Special Operations Forces Medical Handbook

4-84

Inspection: Patient in fetal position, because any movement worsens pain; visible peristalsis suggests bowel
obstruction.
Auscultation: Absence of bowel sounds in all four quadrants suggests peritonitis. Always auscultate before
doing percussion or palpation.
Percussion: Absence of dullness over the liver suggests free air and perforation.
Palpation: Begin with very gentle palpation away from the area of maximal symptoms; board-like abdomen is
unmistakable and indicates obvious peritonitis; shake the pelvis to assess rebound tenderness; ileopsoas and
obturator signs (see Appendicitis section) are suggestive for retroperitoneal inammation.
Serial examinations: Diminishing bowel sounds with increasing tenderness and the development of rebound
indicates peritonitis.
Using Advanced Tools: Lab: CBC with differential, urinalysis, blood cultures for infection. Abdominal X-ray
(if available): free air, dilated loops of bowel, air-fluid levels, calcified gallstones (1/3) or pancreas.

Assessment:
Differential Diagnosis - see list above in Subjective.

Plan:
Treatment

1. Intravenous antibiotics must cover both aerobic and anaerobic bacteria:
   Single Agents: Cefoxitin 2 gm IV q 8 hr, cefotetam 2 gm IV q 12 hr, or cefmetazole 2 gm IV q 8-12 hr
   Combination Agents: Aztreonam 2 gm q 8 hr plus metronidazole 500 mg IV q 8 hr


2. IV uids to compensate for respiratory and third space losses (see Fluid Resuscitation section). Use
   pressor agents at lowest dose needed to maintain adequate perfusion pressure, such as Dopamine 5
   mcg/kg/min.


3. Pain control (see Procedure: Pain Assessment and Control) and antiemetic (e.g., Phenergan 25 mg IV,
   IM, or po) of choice.


4. Nasogastric tube decompression for signicant abdominal distention or vomiting, and keep NPO.


5. Evacuate for denitive surgical treatment.

Patient Education
Activity: Bedrest.
Diet: Metabolic needs during acute peritonitis are great, equivalent to a 50% total body surface area burn.
Caloric requirement is often in the 3000-4000 calorie range and must be given parenterally by IV (not available
in eld conditions).

Follow-up Actions
Return evaluation: Postoperative follow up is contingent upon operative ndings, treatment and hospital
course.
Evacuation/Consultation Criteria: Evacuate ASAP. Consult general surgery.

GI: Peptic Ulcer Disease

COL (Ret) Peter McNally, MC, USA

Introduction: Peptic ulcers are defects in either the gastric or duodenal mucosa. Almost all ulcers are
caused by infection with Helicobacter pylori, consumption of aspirin or NSAIDs (Motrin, Advil, Aleve,
Clinoril, Feldene, etc.) or severe physiologic stress (extensive trauma, burns or CNS injury). Some ulcers
are related to ingestion of fish parasites. Most ulcers cause mid-epigastric pain, often associated with nausea
or vomiting. Complications of ulcers include bleeding, perforation and obstruction. Generally, pain will herald
the presence of an ulcer before complications occur. Ulcer pain is decreased by ingestion of alkali and
patients often give a history of self-medication with bicarbonate of soda, antacids or over-the-counter acid
blocking medicines.

Subjective: Symptoms
Gnawing epigastric pain between the umbilicus and the xiphoid, increased by food and relieved by alkali