of Gastrointestinal
Emergencies
Dr sandya Somaweera
Gastro Intestinal Emergencies (Acute Abdomen)
Sudden severe abdominal pain of unclear aetiology
Why?
Sepsis
Aetiology
Inflammatory bowel conditions acute appendicitis
Bowel perforation
Volvulus
Acute pancreatitis
Acute cholecystitis
Acute pyelonephritis
Diabetic ketoacidosis
Problems
Fluid balance
Dehydration
Why?
Fasting
Nausea and vomiting
Fluid secreted into the GIT is not reabsorbed
(about 9L of gastrointestinal juice is secreted into the gut but only
100 ml is ultimately excreted in faeces)
Large volumes are reabsorbed mainly in large intestine
Gastric and colonic losses hypotonic dehydration as more water
than electrolytes lost
Small intestinal losses isotonic dehydration
Assessment of dehydration
History
Examination
SPO2
Assessment of dehydration
Calculated in litres as % of body water in Kg
Mild 4%
Moderate 6%
Severe 8%
60 kg patient with severe dehydration needs approximately 4.8 L of fluid
Watch for
Overload
Lung bases for fine crepts
Investigations
How?
Crystalloid boluses 20ml/kg over 20 minutes or even a rapid
bolus of 500 ml
Repeat until goals are achieved (pulse rate <100/min), SBP
(>90mmhg), urine output (>0.5ml/kg/hr))
Careful with boluses in elderly and cardiac patients (100 200
ml)
Once B P is stable replace with 5% dextrose to replenish ISF and
ICF
Further monitoring
Passive
CVP guided fluid therapy for fine tuning
leg raising test
IVC
Gocollapsibility
for the CVP trend but not for an absolute reading
Trans
Normal 6-8 cmdoppler
oesophageal H2O
Electrolyte replacement
Mainly sodium and potassium
ECG- tall peaked T waves with a narrow base, ST depression, short QT, long
PR,wide QRS , cardiac arrest
Management
IV calcium to stabilise the myocardium
IV insulin Dextrose
Severe metabolic acidosis should be corrected with Sodium
Bicarbonate
Nebulise with inhaled beta blockers
If not responding renal replacement therapy (dialysis)
Premedication
Prokinetics (metoclorpramide)
Antibiotics
May need to start insulin if blood sugar control is poor infusion (0.1
u/kg/hr)
NG tube and aspirate the stomach contents
Epidural analgesia
Intra op
Intestinal obstruction
Bowel gangrene
Perforation
Faecal peritonitis
Septic shock
SBP< 90 or MAP < 65 mmhg despite adequate fluid
resuscitation
Monitor
CVP
Lactate <4
Abdominal trauma
Blunt or penetrating injury
Patient may present in haemorrhagic shock
Hypotensive resuscitation (only upto a SBP of 80 mmhg)
Early blood and blood products
Do not use excessive crystalloids or colloids
Resuscitation and surgery goes hand in hand in ongoing
bleeding
Questions?
A 85 year old patient is undergoing a laparotomy.
List the factors you would consider when prescribing post op
analgesia ,giving reasons.
Options
Simple PCM,NSAIDS
Opioids mild, strong (Side effects,routes of administration)
Local anesthestics (epidural,TAP)
Monitorng clinical,equipment
Oxygen
Analgesia
IV fluids
Feeding
Antacid prophylaxis
DVT prophylaxis
A 60 year old previously healthy female patient is
admitted to surgical casualty ward with features of
intestinal obstruction
On examination her pulse rate is 124/min,low volume
BP- 80/40
RR- 40/min
Surgeons want to do emergency lap after resuscitation
1.What are the problems you may find in her
2.How would you resuscitate
3.What are your goals of resuscitation
Thank You