ometimes; obliteration of the lumen

- Thicenin of the allbladder )all ! stronly

reflecti4e

- +holelithiasis


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GG

+7F%*I+ +7%LE+W0TITI0+7F%*I+ +7%LE+W0TITI0

A t titiA t titi


80/101

==

Acute panceatitisAcute panceatitis

/lain chest film: - " left side pleural effusion

- #asal parenchymal shado)in

- Ele4ated left hemidiaphram-unreliable

/lain abdominal film:

- *ormal plain films in t)o-thirds of cases

- (uodenal ileus

J .as in a dilated duodenal loop in the LL(

- " asless abdomen due to 4omitin

contS


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11

Acute panceatitisAcute panceatitis

- .eneralised paralytic ileus

- (ilated loops of bo)el 5small bo)el; terminal

ileum; ascendin ! trans4erse colon6 - Loss of the psoas outline

- >ultiple small bubbles )ithin the pancreas

5pancreatic abscess6 - /ancreatic calcification-unreliable


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22

Oltrasound sinsOltrasound sinsof aof acute pancreatitiscute pancreatitis::

- +ontours: smooth ! )ell delineated- +ontours: smooth ! )ell delineated

- Enlarement- Enlarement

- Echote'ture: heteroeneous; hypoechoic to anechoic- Echote'ture: heteroeneous; hypoechoic to anechoic

! less echoenic than the li4er ! less echoenic than the li4er

- "ssociated sins: 4enous compression; pleural - "ssociated sins: 4enous compression; pleural

effusion; ascites; duodenal atonyeffusion; ascites; duodenal atony


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33

"+OTE /"*+FE"TITI0"+OTE /"*+FE"TITI0


84/101

HH

CT signs of acute pancreatitisCT signs of acute pancreatitis::

- *ecrosis; haemorrhae; ! solid parenchyma that- *ecrosis; haemorrhae; ! solid parenchyma that

enhances )ith i$4$contrast medium enhances )ith i$4$contrast medium

- "bscess- "bscess - /ancreatic pseudocyst- /ancreatic pseudocyst

- E'trapancreatic fluid collection- E'trapancreatic fluid collection

- "scites- "scites


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,,


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KK

BL)NT 4"PATI( T/A)MABL)NT 4"PATI( T/A)MA

The third most common oran inQured in theabdomen$

The need for surery is determined by the sizeof the laceration; the amount of hemoperitoneum;

! the patientCs clinical status$

Oltrasound findins:

- Laceration 53U6 5riht lobe X left lobe6

Intrahepatic hematoma:


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GG

- Intrahepatic hematoma: D 7yperechoic in the first 2H hours

D 7ypoechoic ! sonolucent thereafter

- 0ubcapsular hematoma:

D Onilateral; alon the area of laceration

D "nechoic; hypoechoic; septated lenticular;or cur4elinear 5((&ascitic fluid6

- +apsular disruption

- Intraperitoneal fluid

Olt d fi diOltrasound findins


88/101

Oltrasound findinsOltrasound findins

A cescent'shaped h#peechoic collection alon! the i!ht lateal aspect of the li%econsistent with subcapsula hematoma5

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22

0O#"+OTE 0O#+"/0OL"F0O#"+OTE 0O#+"/0OL"F

7"E>"T%>" % T7E LI9EF7"E>"T%>" % T7E LI9EF


93/101

33



94/101

HH

7E/"TI+ +%*TO0I%* PIT77E/"TI+ +%*TO0I%* PIT7

7"E>"T%>"7"E>"T%>"

SPL"NI( IN6)/3SPL"NI( IN6)/3


95/101

,,

SPL"NI( IN6)/3SPL"NI( IN6)/3

>ost commonly inQured

Oltrasound findins:

- 0plenomealy; )ith proressi4e enlarement

- Irreular splenic border

- Intrasplenic hematoma tae loner

- +ontusion 5splenic inhomoeneity6

- 0ubcapsular and pericapsular fluid collections

- ree intraperitoneal blood 5disappear 2-H )ees6

- Left pleural effusion

- Phen the spleen returns to normal J small irreular

foci &normal parenchyma

0/LE*I+ I*YOFW0/LE*I+ I*YOFW


96/101

KK




97/101

GG


7"E>%/EFIT%*EO>7"E>%/EFIT%*EO>


98/101

5F".>E*TE( 0/LEE*65F".>E*TE( 0/LEE*6

BL)NT PAN(/"ATI( IN6)/3BL)NT PAN(/"ATI( IN6)/3


99/101

BL)NT PAN(/"ATI( IN6)/3BL)NT PAN(/"ATI( IN6)/3


100/101

1==1==

#LO*T /"*+FE"TI+ I*YOFW#LO*T /"*+FE"TI+ I*YOFW


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akut abdomen,kuliah atma gi final

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