Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 442 - файл
.pdf
318
https://t.me/medicina_free
M. A. Hardy and C. Yang
for surgery, both of which are seen frequently in
HICs. Of all patients who underwent surgery,
7.4% died, most postoperatively. Half of those
who died experienced a delay of 3 or more days
in presenting to the hospital, and most deaths
occurred after emergency colon resection (26%)
or closure of gastroduodenal perforation (23.7%).
Late presentation was associated with increased
mortality.
In all reports and our experience from LMICs,
the most common presenting symptoms of
patients with abdominal surgical problems were,
not unexpectedly, abdominal pain, distention,
and vomiting, and associated signs were abdominal tenderness, rebound tenderness, guarding,
and pain on coughing and walking or jumping.
Acute appendicitis remains the leading cause of
acute abdomen globally. Approximately onethird of the patients prompting surgery for acute
abdomen in LMICs were 20–40 years of age,
and of those, half had acute appendicitis. There
is little doubt that intra-abdominal infections
(IAIs) are a serious source of morbidity and mortality throughout the world, both in LMICs and
HICs [3].
Over the last 15years, the outcomes of IAI
have improved with early recognition and better use of antibiotics and supportive intensive
care to treat sepsis. It has become obvious that
early recognition, removal of the offending
source by drainage or operation, appropriate
selection of antibiotics, along with resuscitation and stabilization of the patient have
resulted in better outcomes in all environments,
and the resources to implement these strategies
are therefore critical. Surgical sepsis continues
to have high mortality, and early recognition
and treatment of acute abdomen and IAI
remains the main therapeutic goal for these
patients to survive. Many organizations have
published guidelines outlining the clinical
management of IAIs [4, 5], and we will draw
on many to summarize the important lessons in
this chapter. The most recent one consists of
recommendations to clinicians, jointly completed by a group of international and national
societies, for reasonable approaches to the
management of IAIs.
Principles ofDiagnosis
The diagnosis of acute abdomen and IAIs relies
primarily on history and physical exam. Patients
present generally with pain, tenderness that is
localized to the source of infection, fever,
increased white blood cell count with a shift to
the left, sometimes tachycardia, and hypotension
if dehydrated sufciently. If the delay is long
enough, the patient may present in greater distress and show signs of end-organ hypoperfusion
including oliguria and confusion. Adequate
detection of the source through exam, cultures, or
imaging which can then guide targeted treatment
is essential to minimize complications [6, 7].
Ultrasound (USG) and computed tomography
(CT) have both been used over the last two
decades as imaging tools to complete the clinical
assessment of patients with IAIs. While CT has
higher sensitivity, USG is far more universally
accessible, and, when performed by a trained clinician, can be very valuable in detecting perforations and collections. It is now generally
recommended to use USG as the initial diagnostic study following physical examination, and if
that is inconclusive, to resort to CT if that is available. As soon as the diagnosis of an acute abdomen with IAI is made, management includes
appropriate selection of antibiotics and additional
source control as needed via percutaneous or
operative drainage and/or removal.
Principles ofManagement
(Fig.27.1)
The most important tenet in the management of
an acute abdomen, with or without IAI, is to control the source of the problem. If the problem is
mechanical obstruction, then the obstruction has
to be decompressed via nasogastric tube (for
small bowel), colonoscopy (for volvulus), or
reduction and repair (for hernia). If the problem
is bleeding or bowel ischemia, then bleeding
needs to be halted, normal blood ow restored to
the bowel, and dead bowel resected. If the problem is perforation, then the leaking viscus needs
to be drained and potentially resected (for
27 How to Diagnose and Manage Acute Abdomen and Intra-Abdominal Infections in Low…
https://t.me/medicina_free
Fig. 27.1 Principles of
management (Ref. [1])
Patients with
intra-abdominal
infections
Empiric antibiotic
Source control
(as soon as possible in
critically ill patients)
Based on:
- Local epidemiology
- Individual risk factors for MDRO
- Clinical severity
therapy
(if sepsis hypotension
and septic shock)
319
Fluid support
Microbiological culture
- To identify the pathogen(s)
- To determine susceptibility
(always in patients at risk for
MDRO and in critically ill
patients)
appendicitis, small bowel perforation, or diverticulitis) or repaired (for gastroduodenal ulcer). If
the underlying diagnosis is uncertain but an
abscess is found, drainage may be necessary.
Throughout this period, while diagnosis is made
and initial treatment started, the patient must be
resuscitated with intravenous uid therapy to
account for uid losses incurred from limited
intake exacerbated by losses from vomiting and/
or diarrhea. Resuscitation should be guided primarily by the goal of achieving and maintaining
euvolemia with normal blood pressure and urine
output [8, 9]. For any acute abdomen with IAI,
broad- spectrum antibiotics should accompany, if
Vasopressors
(if hypotension persists
following fluid loading)
Reassessment of antibiotic
- To expand antibiotic regimen
- To de-escalate antibiotic regimen
therapy
Re-intervention
(if ongoing infection)
not precede, source control. The antibiotics
should be selected based on the most likely bugs
in the presumed source and then adjusted based
on culture data revealing specic bugs and drug
sensitivities. When formal cultures cannot be
obtained, gram stain can be a helpful starting
point in tailoring antibiotic regimens. Antibiotics
alone can be an effective means of achieving
source control in some patients with contained
localized IAI.This has recently gained popularity
in HICs in treating acute appendicitis; however,
we do not recommend this approach in situations
where follow-up of the patients may be inadequate or infeasible.
320
https://t.me/medicina_free
The rules of IAI source control outlined by
Sartelli etal. [1] and Fig.27.1 are the following:
“(First) Time, Totalization, Technique, and
(Second) Time.” The rst time refers to the starting time of treatment. Each hour in delaying the
rst time equates to a negative risk factor for
patient outcome. Totalization refers to removal of
any infectious source and related devitalized tissues, including ischemic bowel, and washing out
any purulent material from the abdominal cavity.
The “second time” refers to timing of any additional surgical drainage or debridement, which
may be scheduled or “on demand” depending on
the patient’s clinical symptoms and physiological
stability. Non-operative percutaneous drainage of
abscesses under USG guidance requires skilled
personnel generally found only at tertiary centers. Some general surgeons are now trained in
these skills and can successfully drain abdominal
and extraperitoneal abscesses in selected patients.
Surgery remains the most reliable therapeutic
intervention to control surgical infections, as it
allows the opportunity to both drain collections
and identify and directly treat the underlying
source of the infection. Traditionally, extensive
irrigation of the peritoneal cavity with saline is
used prior to closing an infected abdomen, but
this practice has been recently questioned in
favor of targeted focal irrigation. Primary closure
of the abdominal wound following peritonitis has
also been debated over the years for fear of major
wound infection with subsequent sepsis and large
hernia. We advise in most instances to close the
fascia with absorbable sutures and leave the skin
and subcutaneous tissue open and allow it to
granulate with daily packing or the use of a negative pressure-based temporary closure device.
Since the commercial vacuum dressings are quite
expensive, it is possible to make one as described
by Campbell et al. [10]. They use the top of a
Porto-Vac closed drainage container, slice off the
top and simply place it on the center of the
abdominal dressing or wound packing, before the
top Opsite is placed over the whole abdomen
(Fig. 27.2). This was originally designed when
the abdomen was left open to avoid a compartment syndrome with edematous bowel or in cases
of trauma or ischemic bowel when re-exploration
M. A. Hardy and C. Yang
Fig. 27.2 The top of Porto-Vac container top over the
wound covered with Opsite to allow vacuum suction
is indicated. Such vacuum-assisted closure of the
open abdomen is very useful and inexpensive in
LMICs. Leaving an abdomen open, which could
otherwise be closed primarily, introduces risks of
excessive uid and electrolyte loss and intestinal
stula and is recommended only for very specic
situations where re-exploration is indicated
within 48–72h of index exploration. In these circumstances, if an open abdomen is too complex
to manage, one could also temporarily close skin
directly with a running monolament suture
without closing fascia.
The Use ofAntibiotics
Antibiotics should be used as soon as a treatable
infection has been recognized or if there is a high
degree of suspicion of an infection. Appropriate
use of antibiotics may be difcult, and consultation with an ID expert can help avoid under- or
over-use and thereby optimize quality clinical care
while avoiding antibiotic resistance. While uncomplicated IAIs, such as uncomplicated appendicitis
or cholecystitis, require as little as a single preoperative dose of antibiotics, complicated IAIs may
require a short 4–7day course of antibiotic therapy
after operation or drainage is performed. It has
been previously shown that patients with complicated IAI did as well with a 4-day course of antibiotics as those maintained for a longer time as long
as the source was successfully treated [11].
27 How to Diagnose and Manage Acute Abdomen and Intra-Abdominal Infections in Low…
https://t.me/medicina_free
321
However, if the infection is ongoing, individualized judgment must be made regarding continued
use and type of antibiotics. Since patients with IAI
are usually started on empiric antibiotics, these
agents ought to be deescalated based on the ndings of cultures obtained during drainage or exploration. Cultures typically require up to 48–72 h
before a specic answer is available. Empiric antibiotic therapy should include agents with activity
against aerobic Gram-negative bacteria (e.g.,
Enterobacteriaceae), aerobic streptococci, and
also obligate enteric anaerobic organisms found in
the gastrointestinal tract. In selected patients, such
as diabetics or immunosuppressed patients, additional antimicrobials such as antifungals may be
indicated. Similarly, patients with increased risk of
tuberculous or parasitic exposure may require
antimicrobials accordingly. Microbiologic results
obtained during interventions may be based on
Gram stain if no microbiology laboratory is available on site. Even when cultures need to be sent
away to a microbiology laboratory and results are
delayed, the results remain informative in adjusting antibiotics to prevent overtreating the patient
with ineffective antibiotics. Attention must be paid
to the local existing endemic conditions and resistance epidemiology and the clinical condition of
the patients. Surgeons must be aware that drug
pharmacokinetics may be altered signicantly in
critically ill patients particularly as they are high
risk for multisystem organ dysfunction, and adjustments may have to be made in dose, frequency,
and method of administration depending on the
daily changing situation. It may be sometimes
wiser to administer an antibiotic continuously
rather than intermittently, as is usually done, to
achieve higher and more effective serum levels
and reach therapeutic serum levels more
effectively.
Patients who don’t appear to be improving
after 5–7 days following drainage or operation
while on appropriate antibiotics should have further work-up to determine if they need a change
in their antibiotics or reinvestigation for an inadequately controlled or new source. It is beyond
the purpose of this chapter to discuss the worldwide recent problems with expansion of resistant
microorganisms. Even response to common
sources of IAIa, like E. coli and other
Enterobacteriaceae, have now sometimes
become resistant to uoroquinolones, which
were previously very effective. Assistance by a
local ID expert, by telephone or virtually as necessary, is not only desirable but strongly recommended in difcult situations. As we will discuss
later in this chapter, specic antibiotics for some
of the fungal, parasitic, and unusual IAIs encountered primarily in LMICs (e.g., typhoid, TB,
schistosomiasis) require specic regimens which
may include several agents at the same time.
Management of these diseases will most strongly
benet from the advice of a local ID expert.
Management ofSepsis
Sepsis is a dreaded complication of acute abdomen with IAI. It is a systemic inammatory
response to infection and can result in multiorgan
dysfunction leading to death if unrecognized or
untreated. Sepsis may be part of a patient’s initial
presentation, or can occur at any stage in the
patient’s clinical course, even after what is considered a successful drainage or exploration.
Sepsis is the main cause of death in patients with
acute abdomen with IAI with severe sepsis in
27.8%, and septic shock in 67.8% of those who
die [1]. The pathophysiology of sepsis is directly
related to the endotoxins of both Gram-negative
and Gram-positive organisms. This is well
described by Levy and colleagues [12], but its
detailed discussion is beyond the scope of this
chapter. The denition of sepsis has changed over
the years, most recently dened as life- threatening
organ dysfunction caused by a dysregulated host
response to infection [1]. Septic shock is sepsis
with circulatory dysfunction wherein vasopressors are required to maintain a mean arterial pressure of 65mm Hg or greater and serum lactate, a
marker of organ perfusion, is elevated despite
adequate uid resuscitation. Prognostication of
sepsis is most closely captured by trends in a
patient’s Sequential (sepsis-related) Organ
Failure Assessment (SOFA) score, which
includes mean arterial pressure, Glasgow coma
scale score, and several lab values. An increase of
322
https://t.me/medicina_free
M. A. Hardy and C. Yang
2 or more points is associated with a mortality
>10%, while those patients who have septic
shock incur a mortality rate of 40%. The quickSOFA (qSOFA) score, which is based simply on
respiratory rate, mental status, and systolic blood
pressure, is an aptly named way to quickly identify patients at risk of poor outcomes from sepsis
[1, 12–14].
The progression of sepsis is characterized by
relative hypovolemia in the setting of myocardial
depression along with inappropriate vasodilatation and capillary leakage with consequently
decreased venous return to the heart. The release
of inammatory cytokines in response to infection drives this entire dysregulated response,
which in turn increases oxygen demand and
eventually precipitates tissue hypoxia, end-organ
hypoperfusion, and if sustained then ultimately
multiorgan failure.
The mainstay of sepsis management, in addition to targeted treatment of the source of infection with antibiotics and drainage or removal as
indicated, is uid resuscitation to improve circulating blood ow and support cardiac output, followed by vasopressor support to augment
vascular tone. When the overall metabolic
demand from this process exceeds a patient’s
innate ability to ventilate themselves, intubation
and ventilator support may be necessary. Such
management requires trained staff and an intensive care unit (ICU), which may require transfer
to a tertiary facility if not locally available.
Since hypotension is the most common indicator of sepsis, initial resuscitation with crystalloid infusion is critical to restoring perfusion and
oxygenation of various organs. This should not
be based on preset protocols but on patientspecic evidence of preserved end-organ function including mentation, urine output, and vital
signs (heart rate, blood pressure, respiratory rate,
oxygen saturation). Once resuscitative efforts are
established, urgent surgical intervention should
be undertaken as indicated, and resuscitative
efforts continued intraoperatively and postoperatively. In the process of uid resuscitation, one
must be aware of the possibility of generating
bowel edema and abdominal compartment syndrome, pulmonary edema, and respiratory fail-
ure. To avoid this, when adequate resuscitation
has been achieved as evidenced by no further
improvement in vital signs with uid boluses, the
treatment strategy should transition to use of
vasoactive agents rather than additional uid to
maintain organ perfusion. Vasoactive agents
require close monitoring and titration, preferably
in an ICU setting.
Vasopressor Agents
Vasopressor and ionotropic agents are critical to
management of progressive sepsis in IAI, in addition to antibiotics, uid replacement, and intervention to remove the offending causative source.
They should be available, or be made available, at
all local, regional, and tertiary hospitals. The
most common catecholamine agents available
are phenylephrine (alpha), norepinephrine (alpha
and beta-1), and epinephrine (alpha and beta.
They have somewhat different effects on alphaand beta-receptors, but may be carefully substituted for each other to maintain vasoconstriction
and thereby increase blood pressure to organ perfusion levels. Since beta-receptors act mainly on
cardiac contractility and chronotropy and may
cause vasodilatation, norepinephrine (noradrenaline), which has far more alpha-1 activity than
beta-1 activity, is the drug of rst choice to bolster blood pressure without increasing myocardial demand. Vasopressin, which contracts
vascular smooth muscle and functions as an
antidiuretic hormone, is the second line agent for
blood pressure augmentation, though this agent
may be less readily available. Other vasopressors
used instead of norepinephrine include dopamine; however norepinephrine is more efcacious than dopamine and may be more effective
for reversing hypotension in patients with septic
shock [15]. Also, dopamine is more likely to
cause tachycardia and arrhythmias as it is a beta-1
agonist at moderate doses.
Epinephrine (adrenaline) has essentially similar activity on alpha-1 and beta receptors and
therefore functions as both a vasopressor and an
inotrope. It is the agent of choice after
norepinephrine and vasopressin if the patient
27 How to Diagnose and Manage Acute Abdomen and Intra-Abdominal Infections in Low…
https://t.me/medicina_free
323
continues to require blood pressure support and
has evidence of cardiac dysfunction. Adrenaline
infusions are readily available in LMICs and
much less expensive than noradrenaline. Since
they have equivalent vasopressor effect to noradrenalin and are more available, they are used
more often inlocal LMICs hospitals as a rst-line
pressor despite the fact that they are more likely
to cause tachyarrhythmias. Dobutamine, another
inotropic agent, has far greater beta than alpha
activity and therefore increases heart rate and
cardiac output but given its beta-2 activity can
cause peripheral vasodilatation, making it a less
desirable agent for inotropy in an already hypotensive patient. Dobutamine can also cause undesirable tachyarrhythmias.
Sepsis secondary to acute abdomen with IAI
has come under better control in LMICs with the
greater availability in the last decade of antibiotics and vasopressors, even in local hospitals.
However, morbidity and mortality from sepsis
secondary to acute abdomen with IAI remains
signicant, second only to pneumonia. Lack of
ICUs for close monitoring and adequately trained
staff to perform timely surgical interventions for
source control continues to delay progress in this
eld in many LMICs.
Complications ofManagement
ofAcute Abdomen
Complications encountered following operative
interventions on patients who present with an
acute abdomen are numerous and depend on
many factors discussed previously.
The average age of patients presenting with an
acute abdomen in many studies was between 25
and 35years of age (range 15–95) and males predominated at a ratio of 2:1 to 4:1. The most common diagnosis in most studies was appendicitis
accounting for almost 50% of cases followed by
small bowel obstruction (16%), sigmoid volvulus
(12.7%), and perforated ulcer (4.3%) [16]. In
smaller studies appendicitis was less frequent
and only 10% while the most frequent cause of
peritonitis was perforation due to typhoid [17].
Incidence of perforation from diverticulitis or
colon cancer was rare. It appears that in Africa
middle-aged and older people have a much lower
incidence of colon cancer, diverticulitis, or even
appendicitis than those living in HICs. This has
been thought to be due to three times higher
ingestion of dietary ber in SSA as compared to
people in HICs who eat over-processed foods.
About one-third of patients undergoing operations for peritonitis and acute abdomen, including volvulus, colon, and peptic perforations,
developed post-operative complications. The
most frequent were wound infections in about
20% of patients and pneumonia in approximately
10% in several series. Post-operative mortality
varied widely among several reports from 6% to
almost 14% [16–18]. It was frequently associated
with bowel perforation and delay in diagnosis
and treatment that may have been due to lack of
trained surgeons and facilities and then complicated by delay in transfer to a tertiary center. The
main cause of death in all series was sepsis or
hypovolemic shock which could have been prevented by early diagnosis and adequate ICU
management (if an ICU was available). The main
factors associated with the relatively high morbidity and mortality following exploration for
acute abdomen appear to be (1) age of the patient
>65; (2) a delay in diagnosis >72h; (3) a delay in
surgical intervention >48h; (4) diagnosis of peritonitis; (4) duration of operation >2 h; and (5)
major spillage during exploration [18]. Three of
these causes, 2, 3, and 4 can be modied and are
preventable by organization of public awareness
campaigns to prompt rapid consultation in the
event of acute abdominal pain and the improvement in surgical stafng, providing of adequate
equipment and supplies to local and regional
health facilities, and facilitating transport of the
sickest patients to tertiary hospitals and wellequipped ICUs.
Acute Abdomen andPeritonitis
Acute abdomen and peritonitis are among the
main causes of non-trauma surgical emergencies
in many centers worldwide and in many instances
require more surgical interventions than trauma
324
https://t.me/medicina_free
M. A. Hardy and C. Yang
[19]. The proportion of non-trauma surgical
emergencies is reported to be between 30% and
57% [19, 20] with more than half requiring surgical intervention. This pattern is determined by
both the country and rural vs. urban sites and
continues to change as a result of environmental
factors. Acute appendicitis which was thought to
be infrequent among Africans is now the most
common cause of acute abdomen in West Africa
while diverticulitis which was also rarely seen
among the elderly has become more common in
the growing urban areas. This is thought to be
related to increased intake of a rened berdepleted diet which encourages formation of
fecaliths which obstruct the appendix and diverticula by slow moving feces [21].
With the growing incidence of emergent
abdominal surgical non-trauma IAIs needing
exploration, facilities for patients needing emergency care in LMICs were found to be inadequate
in most reports. Frequently, more than half the
patients who needed surgical intervention needed
to be transferred to another facility, thus increasing delay in treatment and leading to complications and fatalities. The general impression has
been that greater attention should be paid to the
expansion, stafng, and provision of needed
equipment and supplies of emergency surgical
services to the increasing number of patients in
LMICs. Deciencies in surgical manpower and
nancial support, as well as the lack of basic laboratory and blood banking services coupled with
difculties in procuring materials required for
resuscitation and surgery, are the main problems
that account for the delay and increased morbidity and mortality [19, 20]. The main reasons for
deaths from acute abdomen and/or peritonitis in
many previous studies focused on late presentation, having spent considerable time in another
hospital and difculty with transfers, inability to
carry out required investigations, and failure to
have needed immediate surgical intervention.
Appendicitis
Epidemiology
Acute appendicitis (AA) remains the most common abdominal surgical emergency and cause for
IAI worldwide and in LMICs. It has been shown
that one-third of these cases were thought to be
complicated [1]. Although in the past acute
appendicitis had a low rate in SSA, Asia, and
Latin America, it appears now to be increasing,
both because of better records probably because
of environmental changes and change in diet.
Diagnosis
Diagnosis is based primarily on clinical history
and ndings familiar to all medical students and
surgeons and will not be detailed here except to
say that it is the “great mimic” and may be easily
confused with other IAIs. Attempts have been
made to differentiate complicated (retrocecal,
perforated) from uncomplicated acute appendicitis without much success except for a CT scan
which is rarely available in LMICs. USG has
been successfully used to identify appendicitis,
especially in pregnant women and may be also
useful to differentiate between complicated and
uncomplicated appendicitis. Imaging may show
increased diameter and wall thickness of the
appendix, appendicolith (may be also seen on
abdominal X-ray), local abscess, and uid around
the appendix.
Management
All general surgeons are very familiar with management of acute appendicitis, and this chapter
will focus on it only briey since it is most common, and its treatment has changed over the years
in HICs but not in LMICs. Although in HICs,
laparoscopic appendectomy has become the standard of care, this is not practical nor indicated at
this time in LMICs because of lack of staff training and of laparoscopic equipment which is
expensive. Treatment of uncomplicated, nonperforated appendicitis with antibiotics alone has
recently gained popularity in HICs. Although it is
tempting to use it in LMICs, it should be avoided
since it requires close follow-up and laboratory
support which the infrastructure in most LMICs
rarely permits. Delay in presentation, in diagnosis, and in operation contribute to high morbidity
and signicant mortality. The estimated rate of
perforation occurring at a higher rate primarily in
the younger and older age groups has been
16–40% in most studies from LMICs.
27 How to Diagnose and Manage Acute Abdomen and Intra-Abdominal Infections in Low…
https://t.me/medicina_free
325
Postoperative antibiotics are not needed if the
appendix is not perforated, but should be used for
4–7days if a peri-appendiceal abscess or perforation is present, under which circumstances the
small wound may be left open above the closed
fascia and packed to avoid wound infection.
Cholecystitis
Epidemiology
Cholelithiasis is a common disease worldwide
but is very rare in Africa (less than 5%) and infrequent in China and Asia (about 5–10%), while in
HICs it is about 8% in men and 16+% in women
[22]. The pathophysiology and diagnosis should
be very familiar to most medical students and is
very familiar to most physicians and to all general surgeons. Acute cholecystitis is related to
cholelithiasis in most instances (more than 90%).
In LMICs it may also occur in many cases with
obstruction of the cystic duct by a helminthic
infection (ascariasis) which may lead to perforation or gangrene of the gall bladder.
Diagnosis
Diagnosis of acute cholecystitis is made on clinical basis and is well known to all trained surgeons
and needs not to be repeated here. The characteristic right upper quadrant pain provoked by fatty
red foods with Murphy’s sign, belching, nausea,
occasional vomiting, and fever with leukocytosis
are only some of the characteristic basic clinical
ndings. The diagnosis is conrmed by ndings
of stones, pericydtocholic uid, and distention of
the gallbladder with thickening of the wall on an
USG.
Management
First-line treatments include fasting, intravenous
uids, antibiotics, and analgesia. Percutaneous
cholecystectomy under USG is a safe alternative
to cholecystectomy for very ill and/or septic
patient who may be unt to undergo surgery or
where the infrastructure for operation is inadequate. Gallbladder perforation or gangrenous
cholecystitis require emergent interventions and
are life-saving. Urgent cholecystostomy (percutaneous transhepatic gallbladder drainage) with
or without delayed laparoscopic cholecystectomy
appears to be the correct clinical approach for
those not t for surgery, or for those who fail to
improve after 2–3days of antibiotic treatment.
Effective treatment is almost always surgical
within 24–48hours but can be delayed and postponed with judicious use of antibiotics. This is
dangerous in diabetic or immunosuppressed or
elderly patients where the gall bladder can
become gangrenous and rupture resulting in a
major complication and frequently death. The
timing of cholecystectomy continues to be debatable. When elective, the operation should be done
under optimal conditions. In HICs the new standard of care for cholecystectomy is laparoscopic
intervention, but in many LMICs it remains an
open approach due to inadequate laparoscopic
training and expertise and the lack of expensive
equipment.
Cholangitis
Epidemiology
Acute cholangitis results from biliary obstruction
combined with bacterial infection in the bile
either by ascent from the intestine or from the
venous portal system. It usually starts following
choledocholithiasis and blockage of the common
bile duct (CBD) which may also be blocked by
tumor or parasites (vide infra). It is not uncommon in LMICs but the record of cases is poor and
unreliable. Its incidence parallels that of cholelithiasis at a much lower frequency in LMICs than
in HICs.
Diagnosis
Clinical ndings associated with acute cholangitis include abdominal pain, jaundice, fever
(Charcot’s triad), and rigor and may mimic acute
cholecystitis when the common bile duct is
compressed by a distended gall bladder. The disease is also charcterized by Charcot’s triad of
right upper quadrant pain, fever, jaundice and rigors; this has been expanded to Reynid’s pentad
with addition of hypotension (shock) and confusion. Diseases which should be differentiated
from acute cholangitis are acute cholecystitis,
gastric and duodenal ulcer, acute pancreatitis,
326
https://t.me/medicina_free
M. A. Hardy and C. Yang
acute hepatitis, and septicemia of other origins as
well as hepatic abscess, and right lower lobe
pneumonia. Laboratory data show elevated white
count and abnormal liver function test with elevated bilirubin and enzymes and alkaline phosphatase. Blood cultures are also helpful for
severity assessment, as well as for the selection
of antimicrobial drugs. Plain X-ray may demonstrate free air, pneumobilia, and ileus. Abdominal
ultrasound (US) and abdominal computerized
tomography (CT) with intravenous contrast are
very helpful studies in evaluating patients with
acute biliary tract disease. Since CT may not be
available, USG must demonstrate the presence of
biliary obstruction and its level as well as the
cause of obstruction which is usually a gallstone
and rarely stricture or tumor. In LMICs it may be
one of the parasites that infect the liver such as
Ascaris, or one of the liver ukes.
Management
Patients with acute cholangitis are at risk for
developing severe infection that can be fatal
unless appropriate medical care is provided at an
early stage. Prompt treatment with appropriate
antibiotics (blood culture) and acute care in an
ICU is mandatory. The best treatment is decompression by biliary endoscopy and removal of
obstructing stone or biopsy of any mass and
placement of a stent to keep the duct open and
draining. If the stone is large, endoscopic sphincterotomy can be done. This requires special
expertise and experience which can usually be
found only at the tertiary hospital. If an open
drainage must be done because of no available
expertise, the simplest procedures such as T-tube
placement without choledocholithotomy should
be done as a temporary solution in unstable
patients to avoid a prolonged operation. Whenever
possible, denitive elimination of the biliary
obstruction should be the goal of surgery. Once
this is accomplished, a cholecystectomy should
be performed after the patient recovers from sepsis and is stable to avoid further stones from that
source. Emergent drainage is essential for severe
cases, whereas patients with moderate and mild
disease should also receive drainage as soon as
possible if they do not respond to conservative
treatment, and their condition has not improved.
Biliary drainage can be achieved via three different routes/procedures: endoscopic, percutaneous
transhepatic, and open methods. Drainage of the
CBD without delay has resulted in reduction of
morbidity and mortality from acute cholangitis.
However, it remains a life-threatening disease.
Diverticulitis
Etiology
Diverticular disease has been considered a “disease of the western civilization” [1] due to the
fact that the incidence and prevalence of diverticular disease differ more than 20–40-fold
between high- and low-risk populations, and tend
to be more common in high-income countries,
where Westernized lifestyles prevail, than in lowincome countries. It is especially rare among the
native black population in rural Africa where a
high intake of dietary ber has been associated
with a reduced risk of diverticular disease in several studies. Although it was previously reported
that diverticular disease was unknown in black
Africans, it has been noted recently that the incidence has increased in the cities. The disease
manifestations range from localized diverticular
inammation best treated with intravenous and
oral antibiotics to perforation and fecal peritonitis which requires colon resection. It is therefore
recommended that the index of suspicious for
diverticular disease of the colon and its complications should also increase.
Diagnosis
Localized inammatory diverticular disease
manifests itself with low-grade fever and tenderness over the site of inammation, on the left or
right lower quadrant. On the right the differential
diagnosis must include appendicitis. It may be
accompanied by diarrhea. Diarrhea may be melanotic or even bloody if there is diverticular bleeding which may be intermittent and copious.
History of similar recurrent episodes increase the
probability of diveticulitis, especially if there is a
history of a previous barium enema or CT scan
that may have shown diverticular disease.
27 How to Diagnose and Manage Acute Abdomen and Intra-Abdominal Infections in Low…
https://t.me/medicina_free
327
Elevated white count with a shift to the left
accompanies the pain which is most signicant if
there is a walled off perforation with an abscess.
This is best demonstrated with a CT scan and
may be detected with an USG.
Management
This subject is extensively covered in standard
surgery textbooks and is presented here for the
sake of completion since it is still relatively rarely
seen urgently with an acute abdomen in LMICs
and is well recognized by surgeons in HICs. The
management of left- and right-sided perforations
or bleeding is all too familiar to western-trained
surgeons despite their differences in the choice of
operative procedure in the emergent situation–
resection with or without colostomy. Implications
of colonic re-anastomoses have been attractive,
but the incidence of leaks and anastomotic breakdowns by inexperienced staff has led to wound
infections and fatalities. This suggests that the
use of diversion may be more prudent. The management of perforated diverticulitis has recently
changed dramatically, due to better radiological
imaging and the availability of non-surgical treatment options by percutaneous drainage and laparoscopic resections. This kind of approaches is
only possible in select tertiary centers in LMICs
where such patients should be transferred for
optimal treatment.
Sigmoid Volvulus
Epidemiology
Sigmoid volvulus is the commonest cause of
large bowel obstruction in many regions of the
world, and in some LMICs it is second only to
acute appendicitis as a cause of acute abdomen.
In Ethiopia it is the most common cause for intestinal obstruction. In Africa it is 4 to14 times more
common in men than in women, and majority of
them are older than 60years of age [23]. The etiology is unknown but it has been suggested in the
past that dietary habits, cultural stool withholding behavior, and chronic constipation can lead to
a redundant sigmoid which can twist along its
narrow mesenteric base.
Diagnosis
The chief complaint is abdominal pain and
inability to defecate and pass atus, and the
physical nding is marked abdominal distention.
About a quarter to half of the patients are rst
seen with an acute abdomen after a delay in
arriving at the hospital which ranges sometimes
up to 5days during which they may take local
remedies, if the transport from distant rural areas
in an LMIC is intermittent or unavailable. In one
study representative of ndings in Ethiopia, but
also found in Pakistan and Uganda, one-half to
two-thirds of the patients developed gangrenous
bowel which carries a far worse prognosis
despite prompt operative intervention. Flat and
upright X-ray of the abdomen is usually a sufcient imaging study to visualize sigmoid volvulus, with its typical bird’s beak sign, in LMICs
where CT scans are rarely available in smaller
than regional hospital.
Management
The primary treatment for almost all the patients
around the world is derotation in the very early
stage with subsequent elective resection, and
most often in LMICs where delay predominates,
primary resection and anastomoses. The overall
mortality of 4.5% to 18% [23] is highly dependent on the delay between onset of symptoms
and intervention. Non-operative treatment of
viable bowel may be a better treatment for older
frail patients and emergent surgery can be made
semi- elective. Without surgery however, recurrence rate is very high, almost 50%, and many
patients refuse surgery after being relieved with
decompression. The highest mortality occurs
when gangrenous sigmoid is resected and a primary anastomosis is performed when compared
to those who have viable bowel. This suggests
that resection with Hartmann’s pouch following
resection for gangrenous bowel is generally
underutilized. The main factors associated with
mortality and with main complications of wound
infection and sepsis are duration of illness,
being female because they appear to ignore
symptoms longer, and most importantly, primary resection and anastomoses in face of gangrenous bowel.
Соседние файлы в папке @xirurgi_2025