Common surgical emergencies

Published on 11/04/2015 by admin

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Last modified 11/04/2015

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5 Common surgical emergencies

Abdominal pain

Abdominal pain is the most frequent presenting complaint on a typical general surgical ‘take’. Diagnosis depends more on clinical assessment of symptoms and signs than on special investigations.

History

• Onset (especially exactly where the pain started)

• Site, radiation and progression

• Nature

• Relieving and exacerbating factors

• Past episodes

• Associated symptoms:

• loss of appetite
• nausea/vomiting
• bowel function
• urinary symptoms
• gynaecological symptoms.

Past medical history

Special note is taken of past illnesses which may be directly relevant to the presenting problem, for example Crohn’s disease in a patient with recurrent right iliac fossa pain, or previous renal stones in a patient with loin pain.

• Medication

• Allergies

• Family history

• Social history (occupation, tobacco and alcohol consumption, home circumstances)

• Systemic enquiry.

Examination

Inspection

• Swellings (bulges at site of hernia orifices)

• Distension

• Scars (beware the scars that are easy to miss, e.g. in the groins, skin creases and loins, laparoscopic scars)

• Discoloration (e.g. bluish colour around umbilicus (Cullen’s sign) or flanks (Grey Turner’s sign) seen in haemorrhagic pancreatitis)

• Visible peristalsis (obstructed bowel)/pulsation (abdominal aortic aneurysm: AAA).

Palpation

• Tenderness (establish area of tenderness and site of maximum severity)

• Guarding (reflex contraction of the abdominal wall in response to palpation)

• Rebound tenderness (exacerbation of pain on sudden release of the palpating hand; care is needed to avoid excessive discomfort)

• Distension

• Masses (establish site and nature)

• Organs (liver, kidneys and spleen)

• AAA (felt as a pulsatile, expansile swelling in the epigastrium)

• Check the groins carefully. Strangulated femoral hernias are quite often missed, especially in elderly women with non-specific symptoms

• Examine the external genitalia

Percussion

A tympanic sound indicates gas, a dull note means solid or fluid beneath. Pain on percussion may also indicate rebound tenderness.

Auscultation

Absent bowel sounds indicate peritonitis or ileus (i.e. inactive bowel following surgery). Tinkling bowel sounds occur in bowel obstruction.

Rectal examination

Look for anal abnormalities (scarring, fissures, skin tags, ulceration, ‘Crohn’s anus’), whether the rectum is empty or contains gas/faeces, nature of faeces (liquid/constipated/blood/melaena/steatorrhoea), tenderness, rectal mucosal lesions and extra-rectal masses.

Differential diagnosis

At the end of your clinical assessment, write down your differential diagnosis in the patient notes, rather than just the presenting problem. For example, ‘epigastric pain’ is a problem but not a diagnosis. It is better to write ‘epigastric pain, differential diagnosis peptic ulceration, pancreatitis, biliary colic’. Later, when the diagnosis is firmly established, check whether it was included in your differential diagnosis. Your diagnostic skills will become much more accurate if you develop the habit of committing yourself to a differential diagnosis after your clinical assessment.

Investigation

There is no blanket series of investigations which is performed for every painful abdomen. Different tests are required depending on the differential diagnosis.

Urine

• Urinalysis is vital to exclude diabetes, pregnancy and microscopic haematuria

• Any condition causing inflammation in the lower abdomen can cause leucocytes in the urine (e.g. appendicitis and diverticulitis) and this does NOT confirm a urinary tract infection (UTI)

• Bilirubin appears in urine in obstructive jaundice

• Urine microscopy and culture (microscopy may demonstrate numerous organisms in UTI)

Blood tests

Haematology

• FBC is nearly always required

• Clotting studies (selectively)

• Group and save serum (G&S; for patients likely to need operation).

Biochemistry

• U&E

• Glucose

• Amylase.

These are useful in almost all cases. (NB: the amylase is often forgotten: beware since pancreatitis can cause pain all over the abdomen.)

The C-reactive protein (CRP) is a non-specific marker of infection/inflammation. Liver function tests should be performed for jaundiced patients and those with suspected biliary or pancreatic problems. More complex tests such as tumour markers are not usually available in the acute A&E setting and are unnecessary to arrive at most common diagnoses.

Plain X-rays

• Erect CXR – vital to exclude free gas under the diaphragm

• Plain abdominal X-ray (AXR) (Boxes 5.1 and 5.2).

Box 5.1 The plain AXR in the acute abdomen is full of useful information. It is often helpful to re-examine the abdomen after inspecting the AXR

Gas pattern

Gas in small or large bowel

Evidence of small or large bowel obstruction (is there gas in the rectum?)

‘Sentinel loop’ of distended small bowel in the upper abdomen in acute pancreatitis

Evidence of free gas (intra- or retroperitoneal)

Air in the biliary tree (choledochal fistula, previous biliary surgery)

Abnormal calcification

Renal, ureteric or bladder stones

Calcified gallstones in gallbladder or gallstone ileus

Calcified aorta or AAA

Pancreatic calcification in chronic pancreatitis

Calcified fibroids and phleboliths

Soft tissue shadows

Loss of psoas shadow in ruptured AAA

Masses/fluid displacing normal bowel pattern

Bones

Rib fractures

Spine/pelvic fractures

Bony metastases

Foreign bodies

Clips from previous surgery

Shrapnel

Swallowed

Rectal

Intrauterine contraceptive device

Box 5.2 Eponymous signs on plain AXR (both radiologists)

Rigler’s sign or ‘double-wall’ sign – air visible on both sides of bowel wall

Chilaiditi’s sign or pseudopneumoperitoneum – presence of bowel between liver and diaphragm mimicking intra-abdominal free air

CT scanning

When teamed with a good clinical assessment, CT scanning is a tremendously useful examination to diagnose acute abdominal pain. It is sometimes said that a CT scan is unnecessary if there is already an indication for laparotomy. However, CT may render some operations unnecessary (e.g. by confirming terminal malignant disease, or demonstrating acute pancreatitis where perforated duodenal ulceration was expected). Other operations may be made easier by providing useful information preoperatively (Table 5.1). The risk of ionising radiation and contrast exposure must always be weighed against these potential benefits.

Table 5.1 Indications for CT scanning in the acute abdomen

Indication Advantage of CT
Pancreatitis Demonstrates pancreatic necrosis
Aortic aneurysm CT scanning is the only reliable way to exclude aortic rupture (ultrasound detects aneurysms but does not exclude rupture)
Severe or non-resolving diverticulitis Allows differentiation between localised perforation of diverticulum, diverticular abscess, diverticular mass
Large bowel obstruction Avoids need for water-soluble contrast enema. Usually accurately demonstrates level of obstruction and cause
Small bowel obstruction with no hernia or scars May detect the cause of the obstruction preoperatively
Suspicion of malignancy Acute abdominal pain is common in advanced malignancy. CT scanning may confirm extensive metastatic disease, avoiding laparotomy when palliative care is more appropriate
Peritonitis in absence of gas on AXR CT scanning is very sensitive for small pockets of free gas after perforation of a viscus
Acute abdomen Standard in many hospitals

Ultrasound

Ultrasound reliably detects free fluid, gallstones, intrahepatic duct dilatation and aortic aneurysm. It is less useful for looking at bowel (sound does not penetrate gas-filled structures). It is operator dependent and picture quality is affected by body habitus and presence of bowel gas. Pelvic ultrasound is useful for detecting gynaecological disorders when diagnosing appendicitis in the female.

Contrast studies

Contrast studies including barium meal, follow-through, water-soluble contrast enema and intravenous urography may each be useful in selected settings.

Patterns of abdominal pain

Appendicitis

Pain is initially central, then localises to the right iliac fossa with guarding and rebound tenderness (Fig. 5.1).

image

Figure 5.1 Symptoms, signs and differential diagnosis of appendicitis. NSAP, non-specific abdominal pain.

Aetiology and pathology

Appendicitis is the commonest cause of the acute abdomen in the United Kingdom. It occurs when there is an obstruction of the lumen either by faecolith or foreign body or enlargement of the lymphoid follicles in its wall. It may affect any age but is rare in the extremes of life.

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