This is defined as severe sudden onset of pain of less than 7 to 10 days duration. The causes of an acute abdomen can be localized to the abdomen but sometimes can be from a systemic non-surgical cause. It is very important to be able to quickly assess and decide whether it is a surgical acute abdomen or medical acute abdomen.

 The usual presentation of a surgical acute abdomen is sudden abdominal pain (colicky or sharp piercing) associated with vomiting and/or constipation. Other features might include abdominal distension and failure to pass flatus. The main causes of a surgical acute abdomen are acute appendicitis, acute perforated duodenal ulcers, acute intestinal obstruction, acute cholecystitis, pancreatitis, ectopic pregnancy and ovarian torsion. Non abdominal causes of pain that mimic an acute abdomen are numerous and may include myocardial infarction, pericarditis, pneumonia or pleurisy.

 EVALUATION                  

• History and physical examination will help narrow down the differential diagnoses and also determine whether the patient requires emergency surgery. Special attention should be paid to the nature of pain, location, onset, duration, intensity, recurrent nature, aggravating and alleviating factors.
• Physical exam should note the general state of the patient, abdominal distension, surgical scars, tenderness, guarding, rebound tenderness, presence of a mass, rectal, cervical or adnexal tenderness.
• Initial tests might include an FBC, U&Es, amylase, lipase, pregnancy test, urinalysis and LFTs. ? Imaging studies may be necessary:

Plain abdominal x-rays may reveal obstruction, perforation (free air under the diaphragm) and other pathology.

Ultrasound is indicated especially for biliary tract disease, pelvic and urinary system pathology.

             TREATMENT 

• Haemodynamically unstable patients might need immediate resuscitation with Normal saline or Ringers lactate, possible transfusion, nasogastric tube for obstruction or persistent vomiting, urinary catheter for monitoring output, broad spectrum empirical antibiotic for peritonitis, suspected perforated viscus or intra-abdominal injection.
• Direct treatment towards the specific condition should be instituted by the specialist after diagnostic workup.

What is causing the kidney injury? Try and classify by cause. The majority of cases of acute renal failure (or acute kidney injury) are due to ischaemic or toxic injury to the kidney and are reversible if treatment is instituted promptly i.e. within hours not days.

Pre-Renal Cases

Most common cause of acute kidney injury and most amenable to therapy. Usually have a history of hypovolaemia or hypotension e.g. bleeding, vomiting, diarrhoea and are usually oliguric.  Rapid recovery of renal failure is to be expected with prompt treatment.  

Acute Renal Failure 

Consider sepsis, malaria, acute glomerulonephritis, acute tubular necrosis, myeloma, nephrotoxic medicines such as gentamicin and NSAID‘s, and other causes such as acute -on-chronic renal failure.  As a minimum, get urine microscopy and an ultrasound of the kidneys for size. Are the kidneys normal sized, small, enlarged or obstructed?

Obstructive Uropathy

Continuous bladder catheterisation is required until the obstruction is relieved.  Relief of obstruction can result in polyuria.  Therefore, rehydrate with IV fluids.  Aim to keep up with the urine output.  Sodium and potassium supplements may be required. Scan kidneys to exclude hydronephrosis. Refer to a urologist for definitive management.

Exclude prostatic enlargement in males and cancer of the cervix in women.

Management of Renal Failure

14. First line: Exclude dehydration in all cases. Give adequate rehydration. Try fluid challenge with sodium chloride 0.9%. Should show response within hours (not days). Aim for a visible jugular venous pressure (JVP) first and then consider giving IV frusemide to encourage diuresis.
14. Second line: If the patient fails to respond to adequate rehydration and fluid challenge with sodium chloride 0.9% [not dextrose 5%] within 24 hours and condition is deteriorating, referral for dialysis is indicated.  If this is not possible, then aim to support patient until the kidneys recover [may take up to 6-8 weeks or more].  Monitor fluid (input and output charting) carefully. Check electrolytes regularly and maintain nutrition. Watch for infections.
14. Third line: Start dialysis or consult dialysis team sooner rather than later so that they can help monitor the patient. Late referrals contribute to the mortality of acute kidney injury (acute renal failure) and endstage renal disease. Selection criteria are applied for the chronic dialysis programme and hence, each individual patient should be discussed with the dialysis team.  

Fluid balance: Daily weights before breakfast.  Aim for no weight gain. 

Previous day‘s losses (urine, vomit etc) +500mls =day‘s fluid intake. Electrolytes:  Ideally measure urea and electrolytes at least on alternate days.  Monitor potassium levels. 

To lower potassium levels in acute hyperkalaemia, give:

10ml of 10% Calcium gluconate/chloride over 10 minutes plus 50ml of 50% glucose over 10 minutes plus 10 units of short acting insulin OR

Salbutamol Nebulised 10gm two times a day review plus 50ml of 50% glucose over 10 minutes plus 10 units of short acting insulin OR 

Calcium Resonium 45mg as enema, keep enema in for as long as possible

General measures in the management of acute renal failure

14. Catheter: Insert a urinary catheter but remove it once sustained diuresis has occurred or if oliguria persists and the patient is started on dialysis or conservative treatment. Avoid long catheterisation periods.
14. Urine: Ward urinalysis test - check for haematuria, proteinuria and glycosuria. Send urine for microscopy (for cells, casts), culture and sensitivity.
14. Diet: High calorie and normal or high protein diet with low sodium and low potassium. Ask for dietician‘s help. For low potassium diet, avoid e.g. oranges, bananas, mangoes.
14. Anaemia: If oliguric do not transfuse unless there is significant bleeding, as there is a high risk of fluid overload. Wait to transfuse until patient is on dialysis.
14. Monitor  BP regularly( e.g. 4 hourly) n                                   
14.   Monitor fluid input/output strictly.
14.  Avoid nephrotoxic medicines such as gentamicin and NSAIDs
14.  Watch for and treat underlying infections.
15. Check weight gain

This is the commonest acute abdominal surgical emergency. Typical symptoms are shifting abdominal pain (starting as vague periumbilical pain then shifting to the right iliac fossa) associated with nausea and occasional vomiting. On evaluation, uncomplicated appendicitis has right iliac tenderness ellicited maximally at McBurney‘s point with possible positive Rovsing sign. The white blood count may be elevated. The diagnosis of appendicitis should be made on clinical grounds but other investigations especially ultrasound scan and CT scan might be necessary in females and where the history is not typical. The other tests are especially useful to exclude other pathologies that might mimic appendicitis. Straightforward appendicitis needs emergency surgery as delays are associated with complications and poor outcome. The treatment of appendicitis is surgical. Laparascopic appendicectomy is now popular among surgeons with special interest and is particularly useful in females where the advantage of visualising pelvic viscera is important. The cosmetic advantages are additional to the less pain, reduced hospital stay and earlier recovery noted with laparascopic surgery.

The use of antibiotics in appendicitis and its complications can be summarized as below:

CONDITION TREATMENT

• Acute appendicitis: Emergency appendicectomy and prophylaxis:

Ceftriaxone 1g IV once only AND

Metronidazole 500mg IV once only

Appendiceal Abcess:Clinical Assessment of mass and institution of IV antibiotics and analgesia

Benzyl Penicillin 2,5MU IV four times a day AND 

Gentamycin 120mg IV once daily AND 

Metronidazole 500mg IV three times a day

• Alternatively

Ceftriaxone 1g IV 2 times a day AND

Metronidazole 500mg IV three times a day

This can be done while serial examinations (daily) for clinical improvement of size of mass. are instituted Serial FBC and USS monitoring for improvement is also important. Failure to improve or deterioration in condition might warrant surgical intervention. If the patient improves elective surgery (six weeks after initial presentation) is advised as operating early is fraught with higher risk of complications.

• Appendiceal abscess. Emergency incision and drainage (with or without appendicectomy) or  USS guided pus drainage plus antibiotics as follows:

  Benzyl Penicillin 2,5MU IV four times a day AND 

  Gentamycin 120mg IV once daily

• Alternatively

• Ceftriaxone 1g IV 2 times a day AND

  Metronidazole 500mg IV three times a day

These treatments are continued till clinical improvement is satisfactory. Interval elective appendicectomy might or might not be necessary.

• Appendiceal rupture/perforation. Generalised peritonitis is typical and prognosis is poor. Aggressive fluid resuscitation, IV antibiotics and urgent laparatomy are all necessary. The IV antibiotic regime is as for appendiceal abscess above.

General Notes

(See National Infection Control Guidelines)

Transmission of infections in healthcare facilities can be prevented and controlled through the application of basic infection control prevention and control practices. The 2 tiers or categories of infection control prevention and practices are A) standard precautions and B) transmission based precautions.  The goal of this two- tier/category system is to minimise risk of infection and maximise safety level within our healthcare facilities.

• Educate healthcare workers not only on what to do but why it is important to do it.
• Emphasising outcomes helps healthcare workers see how their routine job duties interact with the infection control system.

Categories of Infection Control Practices:

1. Standard Precautions (previously known as Universal Precautions) - must be applied to all patients at all times, regardless of diagnosis or infectious status.
2. Transmission based precautions - are specific to modes of transmission e.g. airborne, droplet or contact. 

A) Standard Precautions

Treating all patients in the healthcare facility with the same basic level of ?standard? precautions involves work practices that are essential to provide a high level of protection to patients, healthcare workers and visitors.

These precautions include the following:

• Hand hygiene (hand washing, hand antisepsis)
• Use of personal protective equipment when handling blood substances excretions and secretions.
• Appropriate handling of patient care equipment and soiled linen.
• Prevention of needle stick/sharp injuries.
• Environmental cleaning and spills management.
• Appropriate handling of waste.

• Hand Hygiene

  Appropriate hand washing can minimise micro-organisms acquired on the hands by contact with body fluids and contaminated surfaces. Hand washing breaks the chain of infection transmission and reduces person to person transmission.

   

  NB:  Hand washing or hand antisepsis is the simplest and most cost- effective way of preventing the transmission of infection and thus reducing the incidence of healthcare associated infections.

   

  Types of Hand Hygiene

   

• Hand washing is usually limited to hands and wrists, the hands are washed for a minimum 10-18 seconds with hand washing soap and water.
• Hand antisepsis/Decontamination
• Decontaminate hands with a waterless alcohol based hand gel or rub for 15-30 seconds.

• This is appropriate for hands that are not visibly soiled.

• Surgical hand antisepsis
  • This removes or destroys transient micro-organisms and confers a prolonged effect. The hands and forearms are washed thoroughly with an antiseptic soap for a minimum 2-3 minutes and dried with a sterile towel. This is required before performing invasive procedures.

• NB: Hands should be dried with disposable paper towels.

   

  Use of Personal Protective Equipment.

  Types:

• • Scrub Suit or Gowns
  • Plastic Aprons 
  • Boots or shoes covers
  • Caps 
  • Protective eye wear
  • Gloves

•  

• • Gloves
• Reduce the incidence of hand contamination with infective material which in turn reduces the opportunity for personnel to become infected and/or the organisms to spread to other personnel and /or patients.
• Gloves however should not replace hand washing.

•  

  Gloves are to be worn when touching the following:

• Blood
• All body fluids
• All body secretions
• All body excretions

• Gloves should be removed before touching clean items (e.g. phone, door knobs or patients‘ charts.) After removing gloves, wash hands thoroughly.

   

  A. Important points to remember when using gloves. 

• Use gloves when there is potential exposure to blood, body fluids, excretions or secretions.
• Change gloves between patients, between procedures on the same patient when they become soiled.
• Remove gloves before leaving the patient‘s bedside and decontaminate hands immediately with 70% alcohol hand rub solution.
• Discard gloves after attending to each patient.

•  

• Boots/shoe covers ? These are used to protect the wearer from splashes of blood, body fluids, secretions and excretions.
•      Shoe covers should be disposable and waterproof. ?            Waterproof boots should be washable.

•  

  C. Caps

•      Disposable and waterproof caps that completely cover the hair are used when splashes of blood and body fluids are expected.

•  

  D. Masks

• A surgical mask protects healthcare providers from inhaling respiratory pathogens transmitted by the droplet routes. It prevents the spread of infectious diseases such as varicella (Chicken pox) and meningococcal diseases (meningococcal meningitis.)
• A N95 mask protects healthcare providers from inhaling respiratory pathogens that are transmitted via the airborne route. This helps to prevent the spread of infectious diseases such as TB, or MDR TB.

• NB: In order to prevent the spread of infection, the appropriate mask should be worn by healthcare providers and visitors when attending to a patient suffering from a communicable disease that is spread via the airborne or droplet route.

   

  The patient with a communicable disease via the droplet or airborne route should wear a surgical mask when being transferred to other departments or hospitals or in isolation room to prevent spread of infection.

  Disposable masks are for single use only and should only be discarded after 4-6 hours use.

  Precautions

• Masks should not be worn around the neck
• Masks cannot be worn with beards or unshaven faces.
• Masks should completely seal the face at all times to ensure effective filtering of micro-organisms.

•  

  E. Gowns

• Gowns made of impervious material are worn to protect the wearer‘s clothing/uniform from possible contamination with micro-organisms and exposure to blood, body fluids, secretions and excretions.
• Use gown once for one patient and discard.
• Healthcare workers should remove gowns before leaving the unit.

• Recommendations for use of gowns

• Lab coats or scrub suits should not be viewed as an effective barrier to blood or other body fluids.
• Use of fluid resistant gowns, impervious gowns or plastic aprons, if soiling of clothes with blood or other potentially infectious material is likely, is highly recommended.  

•  

• Plastic Aprons ? A plastic apron protects the wearers‘ uniform from contact with contaminated body fluids.
• The inside of the apron is considered clean, the outside is considered contaminated. The neck of the apron is clean because that part is not touched with contaminated hands.
• Wash hands thoroughly after removing apron.

•  

  Protective eyewear/Goggles

• Should be worn at all times during patient contact where there is a possibility that  patients‘ body fluids may splash or spray onto the care giver‘s face/eyes (e.g. during suctioning, intubation, endoscopy and cleaning of instruments used for these procedures)
• During all dental, surgical, laboratory and post mortem procedures.
• Full face shields may also be used to protect the eyes and mouth of the healthcare worker in high risk situations.

•  

• Re-usable goggles should be washed and decontaminated after removal and in-between use.

• Please note:  All protective equipment should be removed prior to leaving work area.

   

  G. Needles, sharp instruments and other devices.

  All equipment contaminated with blood or other body fluids should be handled with special care. Keep in mind these recommendations:

• Never recap needles
• Never bend or break needles
• Never remove needles from disposable syringes

•  

• Immediately dispose of all disposable syringes and needles, scalpel blades and other sharp instruments, after use, in a colour-coded or labelled leak-proof puncture resistant container.

• B) Transmission based precautions.

  These are designed to supplement standard precautions or protocols and must always be used in conjunction with Standard Precautions isolation techniques. Transmission based precautions provide extra safety by facilitating a concerted effort to control the spread of specific types of bacteria. Whilst mostly used for diagnosed infection, they are useful when a specific diagnosis is suspected. Transmission based precautions are divided into 3 basic categories:

• • Contact
  • Droplet
  • Airborne

•  Contact Precautions:

• Reduces the risk of transmission of organisms from infected or colonised patient through direct or indirect contact.(e.g. Herpes Simplex, Haemorrhagic Fever Virus e.g. Ebola, multi-drug resistant bacteria)
• Precautions include: Hand gloving/Patient placement /Hand washing/Use of aprons and gowns/Patient care equipment/Patient transport

•  Droplet Precautions:

• Reduces the risk of nosocomial transmission of pathogens spread by large droplets particles usually within a metre (e.g. Mumps, Diptheria, Haemophilus and Influenza.) ? Droplets may be expelled during: Sneezing/Coughing/Talking
• Teach cough hygiene i.e. cover mouth when coughing
• Precautions include: Patient Placement/Respiratory protection/Patient transportation.
•  
• Airborne Precautions:
• Designed to provide protection from extremely tiny airborne bacteria or dust particles which may be suspended in the air for an extended period of time.
• Used in addition to Standard Precautions for patients known or suspected to be infected with micro-organisms transmitted by airborne route e.g. TB, chicken pox/measles.
• Precautions include: Respiratory Protection/Patient placement/Patient transportation

While the breast can be affected by many conditions practitioners should take all efforts to exclude malignancy. History and examination is of value in this regard. Common breast conditions are:

• Breast abscess especially in breastfeeding or pregnant women
• Mastitis
• Breast fibroadenomas especially in young women age (1535years).
• Breast cancer especially above the age of 35.
• Ductal papilloma
• Duct ectasia
• Nipple/ breast eczema
• Paget‘s disease of the breast

Breast Abcess typically occurs in a young lactating or pregnant women who has pain and swelling of the breast with an area of maximal tenderness or fluctuancy. Once the diagnosis is made, incision and drainage in theatre under general anaesthesia should be done as they are generally deep abscesses and adequate drainage is advisable under general anaesthesia. Analgesia and antibiotics should be instituted once diagnosis is made.

Preferred therapy:

Cloxacillin 500mg IV four times daily for 2 days THEN

Cloxacillin 500mg po four times daily for 5 days

Alternative therapy:

Clindamycin 300-600mg IV three times a day for 2 days THEN 

Clindamycin 300-600mg po three times a day for 5 days

The wound should be cleaned with saline or povidone iodine and packed or dressed with glycerin and ichthamol daily until healing occurs. The mother should be advised to continue breastfeeding or to express the breast frequently.