1. Part 2 : MANAGEMENT

3. You have made your diagnose of an Acute Abdomen You have made your diagnose of an Acute Abdomen and patient needs operation and patient needs operation such as ? such as ? - Bowel obstruction, - Bowel obstruction, - Strangulation of bowel, like in an inguinal hernia! - Strangulation of bowel, like in an inguinal hernia! - Perforated ulcer - Perforated ulcer What TO DO FIRST..........? What TO DO FIRST..........?

4. Management A.A 1) Resuscitation !! 1) Resuscitation !! then.... then.... 2) Operate.... or.....Transfer 2) Operate.... or.....Transfer

5. Difficulties in diagnosing What to do if not sure about Acute Abdomen..? What to do if not sure about Acute Abdomen..? - Resuscitate for 4 hours and observe patient observe patient - If no improvement : Decide.... - Operate - Operate or or - Transfer - Transfer

6. What do you do in 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 bacilli Colon: aerobic/anaerobic bacilli LIKE: - a Cefalosporine or LIKE: - 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

7. 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? What is that? Half or Full? Half is 17 mmol K/liter Half is 17 mmol K/liter Full is 34 mmol K/liter Full is 34 mmol K/liter

8. How much IV fluids? The right answer is : DEPENDS ON DEHYDRATION DEPENDS ON DEHYDRATION other names: other names: HYPOVOLAEMIA HYPOVOLAEMIA or or DEFICIT DEFICIT

9. How much iv fluid is needed? Rough guidelines for person of 60 kg How much iv fluid is needed? Rough guidelines for person of 60 kg Mildly dehydrated: signs? Mildly dehydrated: signs? - lips and tongue dry - lips and tongue dry - 4 liters iv - 4 liters iv Moderatly dehydrated: signs? Moderatly dehydrated: signs? - also sunken eyes, loss of skin elasticity: - also sunken eyes, loss of skin elasticity: - 6 liters iv - 6 liters iv Severily dehydrated: signs? Severily dehydrated: signs? - also oliguria/anuria, hypotension, clammy extremities: - also oliguria/anuria, hypotension, clammy extremities: - 8 liters iv. Start 4 liters in 1 hour - 8 liters iv. Start 4 liters in 1 hour - also weak and desorientated: - also weak and desorientated: - More than 8 liters, Danger of so much fluid iv ? - More than 8 liters, Danger of so much fluid iv ?

10. More about iv fluids in resuscitation What kind of fluids do you give? What kind of fluids do you give? - First half of deficit: Ringers lactate or Saline - First half of deficit: Ringers lactate or Saline - Second half: 5% dextrose - Second half: 5% dextrose Why dextrose? Why dextrose? Which electrolyte needs to be replaced in a vomiting patient? Which electrolyte needs to be replaced in a vomiting patient? P otassium P otassium How to replace that most simply? - By full or half strength Darrow solution - By full or half strength Darrow solution - Every second bottle.... after the deficit - Every second bottle.... after the deficit

11. Still about Resuscitation How do you know you give enough iv fluids? How do you know you give enough 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 fluid: Maintenance iv fluid: - at least 3 liters iv daily (1 l saline, 2 dextrose) - at least 3 liters iv daily (1 l saline, 2 dextrose) fluid loss: skin: 1000 cc, lungs: 500 cc, urine: 1500cc fluid loss: skin: 1000 cc, lungs: 500 cc, urine: 1500cc Make sure: urine production 3 p.o. day: at least 1500cc Make sure: urine production 3 p.o. day: at least 1500cc

12. Decided: operation is needed.......To transfer or not to transfer ? General rule: General rule: Transfer for operation, but after resuscitation! Transfer for operation, but after resuscitation! If you can’t transfer do a laparotomy If you can’t transfer do a laparotomy Inform patient Inform patient

13. No…… I want to have a CO as my surgeon who attended the training in Malawi………

14. Remember.....what is the most likely diagnose of BOWEL 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 obstruction and congenital anomalies (1%) Malignant diseases, adult pyloric obstruction and congenital anomalies (1%) So make preparations before starting operation

16. Be prepared in bowel obstruction to find Be prepared in bowel obstruction to find Distended and Necrotic bowel Distended and Necrotic bowel so.... ask the theatre nurse BEFORE operation starts for.......? so.... ask the theatre nurse BEFORE operation starts for.......? 1. decompressor (or a urine catheter) 1. decompressor (or a urine catheter) 2. bowel clamps, bowel sutures (chr catg, vicryl) 2. bowel clamps, bowel sutures (chr catg, vicryl) 3. saline for cleaning abdominal cavity 3. saline for cleaning abdominal cavity What kind of anaesthesia? What kind of anaesthesia? - General - General What is the major risk in general anaesthesia in bowel obstruction? What is the major risk in general anaesthesia in bowel obstruction? - Aspiration. - Aspiration. So what do you do to prevent aspiration? So what do you do to prevent aspiration?

17. ABSOLUTE OPERATIVE treatment ? ABSOLUTE OPERATIVE treatment ? 1) In all clinical signs of Perforations 1) In all clinical signs of Perforations - Symptoms of a perforation? - Symptoms of a perforation? - Examples? - perforated peptic ulcer - perforated peptic ulcer - perforated typhoid ulcer - perforated typhoid ulcer 2) In all symptoms of Strangulation 2) In all symptoms of Strangulation OPERATE, unless the patient is moribunt OPERATE, unless the patient is moribunt

18. Operation indications Operation indications

19. 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?

20. Acute abdomen due to BOWEL OBSTRUCTION BOWEL OBSTRUCTION Some information about Some information about OPERATIONS OPERATIONS

21. Operative treatment Incisions Incisions Finding the cause Finding the cause What to do next ? What to do next ? Post operative care Post operative care

22. ANATOMY ANATOMY

23. Incisions Incisions

24. After opening abdomen: finding the cause

25. HOW to DECOMPRESS? In small bowel In small bowel by SUCTION? by SUCTION? 1) via naso gastric tube and maneuver (C) 1) via naso gastric tube and maneuver (C) is the preferred method, why? is the preferred method, why? 2) metal decompressor 2) metal decompressor or or 3) urine catheter, large size 3) urine catheter, large size

26. Finding the cause Is Gut dead Is Gut dead or viable? or viable? Signs? Signs?

27. If a bowel resection is needed What kind of ANASTOMOSIS ? What kind of ANASTOMOSIS ? end/end end/end end/side end/side side/side side/side 1 layer, preferrably vicryl 1 layer, preferrably vicryl

28. What to do in : 1) Necrotic SMALL bowel? 1) Necrotic SMALL bowel? - Resect and do: - Resect and do: - preferrably an end/end anastomosis - preferrably an end/end anastomosis 2) Necrotic LARGE bowel? Resect and do: Resect and do: - Hartmann procedure (preferred ) - Hartmann procedure (preferred ) - Exterization - Exterization - Colon anastomosis + proximal colostomy - Colon anastomosis + proximal colostomy In general: NOT SURE of the anastomosis in LARGE Bowel ALWAYS a proximal colostomy ! In general: NOT SURE of the anastomosis in LARGE Bowel ALWAYS a proximal colostomy ! and transfer later for further management and transfer later for further management

29. What to do in COLON ILEUS due to Cancer? COLON ILEUS due to Cancer? - Proximal colostomy and REFER to surgeon - Proximal colostomy and REFER to surgeon In a PEPTIC ULCER PERFORATION? In a PEPTIC ULCER PERFORATION? - Close the perforation - Close the perforation - Wash out - Wash out

31. What is the diagnose in the next patient? An adult man An adult man Complains of diffullty in passing flatus Complains of diffullty in passing flatus Increasing abdominal distention (tympanic like a drum) Increasing abdominal distention (tympanic like a drum) Not very painful Not 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?: deflation with scope Management?: deflation with scope and pass a rectal tube (36 Ch or 12 mm) and pass a rectal tube (36 Ch or 12 mm) Prepare for operation Prepare for operation

32. The reversed U sign (Frimann Dahls sign)

33. Position

34. Operative management in Sigmoid Volvulus Operative management in Sigmoid Volvulus Loop necrotic Loop necrotic RESECT: 3 choices RESECT: 3 choices - Primary anastomosis with prox colostomy - Primary anastomosis with prox colostomy - or Hartman procedure - or Hartman procedure - or Exteriorization - or Exteriorization Loop not necrotic : Loop not necrotic : - untwist, deflate, fIX sigmoid (PROSC) - untwist, deflate, fIX sigmoid (PROSC) (non absorbable suture material) (non absorbable suture material)

36. Closing Hartmann Do not operate yourself Do not operate yourself Refer to surgeon Refer to surgeon Central Hospital Central Hospital 3 months later 3 months later

37. Other findings at operation: Intussusception Intussusception What to do? What to do? - Manual reduction and inspection of the bowel - Manual reduction and inspection of the bowel - 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 anastomosis resection and anastomosis

40. STOMA COMPLICATIONS

41. What to do in bands and adhesions ?

43. Direct Post op Care: DAILY visits Direct Post op Care: DAILY 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 output Continue urine catheter and measuring urine output - on the third day it should be about: 1500 cc / 24hrs - on the third day it should be about: 1500 cc / 24hrs After 2nd/3rd day: Potassium need: 40 – 80 mmol/24 hrs After 2nd/3rd day: Potassium need: 40 – 80 mmol/24 hrs - 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

44. The END of the Acute Abdomen Thank you Thank you