Surgical Emergencies - Acute_abdomen - MOTEC LIFE-UK
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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
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