Presenations Flashcards
How do you assess an acute surgical admission?
The system of 5
Are they critically unwell? Look, obs, alert/ orientated ❌stabilise, call for help :
Investigations:
- Bedside obs
- Microbiology (culture, MRSA)
- Blood tests (FBC, U&Es, LFTs, amylase, clotting, G&S)
- Imaging (ECG, CXR)
- Specialist tests (CT, endoscopy)
Management:
- O2?
- IV access - fluids, catheter, NBM/ NGt, fluid balance chart
- Drug chart - analgesia, anti-emetics, antibiotics, regular meds
- VTE prophylaxis (LMW H, TED stockings)
- Escalation & MDT involvement
What is ‘the acute abdomen’?
Sudden onset of severe abdo pain <24hrs
Are they critically unwell?
Acute abdomen presentations requiring urgent surgery
- Bleeding e.g. ruptured AAA, ruptured ectopic pregnancy, bleeding gastric ulcer, trauma
- perforated viscus -> peritonitis e.g. peptic ulcer, S/LB obstruction, diverticula disease, IBD
Lay still, tachycardia, rigid abdomen, percussion tenderness, involuntary guarding, reduced/ absent bowel sounds - ischaemic bowel
Severe pain out of proportion signs, acidaemic, raised lactate
Abdo pain presentations that are less acute
Colic - crescendos e.g. ureteric obstruction, bowel obstruction, (biliary colic not true colic pain stays underlying - RUQ pain worse after eating)
- peritonism localised inflammation peritoneum
Pain starts 1 place (visceral peritoneum)-> localising another area (parietal)/ generalised e.g. appendicitis umbilical-> RIF
Investigations for abdo pain
Urine dipstick Pregnancy test ABG Routine bloods - Ca pancreatitis Blood cultures
ECG
USS - KUB, biliary tree, liver, ovaries, FT, uterus
Erect CXR - bowel perforation
CT
Causes of haematemesis
Oesophageal varices - dilations Porto-systemic venous anastomoses in oesophagus
Common cause: alcoholic liver disease -> portal hypertension
- urgent OGD
✅endoscopic banding, antibiotic therapy, somatostatin analogues/ vasopressors, Beta blocker therapy
Gastric ulcers (60%)
Erode Bvs, H.pylori, NSAID, steroids
✅adrenaline injections, cauterisation, PPI IV
Non emergencies:
- Mallory-Weiss tear
Episodes severe/ recurrent vomiting, tear epithelial lining oesophagus, most resolve spontaneously
OGD
Oesophagitis - often due GORD, infections, bisohosphonates, radioT, toxic substances, Crohn’s
Gastritis, gastric malignancy meckel’s diverticulum, vascular malformations
What X-ray sign may indicate a perforated gastric ulcer?
Subdiaphragmatic free gas
What is dysphagia until proven otherwise? What are some other causes?
Oesophageal cancer
- urgent upper GI endoscopy
Other causes: Gastric cancer Benign oesophageal strictures Extrinsic compression Pharyngeal pouch Foreign body Oesophageal web Post stroke Achalasia Diffuse oesophageal spasm Myasthenia gravis Myotonic dystrophy
Most common causes of bowel obstruction
Small bowel - adhesions, hernias
Dilated >3cm, central, valvular conniventes visible
Large bowel - malignancy, diverticula disease, volvulus
Dilated >6/ 9 at caecum, peripheral, haustra lines
Intraluminal - gallstone ileus, ingested foreign body, faecal compaction
Mural - carcinoma, inflammatory strictures, intussusception, diverticula strictures, meckel’s diverticulum, lymphoma
Extramural - hernias, adhesions, peritoneal metastasis, volvulus
Ct IV contracts
Bloods
What examination sign indicated ischaemia may be developing?
Rebound tenderness
Causes of gastrointestinal perforation
Most common: peptic ulcers & sigmoid diverticulum
Chemical -
Peptic ulcer disease
Foreign body (battery)
Infection -
Diverticulitis
Cholecystitis
Meckel’s diverticulum
Ischaemic -
Mesenteric ischaemia
Obstruction lesion (cancer, faeces)
Colitis - Toxic megacolon (UC)
Traumatic -
Iatrogenic (NG tube insertion, anastomotic leak)
Penetrating
Direct rupture (Xs vomiting)
Thoracic perforation e.g. oesophageal rupture symptoms
Pain chest/ neck -> back worse inspiration
Associated vomiting
Resp symptoms
May signs pleural effusion
Palpable crepitus
Gastrointestinal perforation signs on eCXR & abdominal X-RAY
What is the gold standard investigation?
ECXR:
Free air under diaphragm
Thoracic:
Pneumomediastinum
Widened mediastinum
AXR:
Rigler’s sign - both sides bowel wall seen
Psoas sign - loss sharp delineation psoas muscle border
Ct ⭐️
Management of GI perforation
Resus Broad spec antibiotics NG tube IV fluid Analgesia
Peptic ulcer - omental patch
Resus perforated diverticula - hartmans procedure
Thorough washout
Some conservative (sealed, no evidence generalised contamination, unlikely survive)
Causes of Melena
Upper GI bleeding E.g. peptic ulcer disease Liver disease Gastric cancer Oesophageal cancer Oesophageal Varices bleeds Gastritis Oesophagitis Mallory Weiss tear Meckel’s diverticulum Vascular malformations
-OGD
⬇️HB ⬆️urea: creatinine (Hb digested -> urea)
