General Surgery
Seán Keenan
2022
,The Acute Abdomen
Clinical Syndromes that usually require Laparotomy
Peritonitis Rupture of an Organ
- Perforation - Organ Rupture
o Ulcer: Peptic; Duodenal (commoner in H. pylori) o OBGYN: Ectopic pregnant
o Intestinal: Diverticulum; Appendix o GI: Spleen
o Organ: Gall bladder (advanced cholecystitis) o Vascular: Aorta
- Exam and Investigations - Signs of Rupture
o Pain: Tenderness ± rebound pain (Blumberg sign) o Shock: See table below
o Palpation: Abdominal rigidity ± Guarding o Swelling: Abdominal swelling
o Auscultation: Absence of bowel sounds o NB: Spleen rupture may take wks to present
o XR: Erect AP CXR may show gas under diaphragm
o Special: Pain on cough test
Estimating Blood Loss from Patient's Initial Presentation
Parameter Class I Class II Class III Class IV
Blood Loss <750 mL (<15 %) 750-1500 mL (15-30 %) 1500-2000 mL (30-40 %) >2000 mL (>40 %)
Pulse <100 BPM >100 BPM >120 BPM >140 BPM
BP ↔ ↔ ↓ ↓
Pulse Pressures ↔/↑ ↓ ↓ ↓
Respirations 14-20/min 20-30/min 30-40/min >35/min
Urine Output >20 mL/hr 20-30 mL/hr 5-15 mL/hr Negligible
Mental State Slightly anxious Anxious Confused Lethargic
Fluid to give Crystalloid crystalloid Crystalloid + Blood Crystalloid + Blood
Clinical Syndromes that may not require a Laparotomy
Local Peritonitis Colic
- Inflammation - Nature of Presentation
o Intestinal: Diverticulitis; Appendicitis o Muscles: Spasms leads to intermittent pain
o Organ: Cholecystitis; Salpingitis o Restless: Pain may also be full and constant
- Indications of Investigations - Locations affected
o USS/CT: Swelling; Swinging fever; ↑ WCC o GI: Gut; Bile Duct; Gallbladder
- Investigations Options o Urinary: Ureter
o XR: Peritonitis can induce localised ileus o OBGYN: Salpinx; Uterus
- Management Options
o Drainage: Cutaneous; Laparotomy
Acute Abdomen in General
Investigations Management
- General: U&E; FBC; LFTs; CRP - Fluids: Do not rush resuscitation pre-op
- Specific: Amylase; Lactate; Lipase - NB: Anaesthesia mx shock; Replace blood
- Urinalysis: Serum hCG (ectopic pregnancy) - Volume Status: IVI fluids
- AXR: Pneumoperitoneum (Rigler’s/Double wall sign) - Infx: Blood cultures; IV Tazocin
,Acute Abdomen Causes
Infective Vascular
- GIT: Gastroenteritis; Appendicitis; Diverticulitis - Ischaemia: Mesenteric ischaemia; MI (Esp. ♁)
- Urinary: Pyelonephritis - Rupture: Abdominal Aortic Aneurysm
- Biliary: Cholecystitis; Cholangitis Traumatic
- Hepatic: Hepatitis - Trauma: Ruptured spleen; Perforated viscus
- Other: Pneumonia; Malaria (spleen) Metabolic
Inflammatory - Stones: Renal stones; Ureteric stones
- Digestive: Peptic Ulcer Disease; Pancreatitis - Excess: DKA; Lead; Porphyria;
Upper GIT Problems
Peptic Ulcer Diseases GI Haemorrhage
- Location: Epigastrium - Location: Epigastrium
- Sx: UGI Haemorrhage may be seen - Sx: Haematemesis
- Cx: LT NSAID use; Alcohol Excess; H. pylori - Cx: PUD; Typically gastric ulcer
- NB Duodenal: Relieved by eating - NB: Severe bleeds usually involves Left Gastric a.
- NB Gastric: Exacerbated by eating
Lower GIT Problems Hepatobiliary Problems
Appendicitis Biliary Colic
- Location: Umbilical (initial) ➔ RIF - Location: RUQ
- Sx: Rosving’s sign positive; Anorexia; ↑ HR - Sx: Provocation with fatty meal
- Cx: Infection can block appendix - Cx: Gallstone lodges in bile duct
- NB: Rupture leads to peritonitis - NB: No fever or inflammatory markers
Acute Diverticulitis Acute Cholecystitis
- Location: LLQ - Location: RUQ
- Sx: Colicky pain; Fever; Diarrhoea ± Blood - Sx: Murphy’s sign +ve (inspiration tender); Fever
- Cx: Diverticula form in weakened parts of colon - Cx: Inflammation/Infx of gallbladder 2o to stones
- NB: Raised inflammatory markers and WCC - NB: Raised inflammatory markers
Intestinal Obstruction Acute Pancreatitis
- Location: Umbilical - Location: Epigastrium; Radiates to back
- Sx: Vomiting; Constipation - Sx: Pain is often severe ; Low-grade fever; Ileus
- Cx: Malignancy; Adhesions - Cx: Alcohol; Gallstones migrating to pancreas
- NB: Tinkling bowel sounds - NB: Tenderness on exam
Urological Problems
Renal Colic Urinary Retention
- Location: Loin pain radiating to groin - Location: Suprapubic
- Sx: Severe but intermittent pain; Restlessness Acute Pyelonephritis
- CX: Renal stones trapped in GUT - Location: Loin pain
- NB: Visible or non-visible haematuria - Sx: Fever; Rigors; Vomiting
Gynaecological Problems
Ectopic Pregnancy Urinary Retention
- Location: RIF or LIF - Location: Suprapubic
- Sx: Pain; Amenorrhoea; Vaginal bleeding - Sx: Urinary retention; Hesitancy
- Cx: Incorrectly implanted embryo; Usually fallopian - Cx: BPH
- NB: Amenorrhoea typically started 6-9 wks ago
Vascular Problems
Ruptured AAA Mesenteric Ischaemia
- Location: Umbilical radiating towards back - Location: Umbilical
- Sx: Shock; Hypotension; Tachycardia - Sx: Diarrhoea; Rectal bleeding; Ab pain
- NB: May have a hx of CVD - NB: Hx of AF; Metabolic acidosis
,
Seán Keenan
2022
,The Acute Abdomen
Clinical Syndromes that usually require Laparotomy
Peritonitis Rupture of an Organ
- Perforation - Organ Rupture
o Ulcer: Peptic; Duodenal (commoner in H. pylori) o OBGYN: Ectopic pregnant
o Intestinal: Diverticulum; Appendix o GI: Spleen
o Organ: Gall bladder (advanced cholecystitis) o Vascular: Aorta
- Exam and Investigations - Signs of Rupture
o Pain: Tenderness ± rebound pain (Blumberg sign) o Shock: See table below
o Palpation: Abdominal rigidity ± Guarding o Swelling: Abdominal swelling
o Auscultation: Absence of bowel sounds o NB: Spleen rupture may take wks to present
o XR: Erect AP CXR may show gas under diaphragm
o Special: Pain on cough test
Estimating Blood Loss from Patient's Initial Presentation
Parameter Class I Class II Class III Class IV
Blood Loss <750 mL (<15 %) 750-1500 mL (15-30 %) 1500-2000 mL (30-40 %) >2000 mL (>40 %)
Pulse <100 BPM >100 BPM >120 BPM >140 BPM
BP ↔ ↔ ↓ ↓
Pulse Pressures ↔/↑ ↓ ↓ ↓
Respirations 14-20/min 20-30/min 30-40/min >35/min
Urine Output >20 mL/hr 20-30 mL/hr 5-15 mL/hr Negligible
Mental State Slightly anxious Anxious Confused Lethargic
Fluid to give Crystalloid crystalloid Crystalloid + Blood Crystalloid + Blood
Clinical Syndromes that may not require a Laparotomy
Local Peritonitis Colic
- Inflammation - Nature of Presentation
o Intestinal: Diverticulitis; Appendicitis o Muscles: Spasms leads to intermittent pain
o Organ: Cholecystitis; Salpingitis o Restless: Pain may also be full and constant
- Indications of Investigations - Locations affected
o USS/CT: Swelling; Swinging fever; ↑ WCC o GI: Gut; Bile Duct; Gallbladder
- Investigations Options o Urinary: Ureter
o XR: Peritonitis can induce localised ileus o OBGYN: Salpinx; Uterus
- Management Options
o Drainage: Cutaneous; Laparotomy
Acute Abdomen in General
Investigations Management
- General: U&E; FBC; LFTs; CRP - Fluids: Do not rush resuscitation pre-op
- Specific: Amylase; Lactate; Lipase - NB: Anaesthesia mx shock; Replace blood
- Urinalysis: Serum hCG (ectopic pregnancy) - Volume Status: IVI fluids
- AXR: Pneumoperitoneum (Rigler’s/Double wall sign) - Infx: Blood cultures; IV Tazocin
,Acute Abdomen Causes
Infective Vascular
- GIT: Gastroenteritis; Appendicitis; Diverticulitis - Ischaemia: Mesenteric ischaemia; MI (Esp. ♁)
- Urinary: Pyelonephritis - Rupture: Abdominal Aortic Aneurysm
- Biliary: Cholecystitis; Cholangitis Traumatic
- Hepatic: Hepatitis - Trauma: Ruptured spleen; Perforated viscus
- Other: Pneumonia; Malaria (spleen) Metabolic
Inflammatory - Stones: Renal stones; Ureteric stones
- Digestive: Peptic Ulcer Disease; Pancreatitis - Excess: DKA; Lead; Porphyria;
Upper GIT Problems
Peptic Ulcer Diseases GI Haemorrhage
- Location: Epigastrium - Location: Epigastrium
- Sx: UGI Haemorrhage may be seen - Sx: Haematemesis
- Cx: LT NSAID use; Alcohol Excess; H. pylori - Cx: PUD; Typically gastric ulcer
- NB Duodenal: Relieved by eating - NB: Severe bleeds usually involves Left Gastric a.
- NB Gastric: Exacerbated by eating
Lower GIT Problems Hepatobiliary Problems
Appendicitis Biliary Colic
- Location: Umbilical (initial) ➔ RIF - Location: RUQ
- Sx: Rosving’s sign positive; Anorexia; ↑ HR - Sx: Provocation with fatty meal
- Cx: Infection can block appendix - Cx: Gallstone lodges in bile duct
- NB: Rupture leads to peritonitis - NB: No fever or inflammatory markers
Acute Diverticulitis Acute Cholecystitis
- Location: LLQ - Location: RUQ
- Sx: Colicky pain; Fever; Diarrhoea ± Blood - Sx: Murphy’s sign +ve (inspiration tender); Fever
- Cx: Diverticula form in weakened parts of colon - Cx: Inflammation/Infx of gallbladder 2o to stones
- NB: Raised inflammatory markers and WCC - NB: Raised inflammatory markers
Intestinal Obstruction Acute Pancreatitis
- Location: Umbilical - Location: Epigastrium; Radiates to back
- Sx: Vomiting; Constipation - Sx: Pain is often severe ; Low-grade fever; Ileus
- Cx: Malignancy; Adhesions - Cx: Alcohol; Gallstones migrating to pancreas
- NB: Tinkling bowel sounds - NB: Tenderness on exam
Urological Problems
Renal Colic Urinary Retention
- Location: Loin pain radiating to groin - Location: Suprapubic
- Sx: Severe but intermittent pain; Restlessness Acute Pyelonephritis
- CX: Renal stones trapped in GUT - Location: Loin pain
- NB: Visible or non-visible haematuria - Sx: Fever; Rigors; Vomiting
Gynaecological Problems
Ectopic Pregnancy Urinary Retention
- Location: RIF or LIF - Location: Suprapubic
- Sx: Pain; Amenorrhoea; Vaginal bleeding - Sx: Urinary retention; Hesitancy
- Cx: Incorrectly implanted embryo; Usually fallopian - Cx: BPH
- NB: Amenorrhoea typically started 6-9 wks ago
Vascular Problems
Ruptured AAA Mesenteric Ischaemia
- Location: Umbilical radiating towards back - Location: Umbilical
- Sx: Shock; Hypotension; Tachycardia - Sx: Diarrhoea; Rectal bleeding; Ab pain
- NB: May have a hx of CVD - NB: Hx of AF; Metabolic acidosis
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