See pneumoperitoneum

radiographic founding on pneumoperitoneum

1. Pneumoperitoneum By : Rafi Mahandaru / 2013

2. By : Rafi Mahandaru / 212 Pneumoperitoneum

3. Background Pneumoperitoneum is a common medical problem in a recent year As the surgical treatment increase Usually unnoticed by practitioner due to insidious symptom Severe case can lead to unwanted complication Diagnosis can be done by GP Once diagnostic proof, severe case confirm  immediate treatment should achieved by the patient

4. Anatomical Review

5. Physiological Aspects Intra Abdominal Pressure (5-7mmHg) (BMI, Position, Diseases) Abdominal Perfusion Pressure (0-7mmHg APP = MAP - IAP

6. Etiology Ruptur viskus berongga ( yaitu perforasi ulkus peptikum , necrotizing enterocolitis , megakolon toksik , penyakit usus inflamasi ) Faktor iatrogenik ( yaitu pembedahan perut terakhir , trauma abdomen, perforasi endoskopi , dialisis peritoneal, paracentesis ) Infeksi rongga peritoneum dengan organisme membentuk gas dan atau pecahnya abses yang berdekatan

7. Etiology Perforated viscus organ ( 41% ) Residual Air (37 %) Peptic ulcer (16%) Diverticulitis (16%) Trauma (14%)

8. Non surgical Retained post operative air (25 – 60 %) Peritoneal dialysis and catheter placement (0,3 – 25 %)

9. Another Source

10. DP ABDOMEN

11. THORAX

12. ABDOMEN

13. PELVIS

14. CLINICAL SIGN Perforation : Intense abdominal pain Abdominal fullness Shoulder pain Acute distress  dsypnea Abdominal tension Tenderness Tympanic and rigid Rectal Prolapse ??? Crepitus Hypovolemic Shock  immediate decompression

15. Depen on the Causes and size : Benign  may be asymptomatic Vague abdominal pain Viscus organ rupture : Peritonitis sign Onset  Depend on organ Immediate  laparotomy

16. PATOGENESIS CO2  absorbed Hypercapnea Pulmonary vasoconstriction ANS  tachycardia Depressive effect on miocardium Cardiac index decrease 30% during 30 minutes initiation of pneumoperitoneum Decrease cardiac output (CO)  hemodynamic disturbances Decrease urine output Increase Aldosteron Decrease Creatinin clearance Elevated liver enzym Decrease portal Venous flow

17. DIAGNOSIS Purpose Entrapment of free air in the peritoneal cavity is the key Holistic history taking and Physical Examination  the most important Already mentioned above !!! Radiological  Confirming Thorax X-Ray erect  Best Right or Left Lateral Decubitus is allright ! USG, CT and MRI

18. X- Ray Semilunar Shadow gambaran udara (radiolusen) berupa daerah berbentuk bulan sabit ( Semilunar Shadow ) diantara diafragma kanan dan hepar atau diafragma kiri dan lien

19. Decubitus Abdomen Sign Terdapat udara bebas diantara dinding abdomen dengan hepar ( panah putih ). Ada cairan bebas di rongga peritoneum ( panah hitam ).

20. Anterior Subhepatic Space Free Air Linear Shape Triangular Shape Geograpichal Sign Density difference defining

21. Doges Cap Sign Morison Pouch Hepato -Renal Recesses

22. Anterior View of Hepatic Surface

23. Foot Ball Sign >1000 ml air collected  abdominal decompression Here Comes the MASSIVE ones

24. Gas-Relief Sign, Rigler Sign or Double Wall Sign memvisualisasikan dinding terluar lingkaran usus disebabkan udara di luar lingkaran usus dan udara normal intralumen

25. Urachus Sign udara tampak melapisi urachus. Urachus tampak seperti garis tipis linier di tengah bagian bawah abdomen yang berjala n dari kubah vesika urinaria ke arah kepala. Dasar urachus tampak sedikit lebih tebal daripada apeks.

26. Telltale Triangle Sign menggambarkan daerah segitiga udara diantara 2 lingkaran usus dengan dinding abdomen

27. Try To Guess ??? Rigler’s Sign Foot Ball sign Foot ball sign Falciform ligament’s sign

28. CT - Scan Standard Radiological examination Not necessarily needed Benefit : Detect, intraluminal free air Not depend on position and technique What X-Ray can’t shows and if it not specific Disadvantage : High cost Can’t locate perforation Beside the intraluminal fluid is not specific for pneumoperitoneum

29. Differential Chilaiditi ’s s y ndrom e (interposition hepatodiapragmatica , subphrenic displacement of the colon, pseudopneumoperitoneum ) Basal Lung Atelectasis ( colapsed alveoli – linear form, pneumonia, COPD, TBC ) Subphrenic ab c e s s (acute pancreatitis, peritonitis) Peritonitis

30. Management When ur patient has proven for pneumoperitoneum --  Find the Underlying Causes Unstable means Delay  Stabilize A , B , C Management  Abdominal decompression Stable  Confirm

31. Diagnostic confirm  immediate < 20 %  can be managed by non-surgical approach In patients with small amount of intraperitoneal air Without sign of peritonitis Patients should receive intravenous fluid Absolute bowel rest Intravenous broad spestrum antibiotic Get better on two days > 50%

32. Symptomatic patient with proof of peritonitis  Laparotomy (standard surgical management)

33. Conclusion Pneumoperitoneum  akumulasi udara pada rongga peritonel Penyebab terbanyak adalah ruptur Hollow Viscus Abdominal Organ karena berbagai sebab Diagnosis dapat dibuat dengan anamnesis dan pemeriksaan fisik yang teliti Diagnosis radiologi (X-ray, CT-scan, USG, MRI) sebagai konfirmasi sangat penting dalam mendiagnosis Penanganan yang cermat dan tepat waktu meliputi stabilisasi hemodinamik dan penemuan penyakit terkait sangat penting untuk mengurangi mortalitas dan morbiditas pasien

34. Refferences ME ,Breen, Dorfman M, Chan SB. 2008 . Pneumoperitoneum Without Peritonitis : A Case Report.Am J Emerg Med, 26 : 841. e1-2 Churchill , James D Begg . 2006 . Abdominal X-rays Made Easy 2 nd Edition. Elsevier Khan, Ali Nawaz. 201 1. Pneumoperitoneum Imaging : A Journal Diunduh dari http://emedicine.medscape.com , pada 8 Oktober 2012 Daly,   Barry D, J. Ashley Guthrie and Neville F. Cause of Pneumoperitoneum : A Case Report. United Kingdom Mansjoer , Arif , d kk. 2000. Bedah Digestif . Kapita Selekta Kedokteran Jilid 2 Edisi Ketiga (pp 240-252). Jakarta: Balai Penerbit FKUI. Dan L. Longo, Anthony S. Fauci , Dennis L. Kasper, Stephen L. Hauser, J. Larry Jameson, Joseph Loscalzo , Eds. 2008. Harrison’s Principle of Internal Medicine 17 th Edition. USA : The McGraw-Hill Companies. CH, Lee. 2010. Imaging Pneumoperitoneum : A Journal Diunduh dari http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/pneumoperitoneum.htm pada 8 Oktober 2012 Weerakkody , Yuranga dan Jeremy Jones . P neumoperitoneum . Diunduh dari http://radiopaedia.org/articles/pneumoperitoneum pada 8 Oktober 2012 Silberberg , Phillip. 2006. Pneumoperitoneum . Kentucky, USA. Derveaux ,K., F Penninckx . 2007. Crash Courses of Pneumoperitoneum . University Leuven Belgia

35. Thanx ..,