Gastrointestinal emergencies

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Chapter 25 Gastrointestinal emergencies

Greg McDonald

The aim of emergency department assessment of patients with gastrointestinal (GIT) emergencies is to rapidly detect and stabilise those patients requiring urgent surgical or procedural intervention. In pursuing this aim the processes of assessment, investigations appropriate to the disease and management should be followed in an orderly and purposeful manner and must be performed simultaneously in the seriously ill.

ACUTE ABDOMEN

An ‘acute abdomen’ may be defined as an acute intra-abdominal condition causing severe pain and often requiring urgent surgery. The causes may be:

• inflammatory, e.g. appendicitis, diverticulitis, cholecystitis, perforated viscus
• mechanical, e.g. incarcerated hernia, band adhesions, volvulus, intussusception
• vascular, e.g. aortic aneurysm, mesenteric infarction
• neoplastic, e.g. carcinoma colon
• congenital, e.g. malrotation, congenital atresia/stenosis, Meckel’s diverticulum
• trauma.

The priority is to resuscitate the patient as needed and exclude a life-threatening cause of abdominal pain. In-hospital investigation and management is usually required.

Assessment

History

• Who is your patient? Age and sex are two important aetiological factors.

• Patients over the age of 65 years are twice as likely as younger patients to require surgical intervention.
• Gynaecological disorders obviously need to be excluded in women, particularly in their childbearing years. Young women are also more likely to have a final ‘uncertain’ diagnosis (up to one-third of cases).
• Previous medical and surgical histories and a drug history will give important clues to diagnosis and need to be considered for operative fitness.

• When did the pain start? Acute onset of severe pain implies vascular events, perforated viscus or renal colic. Inflammatory causes tend to arise more slowly.
• Where is the pain? Has it moved? Initial visceral pain is usually diffuse and in the midline. Later somatic pain localises better to the site of pathology.
• What is the pain like? The colicky pain of bowel obstruction is typically episodic and gripping with pain-free intervals. In the case of biliary and renal colic, there is more constant pain rising to a crescendo. Constant severe pain indicates advanced or serious illness.
• Which other symptoms accompany this illness? The onset of nausea and vomiting after the onset of pain suggests surgical illness. Constipation is non-specific but absolute constipation (neither faeces nor flatus) indicates bowel obstruction. Diarrhoea, jaundice, haematuria, haematemesis or melaena leads to specific diagnoses.

Remember: Only two-thirds of patients with acute surgical conditions have a ‘typical’ history of illness. Children and the elderly are more likely to have atypical presentations.

Examination

General

Appearance is apprehensive and motionless with peritonitis, unsettled and agitated with colicky pain, and pale and ‘Hippocratic’ with advanced disease. Check temperature, hydration, pulse and blood pressure (with postural drop).

Abdomen

• Inspection—rigid, distended or scaphoid, visible peristalsis, operative scars
• Palpation—guarding, diffuse or local tenderness, rebound tenderness

Note: ‘Rebound’ is not pathognomonic of peritonitis. It is false positive in up to one-quarter of patients and is an observer-dependent sign. Cough and percussion tenderness are often more reliable.

• Percussion—local peritonism, air, fluid, masses, organs

Note: Loss of liver dullness with pneumoperitoneum.

• Auscultation—peristaltic noises coinciding with colic in small bowel obstruction, diffuse increased bowel sounds in gastroenteritis, silent abdomen or occasional tinkling sounds in late bowel obstruction or diffuse peritonitis

Special signs

• Murphy’s sign in cholecystitis; Rovsing’s, psoas and obturator signs in appendicitis; Cullen’s and Grey-Turner’s signs in pancreatitis; costovertebral tenderness with pyelonephritis or perinephric abscess.
• Hernial orifices/scrotum and testes should never be forgotten.
• Rectal examination looking for blood (bright, melaena or occult), faecal loading, local tenderness, masses, prostatomegaly.
• Pelvic examination: incorrect and uncertain diagnoses occur much more frequently in women. A careful vaginal examination will help differentiate pelvic pathology.

Note: Cervical excitation is a ‘classic’ sign of ectopic pregnancy and pelvic inflammatory disease but is an observer-dependent sign.

OTHER SYSTEMS

Exclude non-abdominal pathology causing abdominal pain, e.g. pneumonia, pulmonary embolus and myocardial infarction. Assess operative fitness (cardiovascular and respiratory).

Investigations

Immediate

• Urine—urine analysis, microscopy and culture, pregnancy test (if appropriate)
• Blood—haemoglobin; haematocrit (PCV); white cell count and differential; electrolytes, urea and creatinine (EUC); amylase/lipase (if appropriate); blood gases (if appropriate); group-and-hold serum/cross-match (if blood loss or operation likely)
• Stool—occult blood
• Organ imaging—abdominal X-ray, supine and erect, chest X-ray, erect

Semi-urgent (with appropriate indications)

• Blood—liver function tests, coagulation studies
• Stool—smear and culture for colitis, enteritis
• Organ imaging—abdominal, ultrasound CT scan, angiography
• Endoscopy—proctosigmoidoscopy, panendoscopy

Value of investigations

Pregnancy should be considered and excluded in all women of child-bearing years with acute abdominal pain.

White cell count is non-specific unless a marked neutrophilia (over 20 × 109/L) is present. It is often a late manifestation of significant pathology.

Serum amylase is frequently elevated in a variety of surgical conditions. Levels greater than three times normal strongly suggest pancreatitis. Lipase is more sensitive and specific for pancreatitis and is the test of choice for this disease.

Abdominal X-rays are a poor tool for diagnosing non-specific abdominal pain, but are valuable in confirming specific and serious pathology. Bowel obstruction, paralytic ileus, caecal and sigmoid volvulus have typical findings. A paucity of bowel gas may be the only clue to mesenteric infarction. Don’t forget to check the psoas shadows, the size and shape of solid organs, for calculi and for air in the biliary tree. Avoid abdominal X-rays in pregnancy if possible.

Erect chest X-ray will detect subdiaphragmatic free air, exclude pulmonary pathology and help preoperative assessment. Free air will be absent in about 20% of perforated peptic ulcers. Massive pneumoperitoneum suggests colonic perforation. The chest X-ray is the definitive investigation for Boerhaave’s syndrome (oesophageal rupture).

Abdominal ultrasound is usually indicated for right upper quadrant pain and cholelithiasis, obstructive uropathy, pelvic pathology, suspected abdominal aortic aneurysm (in stable patients) and abdominal masses. It is the investigation of choice in many paediatric patients, e.g. intussusception, pyloric stenosis, appendicitis. Pelvic ultrasound is essential for the diagnosis of gynaecological and pregnancy-related diseases.

CT scanning: spiral non-contrast CT is the initial test of choice for renal colic. Contrast CT is useful in diagnosing many acute surgical conditions, e.g. acute pancreatitis, intra-abdominal sepsis, intra-abdominal trauma. It is increasingly used to confirm the preoperative diagnosis before laparotomy.

Angiography may be both diagnostic and therapeutic in intestinal haemorrhage, mesenteric ischaemia and abdominal trauma.

Proctosigmoidoscopy is a diagnostic tool in bright rectal bleeding, rectal mass and colitis, and is therapeutic in sigmoid volvulus.

Panendoscopy is indicated urgently in life-threatening upper GIT bleeding and semi-electively in stable patients with suspected peptic ulcer or other inflammatory conditions of the upper GIT.

Management

Surgical emergency

Examples of a surgical emergency include perforated viscus, advanced peritonitis, mesenteric infarction and strangulated bowel.

Common indications for laparotomy

Most patients with an acute abdomen will undergo specific imaging prior to surgery. Adequate resuscitation and prophylactic antibiotics will allow imaging before operation.

• Physical findings—diffuse or spreading rigidity; tense or progressive distension; increasing or severe localised tenderness and peritonism; tender abdominal mass with high fever or sepsis; equivocal clinical signs with septicaemia, uncontrolled bleeding, suspected mesenteric ischaemia, deterioration with conservative treatment
• Radiological findings—pneumoperitoneum; gross or progressive bowel obstruction; free contrast extravasation; perforation abscess on ultrasound/CT scan
• Endoscopic findings—perforation or uncontrolled bleeding

Preoperative treatment

1. Airway.
2. Breathing—oxygen by mask.
3. Circulation—intravenous access and appropriate blood tests; volume resuscitation; urinary catheter.
4. Analgesia should be given after initial medical assessment and establishment of a working diagnosis. Small increments of intravenous narcotics greatly benefit the patient.

Note: Narcotics do not mask clinical signs in abdominal pain; they may help in assessment by reducing patient distress and anxiety. Do not deny analgesia to patients in pain.

5. Antibiotic prophylaxis is required with diffuse peritonitis or if infective pathology is suspected. Ampicillin, gentamicin and metronidazole is the usual combination therapy.
6. Preoperative preparation—nasogastric tube; operative fitness; consent (by surgeon).

Surgical admission

Some conditions for which admission to hospital for conservative treatment, observation and semi-elective operation is appropriate are discussed later.

Emergency department observation and discharge

Patients with mild or equivocal tenderness, minor or no laboratory abnormalities and whose condition settles can be discharged for follow-up in the community, after observation in the department. Certain diagnoses, e.g. uncomplicated renal or biliary colic and peptic ulceration, are discharged in most cases for further investigations and referral.

SPECIFIC SURGICAL CONDITIONS

Acute appendicitis

This is the most common general surgical emergency. Most problems occur with extremes of age, < 5 and > 60 years, mostly due to atypical presentation and late diagnosis.

Assessment

• Typical history is vague periumbilical pain, anorexia, nausea, vomiting, pain migration to right iliac fossa, fever. This only occurs in about half of cases.
• Clinical features include: mild/moderate pyrexia; anorexia; McBurney’s point tenderness and peritonism with or without mass; ruptured appendix will often have a quiet peritonitic abdomen with few localising signs.
• Perform vaginal examination to exclude pelvic pathology in women.
• Differential diagnoses: mesenteric adenitis in children; diverticular disease/caecal carcinoma in adults; ovarian cyst, pelvic inflammatory disease, ectopic pregnancy.

Investigations

• Convincing clinical appendicitis—no investigations are required, other than for preoperative assessment if needed.
• Uncertain diagnosis—urine analysis/MSU to exclude urinary tract infection; white cell count is moderately raised (10 to 15 × 109/L with left shift) and is often a late indicator; AXR/CXR rarely necessary, perform only if you suspect another diagnosis or complications.
• Ultrasound is preferred for evaluating right iliac fossa pain in children and fertile female patients if the diagnosis is uncertain.
• CT is more sensitive than ultrasound and may reveal alternative diagnoses; contrast is not needed with newer CT scanners.

Management

1. Surgery as soon as practical. Overnight delay in the stable patient does not significantly worsen outcome.
2. Suspected perforation/generalised peritonitis—urgent surgery.
3. Prophylactic antibiotics reduce infective complications. They should be given in the emergency department if peritonitis or abscess is suspected or if surgery will be delayed. Otherwise antibiotics can be given at induction of anaesthesia.
4. Mass/phlegmon—intravenous antibiotics and fluids; nil by mouth; ultrasound/CT scan; operation at surgeon’s discretion.
5. Uncertain diagnosis—non-specific clinical findings and investigation results; admit; nil by mouth; intravenous fluids; analgesia; close review; ultrasound/CT scan.

Acute cholecystitis

Assessment

• 25% of women and 12% of men have gallstones.
• Past history of fat intolerance, belching and flatulence.
• Right upper quadrant pain becoming constant and severe.
• Mild fever and tachycardia; mild icterus in 10% of cases.
• Tender right upper quadrant with positive Murphy’s sign.
• Palpable gallbladder in about one-third of cases.
• Empyema—toxic/shocked, high spiking temperatures.
• Local perforation—progressing fever, symptoms and signs. Local mass and peritonism.
• Free perforation—general peritonism.
• Cholangitis—common duct stone; right upper quadrant pain; jaundice; fever/rigors.

Investigations

• Urine analysis—bilirubin; exclude renal pathology.
• White cell count—moderate neutrophilia is usual. Marked neutrophilia suggests complications.
• Liver function tests—bilirubin > 60 mmol/L suggests common duct obstruction.
• Abdominal X-ray is often not helpful but may be ordered to exclude other pathology and complications.
• Ultrasound demonstrates stones, debris within the gall bladder, wall thickening, masses or abscesses.
• Hepatobiliary iminodiacetic acid scan (HIDA) may be used if the ultrasound is non-diagnostic, e.g. acalculous cholecystitis.
• Operative fitness assessment (e.g. ECG, CXR, Hb, renal function).

Management

Uncomplicated biliary colic

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