Emergency Medicine

ACUTE ABDOMEN

Surgical Emergencies 263

MANAGEMENT

1 Commence an i.v. inf usion to treat dehydration or shock.

2 Refer the patient to the surgical team for analgesia and antibiotics such as
gentamicin 5 mg/kg once daily, ampicillin 1 g i.v. q.d.s. and metronidazole
500 mg i.v. t.d.s., or for surgery if bowel obstruction or a pelvic abscess is
suspected.

Inflammatory bowel disease

DIAGNOSIS

1 Ulcerative colitis associated with bouts of diarrhoea with blood-stained
mucus may present as a fulminating attack with fever, tachycardia and
hypotension.

2 Crohn’s disease, associated with recurrent abdominal pain, diarrhoea,
malaise and peri-anal fistulae or abscesses, may present acutely with
obstruction, perforation or right iliac fossa pain. This can mimic acute
appendicitis.

3 Gain i.v. access and send blood for FBC, U&Es, blood sugar, lipase/amylase
and blood culture.

4 Request a plain AXR to look particularly for the following:
(i) Ulcerative colitis: extensive mucosal ulceration may leave normal
mucosal islands (pseudopolyps) visible on plain film. Dilation of
the transverse colon >6 cm indicates the presence of a megacolon.
Perforation is a serious risk.
(ii) Crohn’s disease: free air associated with perforation may be seen.
Stenotic regions of small bowel are best visualized with barium
follow-through studies, or on colonoscopy.

5 Organize a CT scan of the abdomen with i.v. contrast.

MANAGEMENT

1 Commence an i.v. inf usion and treat pain wit h i.v. ana lgesia.

2 Refer a l l cases w it h shock, fever, peritonitis, severe bleeding or a n obstructed
bowel immediately to the surgical team.

3 Organize urgent gastroenterology advice for a toxic megacolon with fever,
tachycardia and hypotension.
(i) Start hydrocortisone 200 mg i.v. 6-hourly, and broad-spectrum
antibiotics such as gentamicin 5 mg/kg once daily, ampicillin 1 g
i.v. q.d.s. and metronidazole 500 mg i.v. t.d.s.