Part 2 : Part 2 : MANAGEMENTMANAGEMENT

You have made your diagnose of an You have made your diagnose of an Acute AbdomenAcute Abdomen

and patient needs operationand patient needs operation

such as ?such as ? - - Bowel Bowel obstruction,obstruction,

- Strangulation of bowel, like in an inguinal - Strangulation of bowel, like in an inguinal hernia!hernia!

- Perforated ulcer - Perforated ulcer

What What TO DO FIRST..........?TO DO FIRST..........?

Management A.AManagement A.A

1) Resuscitation !! 1) Resuscitation !! then....then....

2) Operate.... 2) Operate.... or.....Transferor.....Transfer

Difficulties in diagnosingDifficulties in diagnosing

What to do What to do if if notnot suresure about about Acute AbdomenAcute Abdomen....??

- ResuscitateResuscitate for for 4 hours 4 hours and and

observe patientobserve patient- - IfIf nono improvement improvement:: Decide.... Decide....

- - OperateOperate

oror

- - TransferTransfer

What What do you dodo you do in in resuscitation ?resuscitation ?

iv line and iv fluids why?iv line and iv fluids why? naso gastric tube naso gastric tube - aspirate regularly why? - aspirate regularly why?

indwelling catheter why? indwelling catheter why? oxygen in serious cases oxygen in serious cases peri op: antibiotics, if indicated. peri op: antibiotics, if indicated. Colon: aerobic/anaerobic bacilliColon: aerobic/anaerobic bacilli LIKE: LIKE: - a Cefalosporine or- a Cefalosporine or

- Chloramfenicol 500 mg iv 6 hourly- Chloramfenicol 500 mg iv 6 hourly - Gentamycine - Gentamycine

- Metronidazol 7.5 mg/kg iv 8 hourly- Metronidazol 7.5 mg/kg iv 8 hourly

What What kind of kind of iv fluids iv fluids do do you have in your hospital?you have in your hospital?

1) 1) SalineSaline

2) 2) Ringers lactateRingers lactate

3) 3) Dextrose 5%Dextrose 5%

4) Half – and Full strenght 4) Half – and Full strenght DarrowDarrow

What is that? Half or Full?What is that? Half or Full? Half is 17Half is 17 mmol K/litermmol K/liter Full is 34 mmol K/literFull is 34 mmol K/liter

How much How much IV fluids?IV fluids?

The right answer is :The right answer is :

DEPENDS ONDEPENDS ON DEHYDRATIONDEHYDRATION other names: other names:

HYPOVOLAEMIAHYPOVOLAEMIA

or or

DEFICITDEFICIT

How How much iv fluid is neededmuch iv fluid is needed? ?

Rough guidelines for person of Rough guidelines for person of 60 kg 60 kg

• MildlyMildly dehydrated: signs? dehydrated: signs? - lips and tongue dry - lips and tongue dry - - 44 liters iv liters iv• ModeratlyModeratly dehydrated: signs?dehydrated: signs? - also sunken eyes, loss of skin elasticity:- also sunken eyes, loss of skin elasticity: - - 66 liters iv liters iv• SeverilySeverily dehydrated: signs? dehydrated: signs? - also oliguria/anuria, hypotension, clammy - also oliguria/anuria, hypotension, clammy extremities:extremities: - - 88 liters iv . Start liters iv . Start 4 liters in 1 hour4 liters in 1 hour - also weak and desorientated: - also weak and desorientated: - - More than 8 liters, More than 8 liters, Danger of so much fluid Danger of so much fluid iv ? iv ?

More about iv fluids in More about iv fluids in resuscitationresuscitation

What What kind of fluidskind of fluids do you give?do you give? - - First half First half of deficitof deficit: Ringers lactate or : Ringers lactate or

SalineSaline - Second half- Second half: : 5% dextrose 5% dextrose

Why dextrose?Why dextrose? Which electrolyte needs to be replaced in a Which electrolyte needs to be replaced in a vomiting patient?vomiting patient?

PPotassiumotassiumHow to replace that most simply?How to replace that most simply?

- By full or half strength Darrow solution- By full or half strength Darrow solution - Every second bottle.... - Every second bottle.... afterafter the the

deficitdeficit

Still about ResuscitationStill about Resuscitation How do you know you give How do you know you give enough iv fluidsenough iv fluids?? - if he is passing urine - if he is passing urine How much urine before going to theatre?How much urine before going to theatre? - at least 35 - 60 cc/hr- at least 35 - 60 cc/hr - ideally ? 150 cc - ideally ? 150 cc Maintenance iv fluidMaintenance iv fluid:: - at least 3 liters iv daily (1 l saline, 2 - at least 3 liters iv daily (1 l saline, 2

dextrose)dextrose) fluid loss: skin: 1000 cc, lungs: 500 cc, urine: fluid loss: skin: 1000 cc, lungs: 500 cc, urine:

1500cc 1500cc Make sure: urine production 3 p.o. day: Make sure: urine production 3 p.o. day: at at

least 1500ccleast 1500cc

Decided: operationDecided: operation is is neededneeded

.......To transfer or not to .......To transfer or not to transfer ? transfer ?

General rule: General rule: Transfer for operation, but after Transfer for operation, but after

resuscitation!resuscitation! If you can’t transfer do a If you can’t transfer do a

laparotomylaparotomy Inform patientInform patient

No…… I want to have a CO as my No…… I want to have a CO as my surgeon who attended surgeon who attended

the training in Malawi……… the training in Malawi………

Remember .....what is the Remember .....what is the most likely diagnose of most likely diagnose of BOWEL ObstructionBOWEL Obstruction??

External hernia (73%) External hernia (73%) Sigmoid volvulus (13%)Sigmoid volvulus (13%) Intussusception (4%)Intussusception (4%) Bands and adhesions (4%)Bands and adhesions (4%) Malignant diseases, adult pyloric Malignant diseases, adult pyloric

obstruction and congenital anomalies obstruction and congenital anomalies (1%)(1%)

So make preparations before So make preparations before starting operationstarting operation

Be prepared in Be prepared in bowel bowel obstruction obstruction to findto find

Distended and Necrotic bowelDistended and Necrotic bowel so.... ask the theatre nurse so.... ask the theatre nurse BEFORE operation BEFORE operation

starts starts for .......?for .......? 1. decompressor (or a urine catheter)1. decompressor (or a urine catheter) 2. bowel clamps, bowel sutures 2. bowel clamps, bowel sutures (chr catg, (chr catg,

vicryl)vicryl) 3. saline for cleaning abdominal cavity3. saline for cleaning abdominal cavity What kind of anaesthesia?What kind of anaesthesia? - General - General What is the major risk in general anaesthesia in What is the major risk in general anaesthesia in

bowel bowel obstruction?obstruction? - Aspiration. - Aspiration. So what do you do to prevent aspiration?So what do you do to prevent aspiration?

ABSOLUTE OPERATIVE ABSOLUTE OPERATIVE treatment ? treatment ?

1) In all clinical signs of 1) In all clinical signs of PerforationsPerforations

- Symptoms of a perforation?- Symptoms of a perforation?

- Examples?- Examples?

- perforated peptic ulcer- perforated peptic ulcer

- perforated typhoid ulcer- perforated typhoid ulcer

2) In all symptoms of 2) In all symptoms of StrangulationStrangulation

OPERATE, unless the patient is moribuntOPERATE, unless the patient is moribunt

Operation indicationsOperation indications

When When notnot to operate.....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 toAcute abdomen due to

BOWEL BOWEL OBSTRUCTIONOBSTRUCTION

Some information about Some information about

OPERATIONSOPERATIONS

Operative treatment Operative treatment

Incisions Incisions Finding the causeFinding the cause What to do next ? What to do next ? Post operative carePost operative care

ANATOMYANATOMY

IncisionsIncisions

After opening After opening abdomen: abdomen: finding the finding the

cause cause

HOW to HOW to DECOMPRESS?DECOMPRESS?

InIn smallsmall bowel bowel

by SUCTION?by SUCTION?

1) via naso gastric tube and 1) via naso gastric tube and maneuver (C)maneuver (C)

is the preferred method, is the preferred method, why?why?

2) metal decompressor 2) metal decompressor or or 3) urine catheter, large size3) urine catheter, large size

Finding the causeFinding the cause

Is Gut deadIs Gut dead

or viable? or viable?

Signs?Signs?

If a bowel If a bowel resectionresection is is neededneeded

What kind of What kind of ANASTOMOSISANASTOMOSIS ? ? end/endend/end end/sideend/side side/sideside/side

1 layer, preferrably vicryl 1 layer, preferrably vicryl

What to do in :What to do in : 1) 1) Necrotic SMALL bowelNecrotic SMALL bowel?? - - Resect and do:Resect and do: - preferrably an end/end anastomosis - preferrably an end/end anastomosis

2) 2) NecroticNecrotic LARGE bowelLARGE bowel?? Resect and do:Resect and do: - Hartmann procedure (preferred )- Hartmann procedure (preferred )

- Exterization - Exterization - Colon anastomosis + proximal - Colon anastomosis + proximal

colostomycolostomy In general: NOT SURE of the anastomosis in In general: NOT SURE of the anastomosis in

LARGE Bowel LARGE Bowel ALWAYS a proximal ALWAYS a proximal colostomycolostomy!!

and transfer later for further management and transfer later for further management

What to do in What to do in

COLON COLON ILEUSILEUS due to due to Cancer?Cancer? - - Proximal colostomy and Proximal colostomy and

REFER to REFER to surgeon surgeon

In a PEPTIC ULCER In a PEPTIC ULCER PERFORATION?PERFORATION?

- - Close the perforationClose the perforation

- Wash out- Wash out

What is the diagnose in the nextWhat is the diagnose in the next patient?patient?

An An adult manadult man Complains of Complains of diffullty in passing flatusdiffullty in passing flatus Increasing Increasing abdominal distention (tympanic like a abdominal distention (tympanic like a

drum) drum) NotNot very painful very painful General condition is usually good, can drink, General condition is usually good, can drink, Not dehydrated Not dehydrated LIKELY DIAGNOSE? ...............LIKELY DIAGNOSE? ............... How to confirm?How to confirm? X ray: erect abdominal. X ray: erect abdominal. Look for the ?.......Look for the ?....... - Reversed U- Reversed U Management?: Management?: deflation with scopedeflation with scope and pass a rectal tube (36 Ch or 12 and pass a rectal tube (36 Ch or 12

mm)mm) Prepare for operatiPrepare for operationon

The The reversed reversed U signU sign

(Frimann Dahls sign)(Frimann Dahls sign)

Position Position

Operative management in Operative management in Sigmoid Volvulus Sigmoid Volvulus

Loop Loop necroticnecrotic RESECT: 3 choicesRESECT: 3 choices - Primary anastomosis with prox - Primary anastomosis with prox

colostomycolostomy - or Hartman procedure - or Hartman procedure - or Exteriorization- or Exteriorization Loop Loop notnot necroticnecrotic::

- untwist, deflate, - untwist, deflate, fIXfIX sigmoid sigmoid (PROSC) (PROSC)

(non absorbable suture material) (non absorbable suture material)

Closing HartmannClosing Hartmann

Do Do notnot operate operate yourselfyourself

Refer to surgeon Refer to surgeon

Central HospitalCentral Hospital

3 months later3 months later

Other findings at operation:Other findings at operation:

Intussusception Intussusception What to do? What to do?

- Manual reduction and inspection of the - Manual reduction and inspection of the bowelbowel

- check if bowel is vital (how?)- check if bowel is vital (how?)

- if bowel is necrotic or in doubt:- if bowel is necrotic or in doubt:

resection and anastomosisresection and anastomosis

STOMASTOMA COMPLICATIONSCOMPLICATIONS

What to do in What to do in bands and bands and adhesionsadhesions? ?

Direct Post op Care: Direct Post op Care: DAILYDAILY visits visits

Continue NG tube Continue NG tube when to remove ?when to remove ? … …..flatus, peristalsis, less stomach fluid..flatus, peristalsis, less stomach fluid How much fluid / 24 hrs?How much fluid / 24 hrs? … …..3 liters fluid iv:..3 liters fluid iv: - 1 liter 0.9 % Saline, 2 liters 5% dextrose - 1 liter 0.9 % Saline, 2 liters 5% dextrose Continue urine catheter and measuring urine outputContinue urine catheter and measuring urine output - on the third day it should be about: 1500 cc / - on the third day it should be about: 1500 cc /

24hrs24hrs After 2nd/3rd day: Potassium need: 40 – 80 mmol/24 After 2nd/3rd day: Potassium need: 40 – 80 mmol/24

hrshrs - give half strength/ full strength Darrow- give half strength/ full strength Darrow Start oral feeding: when?Start oral feeding: when? - bowel sounds and flatus- bowel sounds and flatus - start thin porridge - start thin porridge

The The END END of the Acute of the Acute AbdomenAbdomen

Thank youThank you