Part 2 : MANAGEMENT
You have made your diagnose of an
Acute Abdomen
and patient needs operation
such as ?
- Bowel obstruction,
- Strangulation of bowel, like in an inguinal hernia!
- Perforated ulcer
What TO DO FIRST..........?
Management A.A
1) Resuscitation !!
then....
2) Operate.... or.....Transfer
Difficulties in diagnosing
What to do if
not sure about Acute Abdomen..?
-
Resuscitate for 4 hours and
-
observe patient
If no improvement: Decide....
- Operate
or
- Transfer
What do you do in resuscitation ?
iv line and iv fluids
why?
naso gastric tube
- aspirate regularly
why?
indwelling catheter
why?
oxygen in serious cases
peri op: antibiotics, if indicated.
Colon: aerobic/anaerobic bacilli
LIKE: - a Cefalosporine or
- Chloramfenicol 500 mg iv 6 hourly
- Gentamycine
- Metronidazol 7.5 mg/kg iv 8 hourly
What kind of iv fluids do you have
in your hospital?
1) Saline
2) Ringers lactate
3) Dextrose 5%
4) Half – and Full strenght Darrow
What is that? Half or Full?
Half is 17 mmol K/liter
Full is 34 mmol K/liter
How much IV fluids?
The right answer is :
DEPENDS ON DEHYDRATION
other names:
HYPOVOLAEMIA
or
DEFICIT
How much iv fluid is needed?
Rough guidelines for person of 60 kg
Mildly dehydrated:
signs?
- lips and tongue dry
- 4 liters iv
Moderatly dehydrated: signs?
- also sunken eyes, loss of skin elasticity:
- 6 liters iv
Severily dehydrated:
signs?
- also oliguria/anuria, hypotension, clammy extremities:
- 8 liters iv . Start 4 liters in 1 hour
- also weak and desorientated:
- More than 8 liters, Danger of so much fluid iv ?
More about iv fluids in resuscitation
What kind of fluids do you give?
- First half of deficit: Ringers lactate or Saline
- Second half:
5% dextrose
Why dextrose?
Which electrolyte needs to be replaced in a vomiting
patient?
Potassium
How to replace that most simply?
- By full or half strength Darrow solution
- Every second bottle.... after the deficit
Still about Resuscitation
How do you know you give enough iv fluids?
- if he is passing urine
How much urine before going to theatre?
- at least 35 - 60 cc/hr
- ideally ? 150 cc
Maintenance iv fluid:
- at least 3 liters iv daily (1 l saline, 2 dextrose)
fluid loss: skin: 1000 cc, lungs: 500 cc, urine: 1500cc
Make sure: urine production 3 p.o. day: at least 1500cc
Decided: operation is needed
.......To transfer or not to transfer ?
General rule:
Transfer for operation, but after resuscitation!
If you can’t transfer do a laparotomy
Inform patient
No…… I want to have a CO as my
surgeon who attended
the training in Malawi………
Remember .....what is the most likely
diagnose of BOWEL Obstruction?
External hernia
(73%)
Sigmoid volvulus
(13%)
Intussusception
(4%)
Bands and adhesions (4%)
Malignant diseases, adult pyloric obstruction and
congenital anomalies (1%)
So make preparations before starting
operation
Be prepared in bowel obstruction
to find
Distended and Necrotic bowel
so.... ask the theatre nurse BEFORE operation starts for .......?
1. decompressor (or a urine catheter)
2. bowel clamps, bowel sutures (chr catg, vicryl)
3. saline for cleaning abdominal cavity
What kind of anaesthesia?
- General
What is the major risk in general anaesthesia in bowel
obstruction?
- Aspiration.
So what do you do to prevent aspiration?
ABSOLUTE OPERATIVE treatment ?
1) In all clinical signs of
Perforations
- Symptoms of a perforation?
- Examples?
- perforated peptic ulcer
- perforated typhoid ulcer
2) In all symptoms of
Strangulation
OPERATE, unless the patient is moribunt
Operation indications
When not to operate.....
LOCALISED INFLAMMATORY MASS
- Appendicitis
unless/until ?
- PID
unless/until ?
- Tb peritonitis
But how to treat ??
- by CONSERVATIV treatment FIRST
What is that?
- suck and drip
- for how long ?
What are signs of improvement in conservativ treatment?
Acute abdomen due to
BOWEL OBSTRUCTION
Some information about
OPERATIONS
Operative treatment
Incisions
Finding the cause
What to do next ?
Post operative care
ANATOMY
Incisions
After opening abdomen:
finding the cause
HOW to DECOMPRESS?
In
small bowel
by SUCTION?
1) via naso gastric tube and
maneuver (C)
is the preferred method, why?
2) metal decompressor
or
3) urine catheter, large size
Finding the cause
Is Gut dead
or viable?
Signs?
If a bowel resection is needed
What kind of ANASTOMOSIS ?
end/end
end/side
side/side
1 layer, preferrably vicryl
What to do in :
1) Necrotic SMALL bowel?
- Resect and do:
- preferrably an end/end anastomosis
2) Necrotic LARGE bowel?
Resect and do:
- Hartmann procedure (preferred )
- Exterization
- Colon anastomosis + proximal colostomy
In general: NOT SURE of the anastomosis in LARGE
Bowel ALWAYS a proximal colostomy!
and transfer later for further management
What to do in
COLON ILEUS due to Cancer?
- Proximal colostomy and REFER to
surgeon
In a PEPTIC ULCER PERFORATION?
- Close the perforation
- Wash out
What is the diagnose in the next patient?
An adult man
Complains of diffullty in passing flatus
Increasing abdominal distention (tympanic like a drum)
Not very painful
General condition is usually good, can drink,
Not dehydrated
LIKELY DIAGNOSE? ...............
How to confirm?
X ray: erect abdominal.
Look for the ?.......
- Reversed U
Management?: deflation with scope
and pass a rectal tube (36 Ch or 12 mm)
Prepare for operation
The reversed
U sign
(Frimann Dahls sign)
Position
Operative management in
Sigmoid Volvulus
Loop necrotic
RESECT: 3 choices
- Primary anastomosis with prox colostomy
- or Hartman procedure
- or Exteriorization
Loop
not necrotic:
- untwist, deflate, fIX sigmoid (PROSC)
(non absorbable suture material)
Closing Hartmann
Do not operate yourself
Refer to surgeon
Central Hospital
3 months later
Other findings at operation:
Intussusception
What to do?
- Manual reduction and inspection of the bowel
- check if bowel is vital (how?)
- if bowel is necrotic or in doubt:
resection and anastomosis
STOMA COMPLICATIONS
What to do in bands and adhesions?
Direct Post op Care: DAILY visits
Continue NG tube
when to remove ?
…..flatus, peristalsis, less stomach fluid
How much fluid / 24 hrs?
…..3 liters fluid iv:
- 1 liter 0.9 % Saline, 2 liters 5% dextrose
Continue urine catheter and measuring urine output
- on the third day it should be about: 1500 cc / 24hrs
After 2nd/3rd day: Potassium need: 40 – 80 mmol/24 hrs
- give half strength/ full strength Darrow
Start oral feeding: when?
- bowel sounds and flatus
- start thin porridge
The END of the Acute Abdomen
Thank you
0
