SURGICAL EMERGENCIES

BY DR F DERY

A) BLEEDING IN SURGICAL PRACTICE

Types of Bleeding1 Vessel Involved• Arterial bleeding is bright red, spurts as a jet

which rises and falls in time with the pulse.• Venous bleeding is dark red and escapes as

a steady flow• Capillary bleeding is bright red and often

rapid ooze2. Commencement of bleeding• Primary haemorrhage: occurs at time of

injury or operation.

Commencement of Bleeding cont,d

• Reactionary haemorrhage: follow primary haemorrhage within 24hrs and mainly due to slipping of ligature or dislodgement of a clot.

• Secondary haemorrhage: occurs after 7-14 days and it is due to infection and sloughing of part of the wall of an artery.

3. Internal (Concealed) bleeding: bleeding may occur but not seen externally as in: ruptured spleen, ruptured ectopic gestation.

4. External (revealed) bleeding: concealed haemorrhage may become revealed as haematemesis or malaena from Peptic Ulcer Disease (PUD)

Examples of Bleeding in Surgical Practice

1. PUD

2. Bleeding haemorrhoids

3. Ectopic gestation

4. Abortions

5. RTA (Road Traffic Accident) or Trauma

• Ruptured spleen

• Fractured femur

1) PUDThere are 3 types-duodenal, gastric, or oesophageal.

Causes:• Reflux of corrosive acid pepsin and sometimes

bile through a lax oesophageal sphincter. The tendency to the oesophageal reflux may be compounded by increased abdominal pressure in the obese and pregnancy and by consumption of fatty meals, alcohol, caffeine and tobacco, all of which relax the sphincter—oesophageal cause

• Helicobacter pylori infection: it is a bacterium—gastric/duodenal cause.

Causes cont,d

• Drugs-NSAIDS, corticosteroids—duodenal/ gastric cause

• Alcohol-reduces local reduction of mucosal blood flow leading to acute erosions—duodenal/gastric cause

• Excessive secretion of gastric acid—duodenal/gastric cause

Symptoms

The main symptom is pain in the epigastrium or right hypochondrium or behind the sternum.

• Heart burn which is worse after meals and at night when recumbent—oesophageal

• Intermittent epigastric pain that is relieved by food or alkalis with night waking and heart burn--duodenal

• Vomiting may occur in both duodenal and gastric ulcers

• Many however do not have symptoms .

Signs

• The only sign is tenderness in the midline of the epigastrium or right hypochondrium

• There may be no signs

• There may be history of malaena stools

Investigations

• Haemoglobin level

• Stool examination to rule out intestinal worms as cause of dyspepsia

• Oesophago-gastro-duodenoscopy plus urease test (for H. pylori)

• Barium meal in the absence of endoscopy

Complications

Oesophageal

• Stricture formation which causes dysphagia

Duodenal/gastric• Bleeding• Perforation• Pyloric stenosis• Hour-glass deformity

Treatment

1. Advice about diet

• Losing weight if obese

• Avoid late large and fatty meals

• Avoid coffee, alcohol

• Stop smoking

• Avoid sleeping flat

• Avoid spicy foods

2 Relief of anxiety and stress

Treatment cont;d

3 Drugsa) For H. pylori eradication use the triple

therapy regimeOmeprazole (PPI) 20mg bd/7days PLUS• Amoxycillin 500mg tid + metronidazole

400mg tid for 7 days OR• Amoxycillin 1gm daily +clarithromycin

500mg bd for 7 days OR• Clarithromycin 500mg bd + metronidazole

400mg bd for 7 days

Treatment cont,d

b) For maintenance

• Omeprazole 20mg bd for 4-6weeks OR ranitidine (H2 receptor antagonist) 150mg daily for 4weeks. Repeat if symptom recur

• For dyspepsia—give antacids eg magnesium trisilicate 15mls tid in between meals but avoid within 2hrs of intake of H2 receptor antagonist. It impedes absorption

2) HAEMORRHOIDSHaemorrhoids are dilated veins occuring in relation to the anus originating in the subepithelial plexus. Haemorrhoids may be external or internal ie internal or external to the anal orificeHaemorrhoids may be

1. Symptomatic-ie a symptom of other condition• Cancer of rectum-compressing rectal veins• During pregnancy-pressure on veins by uterus• From straining-urethral stricture or prostate

Haemorrhoids cont,d

2 Not symptomatic-ie those which are not a manifestation of some underlying disease. They are the majority.

Classification of Haemorrhoids• 1st Degree- remain in the rectum• 2nd Degree- prolapse through the anus on defaecation

but spontaneously reduce• 3rd Degree- as for 2nd degree but require digital reduction• 4th Degree- remain persistently prolapsed

Symptoms

• Passage of bright red blood during defaecation. It usually drops on the stool but not mixed with the stool. If using the bed pan or water closet blood splashes on it.

• Discharge-mucoid discharge is a frequent accompaniment of prolapsed haemorrhoids.

• Pruritis-certainly follows the discharge.• Pain-only when complications supervene.

Signs

• Inspection of the anus may show no evidence of internal haemorrhoids.

• Redundant folds or skin tags can be seen in the position of the haemorrhoids in advance cases

• Straining may show internal haemorrhoids transiently

• Internal haemorrhoids can not be felt unless they are thrombosed

• Patient may present with the complications

Investigation

• Full blood count (FBC)

• Proctoscopy-as you withdraw the proctoscope the haemorrhoids will bulge into the lumen of the proctoscope

Complications

• Profuse bleeding

• Strangulation

• Thrombosis

• Ulceration

• Gangrene

• Fibrosis

• Suppuration

• Anaemia

Treatment

Non operative• No treatment for asymptomatic. Treat

constipation with liquid paraffin 10-30mls nocte or senna granules 1 sachet in water after supper. Avoid prolonged straining at defaecation

• For itch or discomfort-use ointments or suppositories eg anusol, proctosedyl, scheriproct 1 bd for 7 days

• For prolapsed haemorrhoids-lie patient down and elevate the foot end of the bed .

Treatment cont,d

After local anaesthetic cream try gentle digital reduction. If this fails apply cold compresses and sedate patient with diazepam 10mg orally.

• If infected treat with iv gentamycin 2.5mg/kg BW and metronidazole 400mg tid orally for 2-3 days and sitz baths.

• Correct anaemia with iron preparations or blood transfusion

OperativeHaemorrhoidectomy

3) ECTOPIC GESTATIONThis is the embedding of the fertilised ovum and development in some other site other than the uterine cavity

Causes• Infections (eg salpingitis)—causes adhesions in the

tube or destroys the ciliated epithelium which propel the fertilised ovum into the uterus

• Tubal abnormalities like diverticula, abnormal length or kinking

• Incidence increase in women using progestogen only contraceptive

End Result of Tubal Pregnancy• Tubal mole—bleeding occurs around the embryo

causing its death and is surrounded by a blood clot

• Tubal abortion—the embryo in the tube is expelled through the ostium of the tube. Blood may coagulate around the ostium or accumulate in the rectovaginal pouch and becomes encysted

• Tubal erosion with persistence of the pregnancy-the embryo perforates the tube and may become attached to some of the abdominal contents and may grow to term( abdominal pregnancy)

End Result of Tubal Pregnancy cont,d

• Tubal rupture (into peritoneal cavity)—this is also called ruptured ectopic

Ruptured Ectopic

The patient presents with:

1 Abdominal pain

2 Fainting or collapse

3 Signs of severe blood loss:• Low BP• Weak rapid pulse

Ruptured Ectopic cont,d

• Subnormal temperature• Cold clammy skin• Complains of thirst• Restless and may show air hunger

4 Distended abdomen

5 Diffusely tender abdomen

6 Dullness on percussion in the flanks

7 Referred pain to the shoulder if the blood reaches the diaphragm

8 Amenorrhoea of short duration usually 6-8 weeks

Ruptured Ectopic cont,dInvestigation

• Pregnancy test positive—a negative test cannot be taken as prove that no ectopic pregnancy exists

• Ultrasonography (ultrasound)

• Laparoscopy

• Haemoglobin level, group and cross matching

Treatment

Laparotomy

4) ABORTIONS

The expulsion of a fetus before the 28th week of pregnancy

Causes• Severe malformation of the zygote• General disease of the mother– any severe

febrile illness, syphilis, diabetes mellitus, severe hypertension, gross malnutrition

• Uterine malformations including fibroids• Hormone insufficiency eg progesterone

Causes cont,d

• Trauma—coitus, accident

• Drugs—cytotoxic drugs

• Acute emotional disturbance

Varieties of Abortion

1. Threatened Abortion:-there is bleeding but not sufficient enough to kill the embryo. No painful uterine contraction. The cervix is closed.

Management—Bed rest

Varieties of Abortion cont,d

2 Inevitable Abortion:-painful contractions and dilatation of the cervix. Blood loss continues and increases in amount. Products of conception still in the uterus.

Management—pain relief and evacuation of the uterus if not complete.

3 Complete Abortion:-all products of conception expelled. Pain is absent and bleeding is slight. Cervix is slightly open.

Management--observation

Varieties of Abortion cont,d

4 Incomplete Abortion:-parts of the products of conception, usually the fetus is passed out. The placenta is retained. Bleeding can be severe.

Management—evacuate the uterus and prevent infection.

5 Septic Abortion:-uterine cavity infected before an abortion even begins as a result of criminal attempt to procure abortion by passing unsterile instrument through the cervical canal or may follow incomplete abortion. There is suprapubic pain and increase in temperature and pulse rate.

Varieties of Abortion cont,d

• There may be little bleeding. Infection may spread to the other structures of the pelvis.

• Management—broad spectrum antibiotics are given. Penicillin plus gentamycin plus metronidazole are usually combined. If incomplete septic abortion, evacuation follows after 24 hrs of antibiotics

• 6 Missed Abortion:-the embryo dies but is retained in the uterus for several weeks or months. Patient notices little blood stained discharge between 8-12 weeks of pregnancy.

Varieties of Abortion cont,d The uterus is not increasing in size.

Management—no urgency about treatment. Sepsis rarely occurs. D and C is done if patient is worried she is carrying a dead fetus.

7 Habitual Abortion:-if there have been 3 consecutive spontaneous abortion. Repeated mid trimester abortions may result from incompetence of the internal os of the cervix. They are painless abortions

Management—general advice if no cause is found. If an incompetent cervix is the cause a Shrodkhar stitch is applied

Varieties of Abortion cont,d

Complication of Abortions-infectioninjuries to vagina, uterus, bowel

5 RUPTURED SPLEEN

Causes

• Traffic or industrial accidents

• Blows on the abdomen or left lower thorax

• Falls onto a projected object

Cases of ruptured spleen may be divided into two:-acute and delayed

Ruptured Spleen cont,d

AcuteThere is an initial shock ; recover from shock and then show signs of ruptured spleen:

1 General signs of internal haemorrhage:-increasing pallor, a rising pulse rate, sighing respiration and restlessness.

2 Local signs• Abdominal rigidity most pronounced in the left

upper quadrant• Local tenderness

Ruptured Spleen cont,d

• Shifting dullness in the flanks

• Abdominal distension commences 3hrs after the accident and is due to intestinal paresis

• Pain referred to the left shoulder. This is due to blood in contact with the under surface of the diaphragm

• Rectal examination frequently reveals tenderness and often soft swelling due to blood clot in the rectovesical pouch

DelayedAfter the initial shock have passed off the symptoms of serious intra-abdominal injury are postponed for a variable period of up to 15 days or more. These cases only collapse later from internal haemorrhage. The reasons for the delay are:

• The greater omentum as a policeman, shuts off that portion of the peritoneal cavity in the immediate vicinity of the bleeding

• A subcapsular haematoma forms and later burst• Blood clot sealing the rent becomes digested

Investigation

• FBC, grouping and cross matching

• USG

• Plain abdominal x-ray

• Laparoscopy

Treatment

Laparotomy and splenectomy

6) FEMUR FRACTURE (SHAFT)

The injury is usually due to severe violence so that associated injuries are common.

Since we are dealing with bleeding conditions in surgical practice, we will only deal with that aspect of the femur fracture.

There is no obvious bleeding in a simple fracture of the shaft of the femur, but bleeding into the thigh is often in excess of a litre and invariably in adults. Such blood loss must be replaced.