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
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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 ?
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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?
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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
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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
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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?
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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

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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
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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