The patient with diabetes represents to the surgeon a particular challenge in the management of acute abdominal problems. In addition to their ongoing and potential metabolic problems, diabetics have specific difficulty in their ability to handle infections and heal wounds. The present report reviews the general principles in the peri-operative management of diabetics and discusses the implications in the diabetic of several specific clinical problems. In view of the known accelerated atherosclerosis associated with diabetes, the risks of anesthesia and surgery must be assessed in the context of the coronary, cerebral, visceral, and peripheral vascular status. Infections in diabetics (potential or established) must be treated aggressively and promptly. Acidosis in the diabetic with abdominal pain must be considered both a metabolic problem and a possible secondary manifestation of an intra-abdominal process. In view of these challenges, the need for careful, anticipatory management of the diabetic patient facing major abdominal surgery is clear.