Common Surgical Emergencies

Question 1

Roles of Emergency Surgery

Answer 1

1. Remove dead / infected tissues
2. Drain pus
3. Relieve obstruction
4. Repair defect
5. Control bleeding
6. Remove blood clots

Question 2

Classifications of surgical emergencies

Answer 2

1. Surgical infections
2. Obstruction of lumen
3. Perforation / Rupture
4. Bleeding
5. Trauma

Question 3

Surgical infections

Answer 3

Infections best treated by operative intervention / Infections follow surgical procedures

1. Abscess: Confined infection surrounded by pyogenic membrane
2. Empyema: Abscess in an anatomical cavity (e.g. gallbladder)
   - Deep-seated (e.g. liver abscess)
   - Localised (e.g. skin / SC tissue / liver)
   - Organ (e.g. gallbladder, appendix)
   - Cavity (e.g. empyema of thorax)
3. Sepsis (systemic response to infection)
   - haemodynamic instability
   - mental confusion
   - tachypnea
   - 20% associated with bacteraemia
4. Systemic inflammatory response syndrome (SIRS)
   - early response to injury
   - infective / non-infective
5. Bacteraemia
6. Septic shock
   - hypotension
   - organ failure

Question 4

Diagnosis of surgical infections

Answer 4

1. History
2. Examination
   - SC abscess
   - typical acute appendicitis (simple, do not require further investigations)
3. Investigation
   - ↑ WBC
   - Imaging
   —> contrast rim enhancement on CT scan for abscess
   —> US scan for acute cholecystitis

Question 5

Treatment of surgical infections

Answer 5

1. Antibiotics
2. Drainage
   - Incision + Drainage (I+D)
   - Surgical
   - Interventional radiology (e.g. percutaneous drainage of liver abscess)
3. Surgical removal of diseased organ
   - Appendicectomy

Question 6

Obstruction of lumen

Answer 6

1. Bowel obstruction
2. Arterial obstruction
3. Urological system obstruction
4. Biliary system obstruction

Question 7

1. Bowel obstruction

Answer 7

1. Small bowel
   - Adhesion band
   - Tumour
   - Hernia
2. Large bowel
   - Cancer
   - Volvulus

Cardinal symptoms

1. Abdominal pain
2. Abdominal distension
3. Vomiting
4. Constipation

Abdominal X-ray
- Erect + Supine films

Question 8

2. Arterial obstruction

Answer 8

Ischaemia —> Progress to gangrene

E.g.

1. Lower limbs
   - peripheral vascular disease
   - embolism

- ***Acute lower limb ischaemia
—> pulseless
—> pain
—> pallor
—> perishing cold
—> paresthesia (pins and needles)
—> paralysis

2. Intestine
   - thrombosis
   - embolism
   - strangulation

Question 9

3. Urological system obstruction

Answer 9

BPH

- Acute urinary retention —> Emergency management: Bladder catheterisation

Question 10

4. Biliary system obstruction

Answer 10

1. Obstruction of Cystic duct by gallstone —> Acute cholecystitis
2. Obstruction of CBD —> Acute cholangitis, Acute biliary pancreatitis

Management:

1. US
2. Cholecystectomy for Acute cholangitis
3. Endoscopic retrograde cholangiopancreatography (ERCP) / Endoscopic papillotomy (EPT)

Question 11

Perforation / Rupture

Answer 11

1. Spontaneous perforation
   - Hollow viscus e.g. ulcer perforation
2. Spontaneous rupture
   - Ruptured abdominal aortic aneurysm
   - Ruptured hepatocellular carcinoma
3. Traumatic

Question 12

Bleeding

Answer 12

1. GI bleeding
   - Ulcer bleeding (most common cause)
   - Therapeutic endoscopy
2. Intracranial bleeding
   - Trauma, Cerebrovascular accident
   - Pressure effect to the brain inside an enclosed space (i.e. the skull)