authored by Ddembe on 2. May 2007 at 16:04
“Maybe Ddembe can shine his torch on this one. With acute pain in the abdominal area, has a doctor no option but to reach for the scalpel and open up and see with his naked eye?”
A few comments.
A friend of mine (a multi -millionairess not in Ugandan kwacha) died of fulminant pancreatitis in a world class hospital! The diagnosis of pancreatitis even in a good centre is not easy. A barium study is not part of uptodate investigation for pancreatitis. CT scan is the most usefull investiagtin while MRI is gaining more and more utility. Other useful investigations include blood tests including a white cell count and amylase and lipase. Ultrasounds and plain abdominal X-rays can also be usefull while other tests such as ERCP and MRCP are usefull in selected patients.
Enthusiasm has shifted away from early surgical intervention to delayed surgical intervention except for those with infected severe pancreatitis. Even then in suitable centres the management is becoming more and more minimally invasive as opposed to major open surgery. There is evidence that early surgical intervention except in highly selected patients is associated with a higher mortality -so conservative management with aggressive fluid resucitation, oxygen, plus or minus antibiotics is the mainstay of early management.
Your friend is referring to “exploratory laparatomy” as a diagnostic procedure. The reality is that these are used less and less as a result of advances in imaging technologies! Many times now the surgeons have some idea what they will find when they open up the abdomen before they do the procedure whereas in the past it was done as an investigation for the “acute” undiagnosed tummy! Of course the surgeo was able to fix treatble problems once they looked but sometimes, they just opened and closed if they found some nasty not amenable to surgical resection!
Distinction needs to be made between mild acute pancreatitis and or acute severe or necrotising pancreatitis. Haemorrhagic pancreatitis and infected pancreatits have much higher mortalities than mild acute or chronic pancreatitis. Fulminant refers to rapidly progressive overwhelming process that rapidly results in a decline and multisystem or multiorgan failure! These require significant resources including surgical, intensive care, imaging, gastroeneterology etc!
From newspaper accounts, it is obvious that Mayombo had a rapidly progressive process that resulted in coma and multi organ failure! In any centre he would have been a challenge to diagnose and manage!
Everything being equal with equivalent intensive care support in Kampala and Nairobi, the plane trip would have increased his risk of death!