Acute Surgical Conditions

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Acute Surgical Conditions Trauma Management

• Family Medicine Presentation
• By K.V. Liew H.K. Kwong

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Common Principles

• History Physical Examination.
• Provisional Diagnosis.
• Basic investigations (e.g. blood tests, X-rays
  bedside imaging).
• Definitive Imaging (USG, CT-scan), if patient
  is stable fit for transfer to Radiology
  department.
• Resuscitation if needed, then definitive surgical
  treatment if possible, otherwise supportive
  treatment.

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Acute Abdomen

• Abdominal Pain.
• Physical Examination findings (e.g. tenderness,
  rebound guarding).
• Fever.
• Tachycardia haemodynamicaly unstable.
• Septic-looking.
• Usually implies that there is peritonitis, which
  if left untreated, will result in severe
  complications (e.g. DIC shock) and eventually
  DEATH.

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• Classically, requires urgent surgical treatment,
  especially if the precise cause is not known
  (i.e. exploratory laparotomy).
• Nowadays, with newer technology available, the
  incidence of laparotomy is reduced.
• Endoscopic treatments may be used, depending on
  the precise pathology (e.g. ERCP, therapeutic OGD
  laparoscopy).
• Newer X-Ray, CT USG can provide better image
  quality, enabling more precise diagnosis
  treatment (e.g. interventional/therapeutic
  radiology).

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Take-Home Message No. 1

• Not all acute surgical conditions requires
  surgery. Some can be solved by invasive
  non-surgical procedures.
• e.g. ERCP/papillotomy, therapeutic OGD, X-ray
  guided gel-foam embolisation.

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Take-Home Message No. 2

• How do you define acute ?
• By time of onset or urgency for treatment ?
• Acute surgical conditions actually comprise a
  broad spectrum of time-frame, from hyper-acute
  (e.g. seconds to minutes in ruptured AAA) to
  super-acute (e.g. minutes to tens-of-minutes in
  GI bleed) to normal-acute (e.g. tens-of-minutes
  to hours in PPU, ischaemic bowel, strangulated
  hernia) to hypo-acute (e.g. more than a few hours
  in appendicitis, cholecystitis).

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Acute Surgical Conditions (by anatomy)

• Vascular conditions
• Ruptured or Leaking AAA.
• GI Bleed.
• Thrombosis of arteries (e.g. SMA).

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Ruptured AAA

• Symptoms
• Central abdominal pain, usually of persistent
  continuous nature.
• Low Back Pain
• Dizziness.
• History of AAA.
• Requires high index of suspicion, especially when
  did not have Hx of AAA.

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Signs

• Ill-looking. Need not necessarily be so (maybe
  clinically quite well).
• Hypotension, with fast pulse.
• Pallor.
• Abdominal tenderness, rebound guarding.
• Pulsatile, expansile abdominal mass.
• Expansile, pulsatile mass may not be palpable,
  especially if haematoma has formed in abdomen.

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Management

• Emphasis is on RAPID clinical diagnosis, since
  survival depends on it.
• Hcue, ? Hx of coffee ground vomitus, PR to R/O
  GI bleed. Bedside USG.
• Straight to OT, X-match, mention large amounts
  of blood needed.
• If relatively stable, URGENT CT-Abdomen,
  especially if no previous Hx of AAA.
• Poor prognosis with 50 mortality, some centres
  claim 40.

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GI Bleed

• Divided into upper lower GI bleed.
• Can be rapidly fatal.
• No surgical patient should die from GI bleed,
  if managed promptly properly.

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UGI Bleed Symptoms

• Coffee ground vomitus.
• Tarry stool.
• Dizziness/postural dizziness.
• Epigastric pain.
• Hx of peptic ulcer disease.

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UGI Bleed Signs

• Malaena (fresh/old, indication of urgency of
  treatment).
• Haematemesis.
• Pallor.
• Stigmata of liver disease.
• Hypotension, fast pulse.

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Differential diagnoses

• Bleeding peptic ulcer.
• Gastro-oesophageal variceal bleeding.
• Meckels Diverticulum.

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Management

• Try to assess volume of haemorrhage.
• Urgent OGD is essential for diagnostic
  therapeutic purposes.
• Sengstaken-Blakemore Tube for gastro-oesophageal
  variceal bleed.
• Close monitoring of vital signs.
• Can attempt X-ray guided embolisation of arterial
  bleeders.
• If bleeding not controlled, proceed to surgery
  (e.g. fundoplication partial gastrectomy for GU).

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Lower GI Bleed Symptoms

• PR bleed, can be with blood clots.
• Usually not associated with abdominal pain.
• Symptoms of hypovolaemia shock.
• Symptoms of GI tract malignancy (weight loss,
  decreased appetite, change of bowel habit).

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Lower GI Bleed Signs

• Fresh PR bleed, with/without clots.
• Signs of hypotension shock.
• Signs of GI Tract malignancy.

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Differential Diagnoses

• Bleeding rectal ulcer.
• Haemorrhoids.
• Bleeding colonic tumours.

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Management

• PR Proctoscopy is essentially for diagnostic
  purposes assessing volume of blood loss.
• Close monitoring of vital signs.
• Can attempt X-ray embolisation too.
• If bleeding persists, proceed to surgery (e.g.
  suturing of rectal ulcer hemicolectomy).

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Thrombosis of arteries

• For example, SMA, resulting in acute ischaemic
  bowel.
• Severe abdominal pain which is disproportionate
  to abdominal signs of tenderness/rebound/guarding.
  
• Severe metabolic acidosis.
• Embolectomy /- endarterectomy /- gut resection.

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Urological conditions

• Pyelonephritis /- hydronephrosis.
• If patient is septic-looking, haemodynamiccaly
  unstable, degree of urgency is increased.
• Percutaneous nephrostomy (PCN).

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GI Tract Conditions

• Perforated Peptic Ulcer (PPU)
• Symptoms can overlap with those of severe
  Gastro-enteritis (G.E.)
• Classically, sudden onset of continuous, severe
  epigastric/central abdominal pain. May radiate to
  directly to back.
• P/E showed board-like rigidity of abdomen.
• CXRgtfree gas under diaphragm.
• Omental patch repair (can be open/laparoscopic).
• SIRSgtOT within 6hrs. Of onset of symptoms.

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Ischaemic bowel

• Can be due to other causes apart from thrombosis
  of arterial supply.
• Adhesion bands, strangulated hernia, prolonged
  intestinal obstruction (I.O.)
• CT-Abdomen is of significant value in deciding
  whether to operate or not.
• Laparotomy /- gut resection /- ileostomy or
  colostomy.

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Sigmoid Volvulus

• Abdominal pain.
• NBO nor flatus.
• AXR findings of coffee-bean shaped large bowel,
  spoke-wheel shaped bowel ? shaped bowel.
• Flatus Tube can relieved obstruction and thus not
  necessarily need surgery.

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Intussuception

• Right-sided abdo. Pain.
• Mass in Right flank, RLQ feels empty.
• Confused with appendiceal abscess.
• Site of intussuception near region of ileo-caecal
  valve.
• Barium enema can both be diagnostic
  therapeutic.
• Risk of ischaemic bowel/recurrence after
  procedure.

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Hepato-Biliary Conditions

• Ruptured HCC.
• Usually occurs in those who presents with
  undiagnosed HCC.
• CT-Abdomen if patient is stable for transfer.
• X-Ray guided embolisation of branches of hepatic
  artery. ?Limited value.
• Segmentectomy /- partial hepatectomy.

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Cholangitis, Cholecystitis Gallstone
pancreatitis

• Emergency ERCP /- EPT can be life-saving.
• Treat the septic focus.
• Acute cholecystitis appendicitis.