Diagnostic Abdominal Paracentesis

Abstract

We have been fortunate in our group that the executive committee has elected the medical superintendent as chairman of the executive committee. He has in the past spent a large amount of time on administration, so this position did not require him to radically alter his timetable. Nevertheless, in groups where the chairman does not already spend a large part of his time on administrative duties he must get considerable support from his colleagues within his specialty. But any clinician must be able to act as chairman either of his division or of the medical executive committee. The fact that one of our four consultant general surgeons is at the present time mayor of the city illustrates that many consultants can find time for this amount of administration if the will is there.Any group contemplating setting up this type of administration must insist on adequate clerical help to assist both the executive committee and the divisions with clerical work and also to produce and collate the necessary statistics.We agree with the Cogwheel report that it is difficult for hospitals with fewer than 20 to 30 consultants to have a divisional system of administration but consider that all but the smallest groups could elect a small executive committee from their medical advisory committee, who could then meet more regularly than the main committee and come to decisions more quickly and effectively than previously. ConclusionsWe agree with the Cogwheel report that each individual group must tailor the suggestions to their own requirements. If the hospital medical staff do not streamline their own administration before the reunification of the health service and the setting up of area health boards we will probably be administered increasingly by non-medicai administrators and have little say in the running of our hospitals.

Peritoneal Lavage as an Aid in the Diagnosis of Acute Peritonitis of Non-Traumatic Origin

“…This would apply especially to comatose patients or patients on respirators [8]. There are reports of the usefulness of DPL in postoperative cases [6,7,10,13,14] where the diagnosis of intraab dominal sepsis, bleeding or anastomotic leakage is particularly difficult because of the presence of a fresh abdominal wound and slurred responses because of analgesia. It has been suggested that DPL might be use ful in excluding surgical disease in patients thought to be presenting with 'medical' acute abdomens such as occur in porphyria, dia betic ketoacidosis and the serositis of acute rheumatic fever [4,15,16].…”

“…It has been suggested that DPL might be use ful in excluding surgical disease in patients thought to be presenting with 'medical' acute abdomens such as occur in porphyria, dia betic ketoacidosis and the serositis of acute rheumatic fever [4,15,16]. Some surgeons have even used a positive DPL result to help choose the site of the laparotomy incision for example when the DPL suggested a perfo rated appendix rather than a perforated pep tic ulcer [10,17], Even a 'normal' patient, that is one not fitting one of the above cate gories, may present a diagnostic dilemma because of an atypical history and/or equivo cal or changing abdominal signs [9,14], A patient may have severe abdominal pain in the absence of convincing abdominal signs which may reflect a whole range of diseases from spastic colon to mesenteric infarction. In the author's experience [9] the most com mon indication for DPL is the elderly, senile patient with a vague or unreliable history, fever and leucocytosis and confusing, vary ing and equivocal abdominal signs.…”

“…It should be remembered, however, that a polymorpho nuclear leucocyte-rich exudate take 2-3 h to develop [10], If the result of the DPL is equi vocal. because of poor retrieval, or because say the leucocyte count is on the borderline, or if the DPL is negative but clinically there is still much doubt, the catheter can be left in situ and the lavage repeated after a few hours [4,14,21],…”

“…The diagnosis of acute pancreatitis can usually be made with great accuracy on the basis of clinical features and a high serum amylase especially if the attack is mild [32], However, since a number of other diseases presenting as an acute abdomen may also be associated with a high serum amylase [33][34][35], an occasional severely ill patient will be mistakenly treated conservatively while harbouring a disease requiring urgent lapa rotomy [14,32,33]. Examples of this arc patients with perforated peptic ulcers, mes enteric infarction, strangulated bowel and perforations of the biliary tract or proximal intestine [14-16, 21, 28, 32, 34], On the other hand, if a patient with acute pancreati tis is operated on unnecessarily under suspi cion of another cause of peritonitis, he will suffer an increased mortality and morbidity [32], DPL can help the surgeon out of this dilemma with an accuracy approaching 100% [32], The fluid of acute pancreatitis is clear, blood-stained or brown and often con tains macroscopic or microscopic fat glob ules.…”

“…This situation may, however, give a negative DPL [5], Intraperitoneal Haemorrhage DPL will be positive in conditions such as ruptured aneurysms of the aorta or other major abdominal vessels [5,10,14,15] and delayed or spontaneous rupture of the spleen [5,10,37].…”