Emergency Surgery Flashcards
GI perforation
Causes, sx, ix, mx
Causes:
Causes of upper Gl tract perforation include:
• Oesophageal or gastric malignancies
• Peptic ulcer disease
• Boerhaave syndrome (oesophageal rupture secondary to forceful vomiting)
• Ingestion of sharp or caustic materials
• latrogenic e.g. during surgery or endoscopy
Causes of lower Gl tract perforation include:
• Diverticulitis
• Colorectal cancer
• Bowel obstruction
• Colitis (e.g. inflammatory bowel disease)
• Appendicitis
• Infection (e.g. toxic megacolon secondary to C. difficile infection)
• latrogenic (e.g. abdominal surgery or colonoscopy)
• Mesenteric ischaemia
• Invasion of the bowel by other tumours
Sx:
• Abdominal pain, which is sudden in onset and severe
• Nausea and vomiting
• Malaise
• Lethargy
• Peritonism e.g. guarding, rebound tenderness, rigidity on palpation of the abdomen
• Hypotension
• Tachycardia
• Tachypnoea
• Fevers
Ix:
Bedside tests:
• Blood gas to measure lactate and acid-base status which may be deranged due to bowel ischaemia or sepsis
• Pregnancy test in women of childbearing age to rule out obstetric causes of abdominal pain such as ectopic pregnancy.
Blood tests:
• FBC and CRP for inflammatory markers
• LFTs and U&Es which may be deranged in sepsis
• Clotting screen and group and saves to prepare for possible surgery; a coagulopathy may develop secondary to sepsis
• Blood cultures if febrile or other signs of infection to help target antibiotic treatment
Imaging:
• CT with contrast looking for free air (confirming perforation) and the site of perforation; an underlying cause may also be seen (e.g. an obstructing tumour
- Oral contrast may be used as well as IV in order to better identify the site of perforation
• Chest X-ray may show air under the diaphragm (pneumoperitoneum) but is significantly less sensitive than CT
• Abdominal X-ray may show Rigler’s sign (where gas outlines both sides of the bowel wall as it is in the peritoneal cavity as well as the lumen) - also not a first-line test due to limited sensitivity
Mx:
Conservative:
• Make the patient nil by mouth
• Urgent surgical review
• May require critical care input e.g. in cases of organ failure secondary to sepsis
• Consider nasogastric tube insertion e.g. in severe vomiting
Medical:
• Start IV broad spectrum antibiotics
• IV fluid resuscitation as required
• Give analgesia and antiemetics - may need to be parenteral
• Certain cases of perforation may be managed with medical treatment only, for example a localised diverticular perforation in a well patient
Surgical:
• Most cases of perforation will require surgical management with a laparotomy
• This usually involves a thorough washout, identifying the cause of perforation and repairing the defect
• For example, cases of bowel perforation would usually be managed with a bowel resection and formation of a temporary stoma to protect the site of repair
Acute and chronic intestinal ischaemia
Def, causes, sx, ix, mx
Acute mesenteric ischaemia (AMI) is a life-threatening surgical emergency characterised by the abrupt onset of blood flow restriction (hypoperfusion) to a portion of the small intestine. This disruption may be either occlusive or non-occlusive, affecting primarily the superior mesenteric artery.
Chronic mesenteric ischaemia is a pathological condition typically presenting in elderly patients, characterised by insufficient blood supply to the intestines, usually due to gradual blockage or narrowing of the mesenteric arteries.
Causes:
- acute: embolism (from a fib), thrombosis, heart failure, shock
- chronic: smoking, diabetes, hypercholesterolemia, MI, a fib
Sx:
- acute: sudden severe abdominal pain, guarding, nausea, vomiting, signs of shock, metabolic acidosis on ABG, rectal bleeding
- chronic: colicky abdominal pain, worsens after eating, weight loss, diarrhoea, epigastric bruit, melaena or haematochezia
Ix:
- CT angiography as gold standard
- bloods (FBC, LFT, renal, coag, lactate)
- ABG
- duplex ultrasound
Mx:
- resus fluids
- anticoagulation
- embolectomy, arterial bypass or bowel resection if necrosed
- vasodilators
- modify risk factors
Ileus
Def, causes, sx, mx
Ileus is a condition affecting the small bowel, where the normal peristalsis that pushes the contents along the length of the intestines, temporarily stops.
Causes:
- Injury to the bowel
- Handling of the bowel during surgery
- Inflammation or infection in, or nearby, the bowel (e.g., peritonitis, appendicitis, pancreatitis or pneumonia)
- Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia)
Sx:
- Vomiting (particularly green bilious vomiting)
- Abdominal distention
- Diffuse abdominal pain
- Absolute constipation and lack of flatulence
- Absent bowel sounds (as opposed to the “tinkling” bowel sounds of mechanical obstruction)
Mx:
- Nil by mouth or limited sips of water
- NG tube if vomiting
- IV fluids to prevent dehydration and correct the electrolyte imbalances
- Mobilisation to helps stimulate peristalsis
- Total parenteral nutrition (TPN) may be required whilst waiting for the bowel to regain function
Peritonitis
Causes, sx, ix, mx
Causes:
- perforation of a hollow viscus (eg. Oesophagus , duodenal or peptic ulcer
- infection
Sx:
- severe abdo pain
- systemic signs eg. Fever, haemodynamic instability and tachycardia
- nausea and vomiting
- abdominal rigidity and guarding
- rebound tenderness
- percussion tenderness
Ix:
- bloods for infection
- abdo x-ray (look for free gas)
- US
- CT
Mx:
- surgery to control source of inflammation
- antibiotics
- supportive care
Volvulus
Def, rf, sx, ix, mx
Portion of GI tract undergoes abnormal twisting or rotation around its mesenteric axis leading to bowel obstruction or potential vascular compromise
Rf:
- age
- anatomical abnormalities eg. Elongated bowel
- high fibre diets
- chronic constipation
- Parkinson’s
- previous volvulus
Sx:
- acute abdo pain
- abdo distension
- constipation
- nausea and vomiting
- tenderness on exam
- absent bowel sounds
Ix:
- bloods may show inflammation or raised lactate if ischaemic
- abdo x ray (sigmoid volvulus = coffee bean sign, caecal = embryo)
- CT
Mx:
- endoscopic detorsion
- hemicolectomy
- fluid resus
- pain management
- antibiotics
Acute pancreatitis
Causes, sx, ix, staging and mx
Causes:
GET SMASHED
• Gallstones
• Ethanol (alcohol)
• Trauma
• Steroids
• Mumps
• Autoimmune disease (e.g. systemic lupus erythematosus, Sjogren’s syndrome)
• Scorpion stings
• Hypercalcaemia, hypertriglyceridemia, hypothermia
• ERCP
• Drugs (e.g. thiazides, azathioprine, sulphonamides)
Sx:
• The main symptom of acute pancreatitis is epigastric pain which may radiate to the back
• Nausea and vomiting are also common symptoms
• Diarrhoea can occur
On examination, signs may include:
• Abdominal tenderness
• Peritonism, rebound tenderness and guarding may be seen
• Abdominal distension
• Fevers (which may be due to inflammation or superadded infection)
• Tachycardia and hypotension if shocked
• Haemorrhagic pancreatitis may present with Grey-Turner’s sign (bruising in the flank area), Cullen’s sign (bruising around the umbilicus) or Fox’s sign (bruising over the inguinal ligament)
Staging:
Severity of pancreatitis is stratified using the Glasgow Score - each of the following scores 1 point and a score of 3 or more predicts severe pancreatitis:
• PaCO2 < 8kPa
• Age > 55 years
• Neutrophils > 15
• Calcium < 2
• Renal i.e. Urea > 16
• Enzymes i.e. LDH > 600 or AST > 200
• Albumin < 32
• Sugar i.e. Glucose > 10
This should be calculated on admission and at 48 hours.
Ix:
Bedside tests:
• ABG if low oxygen saturations to help with risk stratification (the p02 is needed for the Glasgow criteria)
• ECG to rule out acute coronary syndrome as a cause of pain
• Pregnancy test in women of child-bearing age to rule out causes of abdominal pain such as ectopic pregnancy.
• Capillary blood glucose as hyperglycaemia indicates severe pancreatitis
Blood tests:
• FBC and CRP for inflammatory markers
• U&Es to look for kidney injury; urea is part of the Glasgow criteria
• LFTs are often deranged; a low albumin and high AST indicate severe pancreatitis
• Amylase is the key diagnostic test, with levels over 3x the upper limit of normal indicating acute pancreatitis
• Lipase is not usually measured but can also be used to diagnose pancreatitis
- it is more sensitive and specific than amylase
• LDH and a bone profile for calcium are also required for the Glasgow criteria with hypocalcaemia being a poor prognostic factor
• Blood cultures in patients with fevers or other signs of infection
• Coagulation screen as a baseline - may be deranged in severe illness
• Lipid profile if hypertriglyceridaemia is suspected as a cause of pancreatitis
• Autoimmune markers if the cause of pancreatitis is unclear
Imaging:
• Abdominal ultrasound looking for gallstones and duct dilation
• Chest X-ray for complications such as pleural effusions or acute respiratory. distress syndrome
• CT pancreas with contrast should be done in patients who are deteriorating or have signs of sepsis or organ failure after 6-10 days - may detect complications such as pseudocysts or necrotising pancreatitis
• Magnetic Resonance Cholangiopancreatography (MRCP) may be required in cases of pancreatitis secondary to gallstones
Mx:
Conservative:
• Ensure patients with severe pancreatitis (e.g. Glasgow score 3+, hypotension, oliguria, respiratory distress) are referred for intensive care assessment and input
• Catheterise and monitor input-output
• Insert an NG tube if significant vomiting
• If the patient can eat, encourage oral intake as tolerated - they should not be made nil by mouth unless there is another reason for this
• Enteral nutrition should be started within 72 hours of presentation (e.g. NG feeding) - if this fails parenteral nutrition should be considered
Medical:
• IV fluid resuscitation is the mainstay of treatment - crystalloids should be used and should be titrated to achieve an adequate urine output
• Ensure adequate analgesia is given - opioids may be required
• Antiemetics for nausea and vomiting
• Antibiotics should not be given routinely - in some cases (e.g. confirmed pancreatic necrosis) broad-spectrum antibiotics should be given
• Monitor for and treat any complications
• For alcohol-related pancreatitis, alcohol withdrawal treatment may be required (i.e. benzodiazepines and pabrinex)
Surgical:
• The underlying cause of pancreatitis should be treated; an ERCP may be required for gallstones in cases of jaundice, cholangitis or a dilated common bile duct on imaging
• Laparoscopic cholecystectomy for gallstone pancreatitis should ideally be done in the same admission unless the patient is not fit for surgery
• Surgical or interventional management may be required for complications e.g. drainage of large pancreatic pseudocysts or debridement of pancreatic necrosis
Direct and indirect inguinal hernias
Def, cause, sx, ix, mx
• Indirect inguinal hernias: These hernias follow the path of the descent of the testes, which occurs via the processus vaginalis during fetal development. They are typically congenital and often observed in young males.
• Direct inguinal hernias: These hernias protrude through a weakness in the abdominal wall, specifically the inguinal triangle (Hesselbach’s triangle). They are usually acquired and more common in elderly males.
Causes:
• Indirect inguinal hernias are generally congenital, resulting from a patent processus vaginalis.
• Direct inguinal hernias are typically acquired, caused by factors that raise intra-abdominal pressure such as chronic cough (e.g., in smokers), constipation, heavy lifting, or obesity.
Sx:
- groin swelling
- pain
- palpable mass
Ix:
- clinical diagnosis
- bloods: raised lactate and raised inflammation
- US
- CT
- X ray
Mx:
Open or laparoscopic mesh repair
Appendicitis
Hx, ix, mx
Hx
• Abdominal Pain – Starts central, radiates to RIF
• Associated Symptoms – nausea/vomiting/fever
• Also sometimes develop diarrhoea, constipation or polyuria
• Reduced oral intake
• Often not a typical history/presentation
• Rovsing Sign (palpation of the left iliac fossa causes pain in the RIF)
• Guarding on abdominal palpation
• Rebound tenderness is increased pain when quickly releasing pressure on the right iliac fossa
• Murphy’s Triad (abdo pain, vomiting, fever)
• McBurney’s Point (this is a localised area one third the distance from the anterior superior iliac spine (ASIS) to the umbilicus)
Ix
- Urinanalysis
- BM
- Bloods- raised WCC, U&E, CRP
- Ultrasound
Mx
Appendectomy
Small bowel obstruction
Causes, sx, ix, mx
Causes:
Factors outside the bowel
• Adhesions
• Most common cause in the Western world
• Prior intra-abdominal surgeries increase the risk of adhesion development. The larger the operation, the higher the likelihood of adhesion formation.
• Intra-abdominal hernia
• Incarcerated hernias can precipitate acute obstruction
Factors relating to the bowel wall
• Crohn’s disease - stricturing (rather than fistulating) disease is what specifically causes SBO
• Appendicitis
Factors relating to inside the bowel
• Malignancy
• Foreign body ingestion
• Gallstone ileus
Diseases causing small bowel obstruction in children
• Intussusception
• Volvulus
• Intestinal atresia
• Appendicitis
Sx:
• Abdominal pain with distension (Initially colicky pain that becomes continuous
• Bloating and vomiting (often bilious)
• Failure to pass flatus or stool
• History of abdominal/gynaecological surgery or hernia
• Tympanic, high-pitched bowel sounds on examination
• An empty rectum on examination in complete bowel obstruction
Patients may also present with fever and significant fluid depletion. Peritonitis indicates severe bowel obstruction with developing complications (e.g. perforation, especially in closed-loop obstructions), necessitating urgent surgical intervention.
Ix:
Basic investigations include:
• Basic blood tests including FBC, U+Es, and lactate
• FBC (To identify leukocytosis or anaemia)
• U+Es (To detect organ dysfunction or signs of hypovolaemia)
• Lactate (To establish if there is bowel ischaemia or necrosis, though it can be falsely low due to liver metabolism)
• Amylase (To rule out acute abdomen conditions)
• Abdominal and chest X-ray
• Performed in an upright position to detect pneumoperitoneum
• Absence of air in the rectum can indicate complete obstruction
In the absence of peritonitis and given the patient’s stable condition, the following investigations may be performed:
• CT abdomen and pelvis- Best diagnostic test for identifying the underlying cause, the site of obstruction, and whether it’s a partial vs. complete obstruction
• Small bowel contrast study using gastrograffin- Used as a therapeutic measure in partial SBO. Presence of contrast in rectum 24 hours after ingestion signifies a resolving partial SBO, reducing the need for surgery
• MRI abdomen- Comparable to CT scan, it is useful in young patients to avoid exposure to ionising radiation
• US abdomen- Not as reliable as CT, but can be used in children to avoid ionising radiation exposure
• Diagnostic laparotomy/laparoscopy- Used to distinguish between partial and complete obstruction if imaging doesn’t provide clear evidence
Mx:
• Begin with resuscitation protocols (ABCDE)
• Correct fluid and electrolyte imbalances to reduce operative risk before surgery for obstruction
• Fluid resuscitation and NG tube to aspirate content for decompression (‘Drip and suck’
• Gastrografin can be administered as both a diagnostic and therapeutic measure in cases of partial obstruction. The presence of gastrografin in the rectum 24 hours post-administration indicates a resolving partial SBO, reducing the need for surgical intervention.
• If conservative measures fail, consider surgery. The type of surgery depends on the cause and may include:
• Adhesionolysis
• Bowel resection
• Closure of hernias
• Tumour resection
Large bowel obstruction
Causes, sx, ix, mx
Causes:
• Colonic tumours - overall most common cause
• Strictures, often secondary to diverticular disease, inflammatory bowel disease, or post-surgical anastomosis
• Volvulus, either sigmoid or caecal - most common benign cause
• Hernias
• Adhesions
Sx:
• Cramping abdominal pain
• Bloating
• Absolute constipation, characterized by an inability to pass wind or faeces
• Potential nausea and vomiting, though these are more common in small bowel obstruction and are considered late signs in large bowel obstruction. Faeculent vomiting suggests lower level of obstruction.
Ix:
• Blood tests: FBC (anaemia could suggest malignancy, especially if microcytic i.e. iron-deficiency), electrolyte imbalances and suggest fluid shifts, raised lactate on VBG can suggest ischaemia.
• CEA may be done later on when suspecting colorectal cancer.
• Abdominal X-ray: A primary tool for diagnosing large bowel obstruction
• CT Abdomen: Essential in identifying the cause (e.g. malignancy), as well as providing more details such as the transition point and distinguishing between caecal and sigmoid volvulus.
Mx:
• Supportive care: ‘Drip and suck’ approach - IV fluids, nasogastric tube insertion to help decompress bowel, anti-emetic medication
• Decompression of sigmoid volvulus: Typically achieved using a flexible sigmoidoscope
• Surgical intervention: Approximately 70% of large bowel obstruction patients require surgical intervention, either laparoscopic or open colonic resection, which may involve primary anastomosis or stoma formation.
• Palliative care: For patients with malignant large bowel obstruction unfit for surgery, palliative stenting can be performed to alleviate symptoms.
Femoral hernia
Def, causes, sx, ix, mx
A femoral hernia is a type of hernia that develops in the femoral canal, a space near the groin and thigh. It is often marked by the presence of an irreducible lump in the groin area located inferior to the inguinal ligament and inferior and lateral to the pubic tubercle.
Causes:
- lifting heavy objects
- chronic cough
- constipation
- obesity
- pregnancy
Sx:
- groin lump
- irreducibility
- inflammation
- bowel obstruction features\
Ix:
- physical exam
- US
- CT
Mx:
Open or laparoscopic mesh repair
