DIAGNOSTICS APPROACH TO ACUTE ABDOMEN

INTRODUCTION

To understand the meaning of the term "acute abdomen" indicating that an abnormality nontraumatik spontaneous and suddenly the main manifestations in the abdominal region with the main symptom is usually pain. may require operative measures when more than 6 hours duration .. Because usually the cause of intra-abdominal abnormalities are progressive, it is not good late in the diagnosis and treatment because of worsening outcomes.
Step approach to patients with acute abdominal condition must be carefully and thoroughly. Allegation of suspected acute abdomen should remain even if patients only have mild symptoms and atypical. History and physical examination performed to find probable cause and directs the option to set the primary diagnosis. A clinician then decides if the observation at the hospital to ensure that if additional inspection is required, if the initial surgery is indicated, or if the treatment is more operatif.
Obligation of the clinician must carefully identify the onset of symptoms of the most common cause of general acute abdomen. What's more, they must recognize the specific symptoms of the disease in endemic areas and where they practice.
Common cause of acute abdomen
A. Gastrointestinal tract
- Abdominal pain nonspecific
- Appendicitis
- Obstruction of the small intestine and colon
- Perforation of the peptic ulcer
- Hernia inkarserata
- Perforation of the intestine
- Diverticulitis

2. Liver, spleen and gall
- Acute kolesistisis
- Acute kholangitis
- Liver Abscess
- Acute Hepatitis
- Infrak spleen
3. Pancreas
- Acute pancreatitis
4. Urinary tract
- Renal colic
- Acute pyelonephritis
5. Gynecology
- Acute salpingitis
- A ruptured ectopic pregnancy
6. Vascular
- Acute ischemic colitis
- Mesenteric thrombosis
7. Peritoneum
- Intra-abdominal abscess
- Peritonitis tuberculosis
8. Retroperitoneum
- Bleeding retroperitoneum

we must know about :





Stomach pain
Doing History is based on the experience of the examiner is an active process in which a diagnosis is received to eliminate the possibility of a less fit state. Pain is the most common symptom and often appear on the acute abdomen. Be careful in considering the location, type of onset and progression, and characteristics of pain will eliminate the initial diagnosis.
a. Pain Location
Because the sensory innervation of two complexes which supply the visceral and parietal region of the abdomen, the pain is not localized in the right place. Fortunately, some common symptoms appear to provide clues diagnosis. Stimulation of visceral afferent fibers is mediated mainly by C which is located on the wall cavity and visceral organs in a hard capsule. Unlike somatic pain, visceral pain caused by stretching, inflammation or ischemia, which stimulates nerve receptors, or direct involvement of sensory nerves (for example, infiltration of malignant). Center for stimulus recipients are generally longer to rise, blunt, less localized and extended. Differences in visceral structures associated with different sensory levels of the spine. Because of this, increased wall tension due to distension of the lumen or smooth muscle contraction (colic) which produce diffuse also in the midst of pain epigastrium, periumbilikal, lower abdomen, or flank area. Visceral pain is more often perceived as both underlined the middle of the sensory nerves going to the spine.
In contrast, parietal pain is mediated by nerve fibers c and A delta is responsible for the delivery of a more acute sensation, sharp and localized pain. Direct somatic stimulation of the parietal peritoneum (especially the anterior and superior) by liquid pus, bile, urine, gastro intestinal causes localized pain more precisely. The spread of parietal pain by T6-L1. Terlokalisisr parietal pain is easier than visceral pain due to somatic afferent fibers only fixed on one side of the nervous system. Parietal abdominal pain generally described occurred in four quadrants of the abdomen.
Abdominal pain may be transferred or shifted away from the sick organ. The term referred pain sensations felt indicates major stimulus comes from a far. Excessive sense of place of pain due to the influence of afferent nerves from a large area in the posterior horn of the different spinal cord. For example, pain caused by irritation subdiafragma air, peritoneal fluid, blood, or future; kebahu diverted by the intermediary nerve C-4 (phrenic). Pain may also be transferred kebahu of supra-diaphragmatic lesions such as pneumonia in the lower lobe of the lung, especially in younger patients, although it often feels diregio right scapula, pain over the gall may be similar to angina pectoris if it was in the thoracic anterior or left shoulder. Posterolateral right flank pain seen in appendicitis retrocecal.
Structures ....... Nervous System  Pathways   ..........sensory Level
Liver, Spleen, and the center of the diaphragm  ............. nerve Phrenikus............C3-5
The periphery of the diaphragm, stomach, pancreas, Gallblader, Major Intestinal Smooth.............. Sphlanikus nerve and celiac.................. plexus T6-9
Appendix, colon, and pelvic parts of the nerve............. plexus Sphlanknikus Minor Mesentricus and .......... T10-11
Sigmoid colon, rectum, kidney, ureter, and Testis    ....... nerve Inferior Sphlanknikus ,,,,,,,,, T11-L1
Vesicles urinary and rectosigmoid............ Hypogastric Plexus............. S2-4
Tables. Sensory levels associated with visceral structures.
Pain spreading or shift parallel with the underlying causes of the condition. Place of onset of pain should be distinguished from the pain presentation. Usually the pain begins from the epigastric region or periumbilikal, early visceral pain of acute appendicitis shifted into a sharp pain parietal dikuadran located right down when the peritoneum causes inflammation directly. On a perforated peptic ulcer, pain almost always starts at the epigastrium, but such leakage of gastric contents that runs down the intestinal lumen parakolik. Pain down the right lower quadrant with epigastric pain reduction. Location of pain serves only as a sign of rough towards the diagnosis. Especially portrayals reported only two thirds of cases. This great variation due to image the pain that is not typical, maximum shift away from the primary or the disease is advanced.
In the case of long with diffuse peritonitis, general pain may occur and accelerate the state. Pain is limited dikuadran above may be evaluated by assuming anatomical induced acute organ on which the pain.
b. Rise and Development of Pain
Beginning of pain / pain onset reflects the nature and severity of inflammatory processes. Began to explode (in seconds), rapidly progressive (within 1-2 hours), or gradually (over several hours). Unheralded, excruciating pain generally indicates an intra-abdominal catastrophe such as perforated viscus or a ruptured aneurysm, ectopic pregnancy, or abscesses. On systemic signs (tachycardia, sweating, tachypnea, shock) soon replaced stomach upset and stressed the need for rapid resuscitation and laparotomy.
A less dramatic clinical picture is stable mild illness to be very focused on a defined area within 1-2 hours. Each of the above conditions can be present in this way, but this mode of onset is more typical of acute cholecystitis, acute pancreatitis, intestinal pinch, mesenteric infarction, renal or urethral colic, and high (proximal) small bowel obstruction.
Many patients initially had little vague abdominal discomfort that briefly became diffusely throughout the abdomen. Is whether the patient had acute abdominal pain, or whether the disease might be a medical disorder rather than to; Ainan surgery. Association of gastrointestinal symptoms are rarely at first, and systemic symptoms were absent. Finally, the findings of abdominal pain and become more clear and stable, and locally for smaller areas. This may reflect the condition of slowly evolving or defensive effort to shut down the body's acute process. This broad category includes acute appendicitis (especially retrocecal or retroileal), inkarserata hernia, lower (distal) small intestine and large bowel obstructions, peptic ulcer disease is not complicated, walling-off (usually malignant) visceral perforation, some of the genitourinary and gynecological conditions, and mild form of rapid-onset group mentioned in the first paragraph.

c. Characteristics of Pain
The nature, severity and periodicity of pain provide useful clues to the underlying cause. The main pain is the most common. Shallow sharp constant pain because of peritoneal irritation are typical perforated ulcer or ruptured appendix, ovarian cysts, or ectopic pregnancy. Pain, clutching the installation of small bowel obstruction (and sometimes early pancreatitis) typically disjointed, vague, depth, and height at first, but soon becomes more sharp, unrelenting, and local is better. Not such a pain troubling but rather associated with intestinal obstruction, pain caused by lesions occluding the smaller tract (bile ducts, the tubes of the uterus, and ureter) quickly becomes unbearably intense. Accurately described as colicky pain if there is pain-free intervals that reflect the intermittent contraction of smooth muscle, such as the urethral colic. In a narrow sense, the term colic "gall" is a misnomer because the pain does not forgive bile. The reason is that the gallbladder and bile ducts, in contrast to the ureter and bowel, has no peristalsis. The "pain discomfort" ulcer pain, a "stabbing, heart" pain of acute pancreatitis and mesenteric infarction, and "burning" pain of ruptured aortic aneurysms remains apt description. Although the use of descriptive terms like that, the quality of visceral pain is not relied upon to know the cause.
Painful illness indicate a serious illness or advanced. Colic is usually pain quickly resolved with analgesics. ischemic pain due to pinched bowel or mesenteric thrombosis only slightly appeased even by narcotics. nonspecific abdominal pain is usually mild, but mild pain can also be found with a perforated ulcer that has been locally and in mild acute pancreatitis. An occasional patient complained of pain but will deny the vague feeling of abdominal fullness that feels as if he might be relieved by a bowel movement. This visceral sensation (gas stop sign) is due to a reflex ileus caused by an inflammatory lesion walled off from the free peritoneal cavity, as in retrocecal or retroileal appendicitis.
last episode of pain and factors that aggravate or relieve pain should be recorded. Pain due to local peritonitis, especially when affecting the organs of the upper abdomen, tends to be exacerbated by movement or deep breathing.
physicians should be familiar with the pathophysiology and salient features of the common causes of acute abdomen. Location, character, and severity of pain in relation to the duration of onset along with the presence or absence of systemic symptoms help distinguish rapidly progressive (and usually more serious) surgical conditions (eg, bowel ischemia) of the more lazy or medical causes (eg , ruptured ovarian cyst).

Other symptoms associated with abdominal pain
Anorexia, nausea and vomiting, constipation, or diarrhea often accompany abdominal pain, but because this is a specific symptom, they do not have much diagnostic value.
A. Throw up
If enough visceral afferent fibers are stimulated by the secondary, medullary vomiting center activate efferent fibers to stimulate the vomiting reflex. Therefore, pain in the acute surgical abdomen usually precedes vomiting, while the reverse is true in medical conditions. Vomiting is a prominent symptom in the upper gastrointestinal diseases such as Boerhaave's syndrome, Mallory-Weiss syndrome, acute gastritis, and acute pancreatitis. Severe uncontrolled pain vomiting provide temporary relief in moderate pancreatitis attack. The absence of bile in the vomit that is a feature of pyloric stenosis. Where relevant these findings indicate gastrointestinal disorders, onset and character of vomiting can indicate the level of the lesion. recurrent vomiting bile-stained is a typical early sign of the proximal small bowel obstruction. In the distal small bowel obstruction or a large, long preceded the nausea and vomiting, which may become cloudy in the late cases. Disorders that cause vomiting in younger patients may only lead to anorexia or nausea in older patients. Although vomiting may be present in either acute appendicitis or specific abdominal pain, nausea and anorexia live together more suggestive of the former condition.

B. Constipation
Reflex ileus is often caused by visceral afferent fibers to stimulate efferent fibers of the sympathetic autonomic nervous system (nerves splanknik) to reduce intestinal peristalsis. Therefore, paralytic ileus constipation debasing the differential diagnosis of acute abdomen. Constipation itself is not an absolute indicator of intestinal obstruction. However, obstipation (no part of both the bench and farting) mechanical bowel obstruction is suggested if there is a painful progressive abdominal distension or vomiting repeatedly.

C. Diarrhea
Excessive watery diarrhea and gastroenteritis are the characteristics of other medical causes of acute abdomen. Blood stained diarrhea suggest ulcerative colitis, Crohn's disease, or bacillary dysentery or amebic. It is also similar to ischemic colitis but is often absent in intestinal infarction due to occlusion of superior mesenteric artery.

D. Other Special symptoms
It is helpful if any. Hepatobiliary disorders Jaundice shows; hematochezia or hematemesis, gastroduodenal lesions or Mallory-Weiss syndrome: hematuria, or urethral colic, cystitis. Part of a blood clot or debris mucosal necrosis may be the only evidence of bowel ischemia developed.

Other Aspects Relating to

A. Gynecologic History
Menstrual history is essential for the diagnosis of ectopic pregnancy, mittelschmerz (due to a ruptured ovarian follicle), and endometriosis. History of vaginal or dysmenorrhea may be pelvic inflammatory disease.

B.Riwayat Drugs
Anticoagulants have been involved in a retroperitoneal duodenum and jejunum and intramural hematoma; oral contraceptives in the formation of benign liver adenomas and mesenteric venous infarction. Corticosteroids, in particular, may mask clinical signs of peritonitis even advanced. Pyloric perforation was caused by "" smoking crack.

C. Family History
This often gives the best information about the medical cause of acute abdomen.

D. Travel History
This can increase the possibility of amebic liver abscess or hydatid cyst, the spleen of malaria, tuberculosis, Salmonella typhi infection of the ileocecal area, or dysentery.
E. History of Operations
Any history of a previous abdominal, groin, blood vessels, or chest surgery may be relevant to the current illness. Special attention to the mode of operation (laparoscopic, open, endovascular) and any anatomical reconstruction can explain aspects of the current complaint. If possible within the time limits imposed by the urgency of the current problem, the operating records and pathology reports must be obtained and reviewed.

PHYSICAL EXAMINATION
Tendency to concentrate on the stomach should be rejected in favor of a methodical and complete physical exam umum.Satu should seek specific signs that confirm or rule out differential diagnosis.

(1) General observations: general observations over a fairly reliable indication of the severity of the clinical situation. Most patients, though not comfortable, stay calm. The stretch of patients with visceral pain (eg, intestinal or urethral colic) in contrast to the rigid pads did not move from those with parietal pain (eg, acute appendicitis, general peritonitis). response is reduced or altered sensorium often precedes cardiopulmonary collapse soon.
(2) Signs of systemic: systemic signs usually accompany fast forward or progressive disorder associated with acute abdomen. Extreme pallor, hypothermia, tachycardia, tachypnea, and sweating suggest a large intra-abdominal bleeding (eg, aortic aneurysm rupture or tubal pregnancy). With these findings, we have to proceed quickly with the next inspection and test to exclude extra-abdominal causes and treatment agencies.
(3) Fever: Constant low-grade fever is common in inflammatory conditions such as diverticulitis, acute cholecystitis, and appendicitis. high fever with lower abdominal pain in young women with no signs of systemic disease showed acute salpingitis. Extreme disorientation or lethargy combined with a very high fever (> 39 ° C) or with a swinging fever or chills and rigor indicates that septic shock is coming. It is most often caused by advanced peritonitis, acute cholangitis, or pyelonephritis. However, fever is often mild or absent in the elderly, chronically ill or immunosuppressed patients with serious acute abdomen.
(4) Examination of the acute abdomen
(A) Inspection: Abdominal palpation should be checked prior to ponder. Tense distended abdomen with an old surgical scar showing both the presence and cause (attachment) of small bowel obstruction. A scaphoid abdomen contract with a perforated ulcer seen; visible peristalsis occurred in patients with advanced thin indigestion and fullness seen in the soft clay paralytic ileus or mesenteric thrombosis early.
(B) Auscultation: Auscultation of the abdomen should precede palpation. Peristaltic rushes in sync with the sound in the middle colic and small bowel obstruction in early acute pancreatitis. These tend to last longer but it occurs less frequently than in normal patients or in those with acute cholecystitis. They differ from the high-pitched voice hyperperistaltic not associated with cramping pain gastroenteritis, dysentery, colitis and fulminant colitis. A silent except for stomach pitched tinkly rare or late feature of gastrointestinal disorders or diffuse peritonitis. Except for these patterns is more extreme, many variants of auscultatory heard in paralytic ileus and other conditions that make them very useful for specific diagnosis.
(C) to obtain pain Cough: Patients should be asked to cough and point to the maximum pain. peritoneal irritation that can show confirmed later without causing unnecessary pain to the rigorous testing for rebound tenderness. Unlike peritonitis parietal pain, visceral pain and colic is rarely exacerbated by inspiration or cough.
(D) Percussion: Percussion serves several purposes. Tenderness to percussion is similar to that describe softness rebounds, both reflect the pain and parietal peritoneal irritation. With viscus perforation, free air under the diaphragm may accumulate in the liver normally removes ignorance. Tympani in the air near the midline shows distended stomach distended bowel trapped in a loop. Free peritoneal fluid can be detected by the shift shows ignorance.
(E) Palpation: Palpation performed with the patient resting comfortably in a supine position. Periumbilical incisional hernia and recorded. Keeping assessed by placing both hands on your stomach muscles and press your fingers gently. Properly performed, this maneuver the patient's comfort. If there is a voluntary spasm, the muscles will feel relaxed when patients inhale deeply through your mouth. With the forced seizure true, however, will remain tense muscles and stiff ("board-like") throughout respiration. Except for rare, neurological disorders and, for unknown reasons, renal colic, inflammation of the peritoneum only (by reflex afferent stimulation of the motor efferent fibers) results in stiffness of the rectus muscle. Unlike peritonitis, renal colic leading to seizures confined to the ipsilateral rectus muscle.
Connotes softness of local peritoneal inflammation is the most important findings in patients with acute abdomen. Its extent and severity is determined first by palpation one-or two-finger, starting from the softness of cough and gradually progressing towards it. Tenderness is usually restricted in acute cholecystitis, appendicitis, diverticulitis, and acute salpingitis. If there is a bad company to keep the local softness, one should suspect gastroenteritis or some other intestinal inflammatory process without peritonitis. Compared with the degree of pain, vague aches and unexpected causes minimal obstruction of hollow viscus is not complicated in, walled-off perforation or deep (eg, retrocecal or phlegmons appendicitis or diverticular retroileal), and in severely obese patients.
When the patient raised his head from the bed or examination table, the abdominal muscles will tighten. Tenderness remain in the abdominal wall (eg, rectus hematoma) whereas pain due to peritoneal further reduced intraperitoneal disease (Carnett's test). Hyperesthesia can be demonstrated in the abdominal wall disruption or local peritonitis, but more prominent in herpes zoster, spinal root compression, and other neuromuscular problems. Trigger point sensitivity, lateral rib tenderness coastal edge, and spinal pain aggravated by movement reflects the condition of abdominal parietal wall subsided dramatically after infiltration with local anesthetic agents.
Abdominal mass is usually detected by palpation in. superficial lesions such as distended gallbladder or appendiceal abscess is often tender and discrete borders. If one suspects that keep the stomach is masking a truly gallbladder is inflamed, the right subkostal should be palpated while the patient inhaled deeply. Inspiration suddenly put on hold due to illness (Murphy's sign), or fundus of the gallbladder may be felt as touching the fingers to check for a decline in the diaphragm.
More mass may be attached to the posterior or lateral abdominal wall and often partially walled off by omentum and upper small intestine. As a result, their borders are not clear, and only a dull pain can be caused by palpation. Examples include pancreatic phlegmon and ruptured aortic aneurysm.
Even if the masses can not be directly perceived, its existence can be inferred by other maneuvers. A large psoas abscess arising from perinephric abscess or perforated Crohn enteritis may cause pain when the hips flexed passively or actively extended against resistance (the iliopsoas). Similarly, internal and external rotation of hip flexion can suppress pain (obturator sign) on a loop of small bowel trapped in the obturator canal (obturator hernia). Punch tenderness over the lower rib cage showed inflammatory condition affecting the diaphragm, liver, or spleen or adjacent structures. While this may suggest a liver abscess, spleen, or subphrenic, also common in acute cholecystitis, acute hepatitis, or infarction of the spleen. Costovertebral corner softness common in acute pyelonephritis. Because they are not always present, special signs to help only in conjunction with a compatible history and physical findings associated.
(F) inguinal and femoral annulus; male genitalia: inguinal ring and femoral artery in both sexes and on the genitals of male patients should be examined next.
(G) Examination of the rectum: rectal examination should be performed in most patients with acute abdomen. is a specific blend of tenderness, but tenderness of the right side of the rectum accompanied by lower abdominal rebound tenderness is an indication of peritoneal irritation due to appendicitis or pelvic abscess. Other useful findings include rectal tumor, bloody stools, or blood occult (detected by guaiac testing). rectal examination may be omitted in children diagnosed as having appendicitis because of marked right lower quadrant tenderness, guarding, or rigidity.
(H) pelvic examination: an acute abdomen is diagnosed more often in women than in men, especially in younger age groups. Pelvic examination is essential in women with vaginal, dysmenorrhea, menorrhagia, or lower left quadrant pain. Pelvic examination was carried out very valuable in distinguishing between acute pelvic inflammatory disease that does not require surgery and acute appendicitis, twisted ovarian cyst, or Tubo-ovarian abscess.
Examination support
History and physical examination alone provided the diagnosis in two-thirds of cases of acute abdomen. Additional laboratory and radiological examination is necessary for the diagnosis of many surgical conditions, to be excluded from medical causes are not usually treated with surgery, and to aid in preoperative preparation. Even in the absence of a specific diagnosis, there may be enough information on which to base a rational decision about management. Additional studies are valuable only if they are likely to significantly alter or improve the therapeutic decision. A more liberal use of diagnostic studies is justified in elderly or severely ill patients, including history and physical findings may be less reliable and early diagnosis is important to ensure a successful outcome.
Availability and reliability of this particular study is different in different hospitals. The invasiveness, risk, and cost-effectiveness of the test must be weighed when physicians choose diagnostic studies. The test results should always be interpreted within the clinical context of each case. Basic studies should be obtained in all but the most desperately ill patients. Other tests are less important will be required later as indicated.
Laboratory
Blood A.Pemeriksaan
Hemoglobin, hematocrit, and white blood cell and differential count was taken on admission is very informative. Just go up or marked leukocytosis (> 13,000 / ul), especially in the presence of a leftward shift in the blood smear, is indicative of a serious infection. moderate leukocytosis, often encountered in medical and surgical inflammatory conditions, is specific and may not even exist in the elderly or infirm patients with infections. A low white blood cell count (<8000/uL) is a feature of viral infections such as gastroenteritis and mesenteric adenitis or specific abdominal pain.
A frozen blood specimens for cross-matching should be sent whenever urgent surgery is anticipated. An additional tube of frozen blood can be provided in terms of those needs. Serum electrolytes, urea nitrogen and creatinine are important, especially if hypovolemia is expected (ie, shock, excessive vomiting or diarrhea, abdominal distension tense, or delay of a few days after onset of symptoms). determination of arterial blood gases should be obtained in patients with hypotension, generalized peritonitis, pancreatitis, ischemic bowel as possible, and septicemia. Unexpected metabolic acidosis may be the first clue to a serious illness.
Raised serum amylase levels to strengthen the clinical diagnosis of acute pancreatitis. Value high enough to be interpreted with caution, because the limit commonly accompany normal or ischemic bowel pinched, twisted ovarian cyst, or a perforated ulcer. In addition, the normal or even low-amylase can be seen in hemorrhagic pancreatitis or pseudocyst. Cloudy (like milk) in the serum of patients with abdominal pain suggests pancreatitis despite normal serum amylase.
Hepatobiliary diseases in patients with suspected, liver function tests (serum bilirubin, alkaline phosphatase, AST, ALT, albumin and globulin) is useful to differentiate medical from liver surgery and to measure the severity of the underlying parenchymal disease. Clotting studies (platelet count, prothrombin time and partial thromboplastin time) and peripheral blood stains should be required if the instructions on the history of hematologic disorders may (cirrhosis, petechiae, etc.). Erythrocyte sedimentation rate, often nonspecific acute abdominal grew up in, is a dubious diagnostic value; normal value does not exclude serious surgical disease.
Antibody titers for amebic disease, typhoid, or viral, and other special blood tests can indicate certain diseases, but treatment decisions often can not wait for the results.
B. Urine tests
Urinalysis is easy to do and can reveal useful information. Dark urine or weight lifting type reflects mild dehydration in patients with normal renal function. Hyperbilirubinemia can lead to a tea-colored urine froths when shaken. microscopic hematuria or pyuria can ensure urethral tract infection or urinary colic surgery and negate the need. initial antibiotic treatment should be adjusted after culture and sensitivity reports are available. dipstick testing (for albumin, bilirubin, glucose, and ketones) may disclose medical cause of acute abdomen. Pregnancy tests should be ordered if there is a history of missed period.
C. Stool testing
Gastrointestinal bleeding is not a common feature of acute abdomen. However, fecal occult blood test should be routinely performed. A positive test points to a mucosal lesions that might be responsible for bowel obstruction or chronic anemia, or may reflect unsuspected carcinoma.
Pap bench warm for bacteria, ova, and parasites of animals may show amebic trophozoites in patients with bloody diarrhea or mucus. Stool samples for culture should be taken in patients with suspected gastroenteritis, dysentery, or cholera.

Imaging examination

A. Plain thoracic photo
Photos upright chest are very important in all cases of acute abdomen. Not only is it important for preoperative assessment, but also can indicate conditions that simulate supradiaphragmatic an acute abdomen (eg, lower lobe pneumonia or esophageal rupture). An elevated hemidiaphragm or pleural effusion may direct attention to the subphrenic inflammatory lesions.
B. Plain photo abdomen
In general, image upright (or decubitus lateral) visits contribute little additional information except in suspected bowel obstruction. Although the radiological abnormalities are present in up to 40% of patients, this diagnostic is only half the time. Plain films are shown in patients who had sufficient tenderness or bloating, abnormal bowel sounds, history of abdominal surgery, suspected foreign body ingestion, or who have a depressed sensorium or who are in high-risk category. They are very helpful in patients with intestinal disorders may or ischemia, perforated viscus, renal or urethral calculi, or acute cholecystitis. They rarely value in patients with suspected appendicitis or urinary tract infection. They do not fit in pregnant patients, individuals who are stable in the physical signs of a clear mandate laparotomy already exists, or patients with only mild, address the specific pain. Maximum information obtained by an experienced radiologist apprised of the clinical situation. However, the surgeon who is familiar with the clinical details must review all x-rays.
People should observe the pattern of the hollow viscera gas; free air or abnormal patterns below the diaphragm, the bile radicles, or beyond the bowel wall; line of solid organ and peritoneal fat lines and the density of radiopaque.
Normal bowel gas pattern showed paralytic ileus, mechanical bowel obstruction, or pseudo-obstruction. A pattern of diffuse gas with air outlining the ampulla of the rectum showed paralytic ileus, especially if bowel sounds were absent. Gas distension of the bowel obstruction is the rule. air-fluid levels are usually seen in the distal small bowel obstruction and dilation of the cecum distended with small bowel obstruction in the colon. Along with the clinical findings, typical radiological appearance of colonic dilatation in toxic megacolon or volvulus establish the diagnosis (see Figure 31-15). Adynamic ileus associated with long-standing or acute appendicitis with atypical location of the appendix often produce a pattern of local shows right lower quadrant ileus. These radiological images in patients without previous abdominal surgery should affect the diagnostic decision of appendicitis or other ileocecal disease (tumor, inflammatory disorders). "Fingerprint thumb" mark on the wall of the colon were noted in approximately half of patients with ischemic colitis. An aerial image of refugees stomach or colon may be the only sign of subcapsular splenic hematoma.
Free water should seek specific corresponding hemidiaphragm. Its presence in about 80% of ulcer perforation confirm the clinical diagnosis. massive pneumoperitoneum was observed in the free colonic perforation. Designate air biliary tree, biliary enteric communication, such as surgically created fistula sponteneous or choledochoduodenal or gallstone ileus. Described the portal venous system air pylephlebitis traits. The air between the loops of small bowel perforation may arise from small local.
Obliteration of the psoas muscle margin or enlargement of the shadow shows retroperitoneal kidney disease. Radiopaque densities characteristic appearance and location to confirm the clinical suspicion of bile, kidney staghorn, or urethral calculi, appendicitis, or aortic aneurysm. While pelvic phleboliths can be distinguished, a migrant gallstones may be wrong to mesenteric lymph nodes stiff if air distension of the small intestine or the biliary tree is overlooked in gallstone ileus.

C. Angiography
Angiographic studies indicated if bowel ischemia or intra-abdominal perdarhan constantly under suspicion. They must precede a variety of gastrointestinal contrast study that may obscure the interpretation of the film. Selective visceral angiography is a reliable method for diagnosing mesenteric infarction. Emergency angiography confirmed adenoma or carcinoma of the liver rupture or aneurysm of the splenic artery or other visceral arteries. In patients with massive lower gastrointestinal bleeding, angiography can identify sites of bleeding, may suggest a possible diagnosis (eg, vascular ectasia, polyarteritis nodosa), and even if embolization therapy may be performed. Angiography is of little value in aortic aneurysm rupture or if the findings of peritoneal bright (peritonitis) are present. It is contraindicated in stable patients with severe shock or sepsis, and rarely required if other findings or test is to determine the need for laparotomy or laparoscopy.
D. Contrast X-Ray

In contrast gastrointestinal studies should not be required or considered to be routine screening studies. They help only if certain conditions are considered to be verified or treated with x-ray contrast examination. For suspected perforated esophagus or gastroduodenal area without pneumoperitoneum, contrast media are water soluble (eg, meglumine diatrizoate [Gastrografin]) are preferred. If there is no clinical evidence of bowel perforation, barium enema may identify the degree of bowel obstruction or even reduce sigmoid volvulus or intussusception. Only if there is no possibility of large bowel obstruction should be small bowel barium follow-through a study used to study small bowel obstruction or to look for intramural duodenal (or jejunal) hematoma is best managed conservatively.
An emergency intravenous urogram is rarely necessary to evaluate nontraumatic causes of hematuria. This should be done electively after microscopic examination of urine specimens were centrifuged and stained and cystoscopic examination. HIDA scan ultrasonography and intravenous cholangiography has replaced the yellow in the evaluation of patients and those suspected acute cholecystitis.

E. Ultrasonography

Ultrasonography is useful in the evaluation of upper abdominal pain that does not resemble stomach ulcers or intestinal obstruction and in investigating abdominal mass. Ultrasonography has a diagnostic sensitivity of about 80% for acute appendicitis and most useful in pregnant patients and those presenting with features suggestive of atypical appendicitis or in young women with middle or lower abdominal pain. Color Doppler studies can differentiate cysts and avascular mass play of inflammatory and infectious processes. CT scan may be more useful if excessive intestinal gas, very common in the elderly and the sick, impede satisfactory ultrasound examination. This is especially useful in pancreatic and retroperitoneal lesions and any severe local infection (eg, acute diverticulitis).

F. CT Scan
This has proved very useful in the evaluation of abdominal complaints for patients who do not yet have a clear indication for laparotomy or laparoscopy. CT is helpful in identifying small amounts of free intraperitoneal gas and the site of inflammatory disease that may prompt (appendicitis, Tubo-ovarian abscess) or delay (diverticulitis, pancreatitis, liver abscess) operation.
G. Radionuclide Scan
Liver-spleen scan, HIDA scan, and gallium scan may be useful for localization of intra-abdominal abscess. However, their utility has been greatly decreased by the routine availability of CT scan urgently. Radionuclide blood pool or Tc-sulfur colloid scan can identify the source of intestinal bleeding is slow or intermittent. Technetium scan here occurs may reveal ectopic gastric mucosa in Meckel's diverticulum. Tc-99m hexamethylpropyleneamineoxide (HMPAO) scanning may help in patients with subtle signs of appendicitis. It has a sensitivity rate of 85%, specificity 93%, and 89% accuracy rate. It may also suggest other causes of intra-abdominal inflammation.
Endoscopy
Proctosigmoidoscopy indicated in every patient with bowel obstruction is suspected, too bloody stools, or rectal mass. Minimal air should be used for bowel insufflation. In addition to derive a sigmoid volvulus, colonoscopy can also find the source of bleeding in cases of lower gastrointestinal bleeding has subsided. Gastroduodenoscopy and ERCP is usually performed electively to evaluate the inflammatory condition is less urgent (eg, gastritis, gastric disease) in patients without signs of stomach worrying.
Paracentesis
In patients with free peritoneal fluid, aspiration of blood, bile, or intestinal contents is a strong indication for urgent laparotomy. On the other hand, infected ascitic fluid can establish the diagnosis of spontaneous bacterial peritonitis, TB peritonitis, or chylous ascites (see Chapter 23), which rarely require surgery. Culdocentesis may be useful for suspected ruptured corpus luteum cyst.
Peritoneal cytology (obtained by direct aspiration through a fine catheter) or diagnostic peritoneal lavage can reveal tumors or acute inflammation of intra-abdominal problems. This investigation should be used selectively after the imaging findings in patients with vague and poorly on those who would tolerate a negative laparotomy.
Laparoscopy
Laparoscopy is now a therapeutic and diagnostic modalities. In young women, may discriminate problems nonsurgical (graafian follicle rupture, pelvic inflammatory disease, Tubo-ovarian disease) of the appendix. In the unconscious, elderly or critically ill patients, who often deceptive manifestations of acute abdomen, may facilitate earlier treatment in those with positive findings while eliminating the added morbidity of laparotomy in negative cases. Where confirmed appendicitis, laparoscopic appendectomy can be performed. Increasingly, surgeons must gain a new laparoscopic skills to deal with other conditions of acute intra-abdominal (eg, adhesive intestinal obstruction) which had previously demanded a formal laparotomy.
DIAGNOSIS
Age and sex factors of helping patients in the differential diagnosis: mesenteric adenitis mimicking acute appendicitis in the young; gynecological disorders complicate the evaluation of lower abdominal pain in women of childbearing age, and malignant and vascular diseases are more common in older people. Causes of acute abdominal disease patterns reflect the indigenous population, and public awareness in the local lead clinicians will improve diagnostic accuracy. Clinical picture at the beginning of the case often is unclear. The following observations should be kept in mind:
(1) Every patient with acute abdominal pain persists for more than 6 hours should be regarded as having a problem that requires surgical in-hospital evaluation. Well-localized pain and tenderness usually indicates a surgical condition. systemic hypoperfusion in conjunction with general abdominal pain is rarely due to medical problems.
(2) acute cholecystitis, appendicitis, intestinal obstruction, cancer, and acute vascular conditions are the most common cause of acute abdominal surgery in older patients. In children, appendicitis accounts for one-third of all cases and specific abdominal pain for almost all the rest.
(3) acute appendicitis and intestinal disorders are the final diagnosis in these cases most often erroneously believe nonsurgical first. Appendicitis must always remain a concern, especially if sepsis or inflammatory lesion is suspected. This is the most common cause of peritoneal findings strange that produce ileus or bowel obstruction. Half of children with appendicitis present with marked facial flush (due to high serotonin levels). The findings mark the cessation of gas or x-ray of the right lower quadrant ileus should increase the likelihood of appendicitis or retroileal retrocecal. Appendicitis is less likely in a previously healthy person if the history of exceeding the duration of 3 days' and the patient is afebrile, considerable pain, ileus, or leukocytosis. Pelvic appendix, with mild abdominal pain, vomiting, and diarrhea often, simulating gastroenteritis. Early signs may be mild abdominal and pelvic and rectal examination unremarkable. A number of low white blood cell lymphocytosis assistance or gastroenteritis. Atypical presentation of appendicitis is encountered during pregnancy. Maternal disease and fetal death in these cases is largely due to complications following a delayed diagnosis. The appendix is well tolerated during pregnancy, and removal of normal appendix is more often tolerated than observation of the perforation.
(4) salpingitis, dysmenorrhea, ovarian lesions, and urinary tract infections complicate the evaluation of acute abdomen in young women. Many diagnostic errors can be avoided by taking a careful menstrual history and pelvic examination and urine. study of ultrasound and pregnancy tests are very helpful in appropriate cases. Compared with patients with appendicitis, patients with acute salpingitis tend to present with a longer history of pain, often associated with the menstrual cycle, and high fever, signs of bilateral pelvic, and white blood cell count increased sharply.
(5) atypical manifestations of intestinal disorders, especially early cases, be easily missed. Emesis, abdominal distension, and air-fluid levels on x-ray may be negligible in the Richter hernia, proximal or closed loop small bowel obstructions, and the initial cecal volvulus. Intestinal obstruction in an elderly woman who has no previous surgery showed an incarcerated femoral hernia, or, rarely, an obturator hernia or gallstone ileus. There may be no pain or pain in the hernia. Carefully check the inguinofemoral region; repeat rectal and abdominal examination, and examine the obturator sign. Transient mild upper abdominal pain a few days later, followed by signs of intestinal obstruction is typical of gallstone ileus. Look for radiopaque stones and air in the biliary tree outlining the plain abdominal x-ray.
(6) Elderly or cardiac patients with severe diffuse pain unremitting abdomen but no peritoneal signs or abnormalities in the abdomen commensurate film may be used to intestinal ischemia. arterial blood pH should be measured and visceral angiography was conducted.
(7) The disease causes acute abdominal exploratory laparotomy must be removed before considered. Upper abdominal pain may be encountered in the myocardial infarction, acute pulmonary conditions (pneumothorax, lower lobe pneumonia, pleurisy, empyema, infarction), and hepatitis. General or abdominal discomfort may be felt on migrated acute rheumatic fever, polyarteritis nodosa and other types of diffuse vasculitis, acute intermittent porphyria, and acute pleurodynia. Sharp flank pain, often accompanied by convulsions and hyperesthesia rectus skin, osteoarthritis can be caused by nerve compression or thoracic spine. Similarly, joint disorders and acute bursitis can result in hip pain radiating to the lower quadrant. Pinpricking wonderful tingling sensation along the dermatomes or are characteristic of herpes zoster preeruptive. Medical conditions can usually be distinguished from the surgery by careful assessment of history and physical examination. Family history may provide the first clue. History is usually atypical in several aspects, and the openness of thought will reveal the details as normal or exaggerated symptoms or concurrent extra-abdominal complaints leading to the true cause. Although the apparent severity of illness, local abdominal pain rarely present voluntarily maintain. Fever and associated systemic signs may be comparable with the degree of pain. Laboratory studies and x-ray will verify the diagnosis and avoid surgery.
(8) Beware of acute cholecystitis, acute appendicitis, and peptic ulcer perforation in patients already hospitalized for diseases that affect other organ systems. their presentation is often atypical, leading to delayed diagnosis and complications.
(9) Exploration of the most frequently performed without profit to salpingitis, mesenteric adenitis, gastroenteritis, pyelonephritis, and acute hepatitis virus.
(10) non-specific abdominal pain, consisting of one-third of all cases, the most common cause of acute abdomen, especially in children. Generally mild, short-lived, and rarely associated with other serious symptoms, get better without specific treatment. Most cases are diagnosed a mild virus and bacterial infections, irritable bowel syndrome, gynecological problems, abdominal wall pain, psychosomatic illness, or worm infection.
INDICATIONS FOR SURGERY FOR EXPLORATION

 Indications for surgery tndakan presence visible when a specific diagnosis, but sometimes surgery should be performed before the proper diagnosis is reached. (As a working diagnosis). List of several indications for urgent laparotomy or laparoscopy. Among patients with acute abdominal pain, which is over the age of 65 years more often require surgery (33%) than younger patients (15%).
 Exploration is recommended in patients with inconclusive but persistent right lower quadrant pain. Pain in the upper left quadrant is rarely require urgent laparotomy, and the cause can usually wait for confirmation of elective studies.
HANDLING preoperative
When the initial assessment, parenteral analgesics for pain relief should not be given. At moderate doses, analgesics do not obscure the physical findings that are useful or masking-effect. With cramped rectus, abdominal mass may be apparent. Ongoing pain despite adequate doses of narcotics indicate a serious condition that often requires corrective surgery.
Resuscitation of critically ill patients are discussed in Chapter 2. Treatment should be limited to essential requirements. Special attention should be given to heart drugs and corticosteroid use and to control diabetes. Antibiotics are indicated for several conditions of infection or as prophylaxis during the perioperative period.
Usually nasogastric tube should be inserted in patients scheduled for surgery and for those with hematemesis or excessive vomiting, suspected intestinal obstruction, or severe paralytic ileus. These precautions can prevent aspiration in patients suffering from a drug overdose or alcohol poisoning, coma patients or weak, or elderly patients with impaired cough reflex. However, because the tube interfere with coughing and discomfort, it should be removed after safe to do so.
Urinary catheters should be placed in patients with systemic hypoperfusion. In some elderly patients, eliminating the cause of pain (acute bladder distension) or signs of stomach unmasks relevant.
Approval information (imformed consent) for the operation may be difficult to obtain when diagnosis is uncertain. It is wise to discuss with patients and families the possibility to do some operations; openings, temporary or permanent stoma; impotence or sterility, and postoperative intubation for mechanical ventilation. Every time a proper diagnosis is uncertain, especailly in the young or weak or very sick patients, preoperative discussion of honest diagnostic dilemma and the reason for laparotomy or laparoscopy would decrease postoperative anxiety and misunderstandings later on.

D. Contrast X-Ray

In contrast gastrointestinal studies should not be required or considered to be routine screening studies. They help only if certain conditions are considered to be verified or treated with x-ray contrast examination. For suspected perforated esophagus or gastroduodenal area without pneumoperitoneum, contrast media are water soluble (eg, meglumine diatrizoate [Gastrografin]) are preferred. If there is no clinical evidence of bowel perforation, barium enema may identify the degree of bowel obstruction or even reduce sigmoid volvulus or intussusception. Only if there is no possibility of large bowel obstruction should be small bowel barium follow-through a study used to study small bowel obstruction or to look for intramural duodenal (or jejunal) hematoma is best managed conservatively.
An emergency intravenous urogram is rarely necessary to evaluate nontraumatic causes of hematuria. This should be done electively after microscopic examination of urine specimens were centrifuged and stained and cystoscopic examination. HIDA scan ultrasonography and intravenous cholangiography has replaced the yellow in the evaluation of patients and those suspected acute cholecystitis.

E. Ultrasonography

Ultrasonography is useful in the evaluation of upper abdominal pain that does not resemble stomach ulcers or intestinal obstruction and in investigating abdominal mass. Ultrasonography has a diagnostic sensitivity of about 80% for acute appendicitis and most useful in pregnant patients and those presenting with features suggestive of atypical appendicitis or in young women with middle or lower abdominal pain. Color Doppler studies can differentiate cysts and avascular mass play of inflammatory and infectious processes. CT scan may be more useful if excessive intestinal gas, very common in the elderly and the sick, impede satisfactory ultrasound examination. This is especially useful in pancreatic and retroperitoneal lesions and any severe local infection (eg, acute diverticulitis).

F. CT Scan
This has proved very useful in the evaluation of abdominal complaints for patients who do not yet have a clear indication for laparotomy or laparoscopy. CT is helpful in identifying small amounts of free intraperitoneal gas and the site of inflammatory disease that may prompt (appendicitis, Tubo-ovarian abscess) or delay (diverticulitis, pancreatitis, liver abscess) operation.
G. Radionuclide Scan
Liver-spleen scan, HIDA scan, and gallium scan may be useful for localization of intra-abdominal abscess. However, their utility has been greatly decreased by the routine availability of CT scan urgently. Radionuclide blood pool or Tc-sulfur colloid scan can identify the source of intestinal bleeding is slow or intermittent. Technetium scan here occurs may reveal ectopic gastric mucosa in Meckel's diverticulum. Tc-99m hexamethylpropyleneamineoxide (HMPAO) scanning may help in patients with subtle signs of appendicitis. It has a sensitivity rate of 85%, specificity 93%, and 89% accuracy rate. It may also suggest other causes of intra-abdominal inflammation.
Endoscopy
Proctosigmoidoscopy indicated in every patient with bowel obstruction is suspected, too bloody stools, or rectal mass. Minimal air should be used for bowel insufflation. In addition to derive a sigmoid volvulus, colonoscopy can also find the source of bleeding in cases of lower gastrointestinal bleeding has subsided. Gastroduodenoscopy and ERCP is usually performed electively to evaluate the inflammatory condition is less urgent (eg, gastritis, gastric disease) in patients without signs of stomach worrying.
Paracentesis
In patients with free peritoneal fluid, aspiration of blood, bile, or intestinal contents is a strong indication for urgent laparotomy. On the other hand, infected ascitic fluid can establish the diagnosis of spontaneous bacterial peritonitis, TB peritonitis, or chylous ascites (see Chapter 23), which rarely require surgery. Culdocentesis may be useful for suspected ruptured corpus luteum cyst.
Peritoneal cytology (obtained by direct aspiration through a fine catheter) or diagnostic peritoneal lavage can reveal tumors or acute inflammation of intra-abdominal problems. This investigation should be used selectively after the imaging findings in patients with vague and poorly on those who would tolerate a negative laparotomy.
Laparoscopy
Laparoscopy is now a therapeutic and diagnostic modalities. In young women, may discriminate problems nonsurgical (graafian follicle rupture, pelvic inflammatory disease, Tubo-ovarian disease) of the appendix. In the unconscious, elderly or critically ill patients, who often deceptive manifestations of acute abdomen, may facilitate earlier treatment in those with positive findings while eliminating the added morbidity of laparotomy in negative cases. Where confirmed appendicitis, laparoscopic appendectomy can be performed. Increasingly, surgeons must gain a new laparoscopic skills to deal with other conditions of acute intra-abdominal (eg, adhesive intestinal obstruction) which had previously demanded a formal laparotomy.
DIAGNOSIS
Age and sex factors of helping patients in the differential diagnosis: mesenteric adenitis mimicking acute appendicitis in the young; gynecological disorders complicate the evaluation of lower abdominal pain in women of childbearing age, and malignant and vascular diseases are more common in older people. Causes of acute abdominal disease patterns reflect the indigenous population, and public awareness in the local lead clinicians will improve diagnostic accuracy. Clinical picture at the beginning of the case often is unclear. The following observations should be kept in mind:
(1) Every patient with acute abdominal pain persists for more than 6 hours should be regarded as having a problem that requires surgical in-hospital evaluation. Well-localized pain and tenderness usually indicates a surgical condition. systemic hypoperfusion in conjunction with general abdominal pain is rarely due to medical problems.
(2) acute cholecystitis, appendicitis, intestinal obstruction, cancer, and acute vascular conditions are the most common cause of acute abdominal surgery in older patients. In children, appendicitis accounts for one-third of all cases and specific abdominal pain for almost all the rest.
(3) acute appendicitis and intestinal disorders are the final diagnosis in these cases most often erroneously believe nonsurgical first. Appendicitis must always remain a concern, especially if sepsis or inflammatory lesion is suspected. This is the most common cause of peritoneal findings strange that produce ileus or bowel obstruction. Half of children with appendicitis present with marked facial flush (due to high serotonin levels). The findings mark the cessation of gas or x-ray of the right lower quadrant ileus should increase the likelihood of appendicitis or retroileal retrocecal. Appendicitis is less likely in a previously healthy person if the history of exceeding the duration of 3 days' and the patient is afebrile, considerable pain, ileus, or leukocytosis. Pelvic appendix, with mild abdominal pain, vomiting, and diarrhea often, simulating gastroenteritis. Early signs may be mild abdominal and pelvic and rectal examination unremarkable. A number of low white blood cell lymphocytosis assistance or gastroenteritis. Atypical presentation of appendicitis is encountered during pregnancy. Maternal disease and fetal death in these cases is largely due to complications following a delayed diagnosis. The appendix is well tolerated during pregnancy, and removal of normal appendix is more often tolerated than observation of the perforation.
(4) salpingitis, dysmenorrhea, ovarian lesions, and urinary tract infections complicate the evaluation of acute abdomen in young women. Many diagnostic errors can be avoided by taking a careful menstrual history and pelvic examination and urine. study of ultrasound and pregnancy tests are very helpful in appropriate cases. Compared with patients with appendicitis, patients with acute salpingitis tend to present with a longer history of pain, often associated with the menstrual cycle, and high fever, signs of bilateral pelvic, and white blood cell count increased sharply.
(5) atypical manifestations of intestinal disorders, especially early cases, be easily missed. Emesis, abdominal distension, and air-fluid levels on x-ray may be negligible in the Richter hernia, proximal or closed loop small bowel obstructions, and the initial cecal volvulus. Intestinal obstruction in an elderly woman who has no previous surgery showed an incarcerated femoral hernia, or, rarely, an obturator hernia or gallstone ileus. There may be no pain or pain in the hernia. Carefully check the inguinofemoral region; repeat rectal and abdominal examination, and examine the obturator sign. Transient mild upper abdominal pain a few days later, followed by signs of intestinal obstruction is typical of gallstone ileus. Look for radiopaque stones and air in the biliary tree outlining the plain abdominal x-ray.
(6) Elderly or cardiac patients with severe diffuse pain unremitting abdomen but no peritoneal signs or abnormalities in the abdomen commensurate film may be used to intestinal ischemia. arterial blood pH should be measured and visceral angiography was conducted.
(7) The disease causes acute abdominal exploratory laparotomy must be removed before considered. Upper abdominal pain may be encountered in the myocardial infarction, acute pulmonary conditions (pneumothorax, lower lobe pneumonia, pleurisy, empyema, infarction), and hepatitis. General or abdominal discomfort may be felt on migrated acute rheumatic fever, polyarteritis nodosa and other types of diffuse vasculitis, acute intermittent porphyria, and acute pleurodynia. Sharp flank pain, often accompanied by convulsions and hyperesthesia rectus skin, osteoarthritis can be caused by nerve compression or thoracic spine. Similarly, joint disorders and acute bursitis can result in hip pain radiating to the lower quadrant. Pinpricking wonderful tingling sensation along the dermatomes or are characteristic of herpes zoster preeruptive. Medical conditions can usually be distinguished from the surgery by careful assessment of history and physical examination. Family history may provide the first clue. History is usually atypical in several aspects, and the openness of thought will reveal the details as normal or exaggerated symptoms or concurrent extra-abdominal complaints leading to the true cause. Although the apparent severity of illness, local abdominal pain rarely present voluntarily maintain. Fever and associated systemic signs may be comparable with the degree of pain. Laboratory studies and x-ray will verify the diagnosis and avoid surgery.
(8) Beware of acute cholecystitis, acute appendicitis, and peptic ulcer perforation in patients already hospitalized for diseases that affect other organ systems. their presentation is often atypical, leading to delayed diagnosis and complications.
(9) Exploration of the most frequently performed without profit to salpingitis, mesenteric adenitis, gastroenteritis, pyelonephritis, and acute hepatitis virus.
(10) non-specific abdominal pain, consisting of one-third of all cases, the most common cause of acute abdomen, especially in children. Generally mild, short-lived, and rarely associated with other serious symptoms, get better without specific treatment. Most cases are diagnosed a mild virus and bacterial infections, irritable bowel syndrome, gynecological problems, abdominal wall pain, psychosomatic illness, or worm infection.
INDICATIONS FOR SURGERY FOR EXPLORATION

 Indications for surgery tndakan presence visible when a specific diagnosis, but sometimes surgery should be performed before the proper diagnosis is reached. (As a working diagnosis). List of several indications for urgent laparotomy or laparoscopy. Among patients with acute abdominal pain, which is over the age of 65 years more often require surgery (33%) than younger patients (15%).
 Exploration is recommended in patients with inconclusive but persistent right lower quadrant pain. Pain in the upper left quadrant is rarely require urgent laparotomy, and the cause can usually wait for confirmation of elective studies.
HANDLING preoperative
When the initial assessment, parenteral analgesics for pain relief should not be given. At moderate doses, analgesics do not obscure the physical findings that are useful or masking-effect. With cramped rectus, abdominal mass may be apparent. Ongoing pain despite adequate doses of narcotics indicate a serious condition that often requires corrective surgery.
Resuscitation of critically ill patients are discussed in Chapter 2. Treatment should be limited to essential requirements. Special attention should be given to heart drugs and corticosteroid use and to control diabetes. Antibiotics are indicated for several conditions of infection or as prophylaxis during the perioperative period.
Usually nasogastric tube should be inserted in patients scheduled for surgery and for those with hematemesis or excessive vomiting, suspected intestinal obstruction, or severe paralytic ileus. These precautions can prevent aspiration in patients suffering from a drug overdose or alcohol poisoning, coma patients or weak, or elderly patients with impaired cough reflex. However, because the tube interfere with coughing and discomfort, it should be removed after safe to do so.
Urinary catheters should be placed in patients with systemic hypoperfusion. In some elderly patients, eliminating the cause of pain (acute bladder distension) or signs of stomach unmasks relevant.
Approval information (imformed consent) for the operation may be difficult to obtain when diagnosis is uncertain. It is wise to discuss with patients and families the possibility to do some operations; openings, temporary or permanent stoma; impotence or sterility, and postoperative intubation for mechanical ventilation. Every time a proper diagnosis is uncertain, especailly in the young or weak or very sick patients, preoperative discussion of honest diagnostic dilemma and the reason for laparotomy or laparoscopy would decrease postoperative anxiety and misunderstandings later .

Literatur :
1. curent surgical  diagnostic and treatment
2. De Jong , BUku ajar Bedah.
3. Greenfield, Texbook of Surgery