Surgical emergencies

Steven Goh October 2013

Overview

Definition

Common acute surgical abdomen

Syndrome recognition

Assessing patients

ACUTE ABDOMEN

17 Male

Fit & well..

2/7 RIF pain - worsening

Continuous and colicky

Fever + Nausea + Vomiting +

Temp-38.1, HR-100/min, BP-100/60

72yr Male

Fit & well..

1/7 Left lumbar, back pain - sudden

Continuous - worsening

Nausea + Vomiting +

No urinary symptoms

HR-88/min, BP-118/84

49 Female

Fit & well..

Central chest, RUQ ,back pain - sudden

Sweating + Palpitations + Nausea +

HR-98/min , BP-104/64

31 Female

Known BP, previous appendicectomy

3/7 lower abdominal pain

Nausea- , Vomiting - ,Fever -

Loss of appetite

No urinary or other bowel symptoms

Vitals stable, Examination – NAD

Abdominal pain

A huge clue to the underlying pathology

‘’Listen to the patient: they’ll tell you what’s wrong’’

Foregut oesophagus > ampulla of Vater

Midgut above > two thirds along the transverse colon

Hindgut above > anus

Visceral Pain

Foregut

(epigastrium)

Midgut

(umbilical)

Hindgut

(hypogastrium)

Biliary Colic

Peptic ulceration

Small Bowel

Obstruction

Acute colitis

Diverticulitis

Practical Classification

Intra-abdominal Catastrophe

Localised Sepsis/Inflammation

Obstruction

Generalised Peritonitis

Intra-abdominal catastrophe

Ruptured AAA

Acute Mesenteric Ischaemia

Trauma / Intra-peritoneal haemorrhage

Severe Acute Pancreatitis

Diffuse Faecal Peritonitis /

other endotoxaemias

Localised Sepsis

Appendicitis

Acute cholecystitis

Salpingitis

Acute pyelonephritis

Ascending cholangitis

Acute diverticulitis

numerous other examples

Obstruction

Small Bowel

Colonic

Acute Pseudo-obstruction

Renal / Ureteric colic

Biliary colic

Generalised Peritonitis

Faecal

Obstructed colon ‘closed loop’; perforated carcinoma

Purulent

Perforated appendix; established perforated DU

Inflammatory

Biliary peritonitis; ruptured ovarian cyst

Chemical

Abdo pain

Non-specific abdominal pain (NSAP) 35%

Acute appendicitis 17%

Intestinal obstruction 15%

Urological causes 6%

Gallstones disease 5%

Colonic diverticular disease 4%

Trauma 3%

Abdominal malignancy 3%

Perforated peptic ulcer 3%

Pancreatitis 2%

Surgery 2005 23:6 Acute Abdomen: investigations, peritonitis 199-207

NSAP

Viral infections

Bacterial gastroenteritis

Worm infestation

Irritable bowel syndrome

Gynaecological causes

Pyscho-somatic pain

Abdominal wall pain Iatrogenic nerve injury, hernias, nerve root pain, rectus sheath haematoma

Non-abdominal eg cardiac, respiratory

NSAP

Risk missing serious underlying disease

Malignancy subsequently found in 10%

patients >50 years old admitted

Half had colonic carcinoma

Half were discharged with diagnosis

NSAP!

Assessing the patient..

A..B..C..

Preliminary assessment

Analgesia

Bloods

Fluids..

Antibiotics

Assessing the patient

Demography

Presenting complaint : duration..

HPC

Vomiting

Bowel symptoms – alternating?

Co-morbidities – DM, HT, MI, Asthma..

Quickly...

Previous surgical history

Anaesthetic problems

Drug history - Aspirin, NSAID, steroids

anti-coagulants, ALLERGIES!

Other systems ?

Females – LMP? OCP?

*Alcohol ; Smoking

Examination

Quick look test – colour, hydration,

shocked? agitated? restless? still?

JACCOL

Chart – temp, HR, BP, JVP

CVS , RS

Contd..

ABDOMEN

Distension / swellings – 5Fs?

Skin lesions

Movements? Visible pulsations? Peristalsis?

Palpate – tenderness, LKBS..AAA..

Bowel sounds

Groin.. Genitalia.. PR? PV?

Labs..

FBC, Coag, G&S

LFT, UEC

Amylase , Βhcg

Urine, Stool

CXR

AXR

KUB..USS..CT..

CXR

AXR

AXR

AXR

AXR

Management

Appropriate diagnosis

Life-saving measures

ABC; Appropriate antibiotics for severe sepsis

(cholangitis); O2; volume replacement; cross match;

operating theatre

Simple Investigation and Treatment

NGT; IVI; analgesia; plain radiology; G+S; bloods

Correct dispersal

GI bleed

Ischaemic limb

Medical

Many many more........

Surgery 2005 23:6 Acute Abdomen: investigations, peritonitis 199-207

Thank you

Syndrome recognition

Catastrophe

Sudden onset

Severe back groin or buttock pain

Generalised abdominal pain if intraperitoneal

Low BP Low filling pressures

Cool periphery ‘shut down’

Tachycardia

Pulsatile Mass / haematoma (can be difficult)

GI Obstruction

Appropriately located colic

Vomiting if gastroduodenal or small bowel

Constipation

Distension with high pitched sounds

Loops of bowel on plain AXR

Must look for a strangulated hernia

Acute Pancreatitis

Gradual onset pain radiating to back

Very few signs except epigastric tenderness

Can be atypical and clinical state may vary greatly

High Amylase (beware false hyperamylasaemias)

Acute Mesenteric Ischaemia

Classically very severe generalised pain in

the absence of clinical signs

Sudden onset

Embolic source or arterial history

Acidosis

Very high leucocytosis

Endotoxaemia

Hypotension

Poor urine o/p, renal failure

Tachycardia

Fever

Warm periphery

Septic source may be very obscure, so look for

clues (eg jaundice = cholangitis)

Severe Peritonitis

Signs of generalised peritonism

Endotoxaemia

Rigid abdomen, patient lying very still

Tachycardia, hypotension, fever

Pallor, dehydration, fetor oris

Some clue as to the origin of the sepsis

Leucocytes may be depressed if very severe

Differentiate..

Peritonism

The signs of localised or generalised peritoneal irritation ie rebound or guarding

Peritonitis The patient is septic, possible endotoxic, with the

signs of peritonism

Voluntary guarding ‘Localised rigidity with no rebound tenderness’

This is not pathological. Best totally ignored