BiteMedicine - Lecture 36 (General Surgical Emergencies) Slide

• Q&A with Mr Tomasi

• Cover two key general surgical emergencies

• Provide important differential diagnoses

• Pathophysiology, clinical features, investigations, management, prognosis

• Multi-step SBAs: for a full understanding of the patient journey

• Summary and Q&A

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Aims and objectives

Introducing our special guest

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Covered today…• Small bowel obstruction• Large bowel obstruction

Next time…• Appendicitis• Perforated peptic ulcer• Diverticulitis / diverticular bleeding• Ischaemic colitis and mesenteric ischaemia

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Conditions to cover

6

Overview

CholecystitisUreteric colic

PyelonephritisHepatitis

Pneumonia

AppendicitisUreteric colic

Inguinal herniaIBD

Testicular torsionGynaecological causes

UTI

Ureteric colicPyelonephritis

Pneumonia

DiverticulitisUreteric colic

Inguinal herniaIBD


UTI

Epigastric region• Peptic ulcer disease• Pancreatitis• Cholecystitis• Myocardial infarction

Periumbilical region• Appendicitis• Small bowel obstruction• Large bowel obstruction• Abdominal aortic aneurysm

© BiteMedicine 2020

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Overview



Pneumonia


Inguinal herniaIBD


UTI


Pneumonia


Inguinal herniaIBD


UTI




8

Overview



Pneumonia


Inguinal herniaIBD


UTI


Pneumonia


Inguinal herniaIBD


UTI




9

Overview



Pneumonia


Inguinal herniaIBD


UTI


Pneumonia


Inguinal herniaIBD


UTI




History and examinationA 60-year-old female presents to the emergencydepartment with central abdominal pain,nausea and vomiting. The pain has been‘coming and going’.

She has had a previous open appendicectomy.

Examination reveals central abdominaltenderness with ‘tinkling’ bowel sounds andabdominal distension. The rectum is empty.

ObservationsHR 130, BP 100/70, RR 20, SpO2 95%, Temp 37.8

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Case-based discussion: 1

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A 60-year-old female presents to the emergency department with central abdominalpain, nausea and vomiting. The pain has been ‘coming and going’. She has had aprevious open appendicectomy. Examination reveals central abdominal tendernesswith ‘tinkling’ bowel sounds and abdominal distension. The rectum is empty.


Q1 Q2

What is the most common cause of the underlying diagnosis?

Case history

Volvulus

Incarcerated hernia

Colorectal cancer

Bowel adhesions

Crohn’s disease

app.bitemedicine.com

Q3 Q4





13


Definition• Small bowel obstruction (SBO) is a mechanical or functional obstruction of the small intestine that

prevents the normal passage of digestive contents

Epidemiology and risk factors• Rare in those without previous surgery (‘virgin’ abdomen)• Previous surgery increases risk by 12-fold• Average age is 60-years-old

14

Introduction

15

Very basic anatomy

16

Important causes

Causes Comments

Bowel adhesions: the most common cause Due to previous abdominal surgery

Incarcerated hernia Usually femoral or inguinal

Crohn’s disease Due to stricture formation

Volvulus Commonly causes large bowel obstruction

Intussusception More common in children

Paralytic ileus Functional obstruction due to failure of peristalsis

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Important causes

Causes

Bowel adhesions: the most common cause

Incarcerated hernia

Crohn’s disease

Volvulus

Intussusception

Paralytic ileus

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Linking pathophysiology and symptoms


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Clinical features

Symptoms Signs

Colicky, central or generalised abdominal pain Abdominal tenderness and distension

Nausea and vomiting: an EARLY symptom in SBO

Tinkling bowel sounds

Bloating Rectal examination: rectum may be empty• Blood suggests strangulation and ischaemia

Absolute constipation: a LATE symptom in SBO Tachycardia and hypotension

20

Differentials



Pneumonia


Inguinal herniaIBD


UTI


Pneumonia


Inguinal herniaIBD


UTI








21


22

An abdominal X-ray is performed…

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A 60-year-old female presents to the emergency department with central abdominalpain, nausea and vomiting. The pain has been ‘coming and going’. She has had aprevious open appendicectomy. Examination reveals central abdominal tendernesswith ‘tinkling’ bowel sounds and abdominal distension. The rectum is empty.


Q2Q1

What bowel diameter suggests small bowel dilatation on imaging?

Case history

> 6 cm

> 1 cm

> 3 cm

> 9 cm

> 12 cm


Q3 Q4

25

Investigations

Primary investigations• Bloods:

• FBC: elevated white cell count with neutrophilia• U&Es: pre-renal AKI and assess for electrolyte imbalances (paralytic ileus)• CRP: usually raised• Group and save: patients may require surgery• VBG: to assess the degree of lactic/metabolic acidosis (suggests ischaemia)• Abdominal X-ray: first-line imaging; dilated small bowel loops (>3cm) with fluid levels

• CT abdomen and pelvis with contrast: gold standard imaging

Investigations to consider• Erect chest X-ray: to assess for pneumoperitoneum if concerned about perforation• Contrast studies: the patient can drink water-soluble contrast (e.g. gastrograffin) and have serial X-

rays; if the contrast fails to reach the colon this is an indication for surgery

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What does the patient’s CT scan demonstrate?Q3

27

Management

“Never let the sun rise or set on small-bowel obstruction”

28

Management

+

29

ManagementConservative initial management• IV fluid resuscitation• Nasogastric (NG) tube: for abdominal decompression• IV antibiotics: patients receive broad-spectrum prophylactic antibiotics, often pre-operatively• Analgesia and anti-emetics

Surgical management• Emergency laparotomy to treat the underlying cause • Surgery is indicated in the following instances (bowel resection):

• Evidence of bowel ischaemia regardless of the cause• A non-adhesional cause (e.g. strangulated hernia)• Failure of conservative management for adhesional obstruction

• Adhesiolysis

30

A 60-year-old female presents to the emergency department with central abdominal pain,nausea and vomiting. The pain has been ‘coming and going’. She has had a previous openappendicectomy. Examination reveals central abdominal tenderness with ‘tinkling’ bowelsounds and abdominal distension. The rectum is empty.


Q1

The patient requires small bowel resection of a significant portion of bowel. Post-operatively, she is discharged and returns to clinic complaining of loose stools and crampy abdominal pain. What is the cause?

Case history

Recurrence of adhesional small bowel obstruction

Short gut syndrome

Dumping syndrome

Gastroenteritis

Achlorhydria

Q4Q3Q2

32

Complications

System Complication

Gastrointestinal • Bowel ischaemia and perforation

Infective • Sepsis• Aspiration pneumonia

Iatrogenic • Short-gut syndrome: if bowel has been resected, there is a risk of malabsorption

History and examinationA 70-year-old male presents to the emergencydepartment with generalised abdominal painand an inability to pass flatus or faeces for thepast 5 days.

He has a background of Parkinson’s disease andhypertension


33


34

A 70-year-old male presents to the emergency department with generalisedabdominal pain and an inability to pass flatus or faeces for the past 5 days.

He has a background of Parkinson’s disease.


Q1 Q2

What is the most common cause of the underlying diagnosis?

Case history

Caecal volvulus

Bowel strictures

Colorectal cancer

Bowel adhesions

Toxic megacolon


Q3

History and examinationA 70-year-old male presents to the emergencydepartment with generalised abdominal painand an inability to pass flatus or faeces for thepast 5 days.

He has a background of Parkinson’s disease andhypertension.


35


Definition• Large bowel obstruction (LBO) occurs due to mechanical or functional obstruction of the large

intestine that prevents the normal passage of contents

Epidemiology and risk factors• Increasing age: usually in people over 65 years old

36

Introduction

37

The three most common causes

Causes Comments

Colorectal cancer The most common cause

Stricture A complication of diverticulitis, inflammatory bowel disease, or post-anastomosis

Volvulus Sigmoid or caecal

Definition• Large bowel obstruction (LBO) occurs due to mechanical or functional obstruction of the large

intestine that prevents the normal passage of contents

Epidemiology and risk factors• Increasing age: usually in people over 65 years old• Colorectal cancer: smoking, obesity, processed meat, IBD• Stricture: diverticulitis, IBD• Volvulus: chronic constipation, neuropsychiatric conditions (sigmoid), female (caecal)

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Introduction

39



40


Less significant than in SBO


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Clinical features

Symptoms Signs

Colicky, generalised abdominal pain Abdominal tenderness and distension

Bloating Tinkling bowel sounds

Absolute constipation: no passing of faeces of flatus

Rectal examination: empty rectum

Vomiting: may be faeculent; a LATE symptom in LBO

Tachycardia and hypotension

42

Differentials



Pneumonia


Inguinal herniaIBD


UTI


Pneumonia


Inguinal herniaIBD


UTI



43

What does the patient’s abdominal X-ray demonstrate?Q2Q1 Q3

44

InvestigationsPrimary investigations• Bloods:

• FBC: elevated white cell count with neutrophilia• U&Es: assess for pre-renal AKI• CRP: raised • Venous blood gas: to assess the degree of lactic/metabolic acidosis • Group and save: patients may require surgery

• Abdominal X-ray: first-line imaging• Dilated large bowel may be visible (> 6cm in the colon; > 9cm in the caecum)

• CT abdomen and pelvis with contrast: gold standard imaging

Investigations to consider• Erect chest X-ray: to assess for pneumoperitoneum if concerned about perforation• Contrast enema: a water-soluble contrast fluid can be used to identify obstruction if the above

investigations are equivocal

45

Management

+

46

A 70-year-old male presents to the emergency department with generalisedabdominal pain and an inability to pass flatus or faeces for the past 5 days.

He has a background of Parkinson’s disease.


Q2

CT demonstrates sigmoid volvulus. What is the most appropriate management?

Case history

Right hemicolectomy

Stenting

Hartmann’s procedure

Defunctioning colostomy

Rigid sigmoidoscopy and flatus tube insertion


Q3Q1

48

Management

Conservative initial management• IV fluid resuscitation• Nasogastric (NG) tube: for abdominal decompression• IV antibiotics: patients usually receive prophylactic antibiotics due to the risk of bacterial

translocation • Analgesia and anti-emetics

Treat the cause• Colon cancer: stenting or surgical resection, e.g. Hartmann’s procedure• Rectal cancer: defunctioning colostomy• Diverticular disease: Hartmann’s procedure or resection, with or without a stoma• Sigmoid volvulus: rigid sigmoidoscopy with flatus tube insertion• Caecal volvulus: usually requires surgery; right hemicolectomy is often performed• Unclear cause: exploratory laparotomy

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Complications and prognosis

System Complication

Gastrointestinal • Bowel ischaemia and perforation

Infective • Sepsis• Aspiration pneumonia

Covered today…• Small bowel obstruction• Large bowel obstruction

Next time…• Appendicitis• Perforated peptic ulcer• Diverticular bleeding• Ischaemic colitis / mesenteric ischaemia

50

Conditions to cover

53

References

1. Slides 6-10, 14, 21, 22, 36, 39, 46. Upper body front.png: Mikael HäggströmBackground made transparent by Frédéric MICHELforThis image was improved or created by the Wikigraphists of the Graphic Lab (fr). https://commons.wikimedia.org/wiki/File:Human_body_silhouette.svg

2. Slide 16. LadyofHats / Public domain. https://commons.wikimedia.org/wiki/File:Digestive_system_diagram_an.svg

3. Slide 23 and 24. James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0). https://commons.wikimedia.org/wiki/File:Upright_X-ray_demonstrating_small_bowel_obstruction.jpg

4. Slide 28. Hellerhoff / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0). https://commons.wikimedia.org/wiki/File:Pneumatosis_intestinalis_CT_LF_Darmischaemie.jpg

5. Slide 47. Hellerhoff / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0). https://commons.wikimedia.org/wiki/File:Sigmavolvulus_-_Coffee-bean-sign_-_LSL.jpg

https://commons.wikimedia.org/wiki/File:Human_body_silhouette.svg

https://commons.wikimedia.org/wiki/File:Digestive_system_diagram_an.svg

https://creativecommons.org/licenses/by-sa/3.0

https://commons.wikimedia.org/wiki/File:Upright_X-ray_demonstrating_small_bowel_obstruction.jpg


https://commons.wikimedia.org/wiki/File:Pneumatosis_intestinalis_CT_LF_Darmischaemie.jpg


https://commons.wikimedia.org/wiki/File:Sigmavolvulus_-_Coffee-bean-sign_-_LSL.jpg

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BiteMedicine - Lecture 36 (General Surgical Emergencies) Slide

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