Surgical Emergenciesthe

G1Group

B yQ u a h C h e e S i a n

Pa r t h i b a n S .

S H O C KI M M E D I A T EM A N A G E M E N T SS I G N SI N V E S T I G A T I O N SI N F O G R A P H I C S

Introduction..

S U R G I C A L E M E R G E N C I E S

Sign of Shock

• ↑ HR (>100)• ↓ pO2 (< 90%)• ↑ RR (> 20)• SBP < 90 mmHg

Signs of ShockSURGICAL EMERGENCIES

CP presentation

S U R G I C A L E M E R G E N C I E S

Immediate Management

CP presentation

S U R G I C A L E M E R G E N C I E S

Investigations

What specific laboratory studies will help you?

CP presentation

These are the appropiate initial screening tests.

i. FBCii. BUSE/Criii. Blood glucoseiv. Coagulation profilev. Blood grouping/ X

matchingvi. Investigate source of

bleed

IV Fluids

Colloid or Crystalloids?• Theoretical advantage of colloids remains in IV space, smaller volume required

• Risks: Anaphylaxis, Coagulopathy• Evidence: No significance difference in

outcome between 4% albumin & NS

NS or RL?

• NS has strong anion gradient• Cause Hyperchloremic Metabolic acidosis

Worsen Coagulopathy• HyperKalemia after 6 hours

Cannula Size

O2 Delivering

Oxygen

• Target SpO2: 95-99% (Normal pt)• 88-92% (COPD pt)

1.Nasal prong: 2-5L/min (28-35%)2.Simple face mask: 5-15L/min (35-50%)3.Venturi mask: (24-60% based on valve)4.Non-Rebreathing mask (up to 85% in 15L/min)

CP presentation

Thanks

Upper Gastrointestinal Bleeding

SITI NUR AQILAH MOHD AZRYYEE ZHEN AUN

Variceal

Non-variceal:I. Bleeding PUDII. CA gastric, esophagusIII. Drugs?IV. Mallory Weiss tearV. Others: AVM, Dielafoy syndrome

AETIOLOGYUPPER GASTROINTESTINAL BLEEDING

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PEPTIC ULCER DISEASE

ESOPHAGEAL VARICES

CARCINOMA STOMACH,

ESOPHAGUS

Managementstep-wise management of patients with upper

gastrointestinal bleeding

GENERAL MANAGEMENTUPPER GASTROINTESTINAL BLEEDING

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In addition…• Stop any aspirin, NSAID, anticoagulant, B-blockers• Tranexamic acid• IV Pantoprazole 80 mg bolus, 8 mg/hour continuous infusion for

72 hours• Suspected oesophageal varices: vasoconstrictors till bleed dealt with

endoscopy, gastric lavage with large (32 F) NG tube for better visualization• IV Terlipressin 2 mg 6th hourly or• S/C sandostatin 50-100 micrograms BD

SPECIFIC MANAGEMENTUPPER GASTROINTESTINAL BLEEDING

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In acute UGIB: • emergency endoscopy (within 24 hours)

For bleeding PUD; • if Forest grade I, IIa and IIb proceed with endoscopic

therapy, CLO test3 modalities (choose 2):

• Adrenaline (1:10000) 15-30 mlOGDS ELECTROCOAGULATI

ON HEMOCLIP

DEFINITIVE MANAGEMENTUPPER GASTROINTESTINAL BLEEDING

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If endoscopic therapy fail…Laparotomy and under-running of bleed gastric or duodenal ulcer with silk suture

DEFINITIVE MANAGEMENT

Duodenal ulcer: truncal vagotomy + (pyloroplasty or post. gastrojujenostomy or antrectomy)Gastric ulcer: truncal vagotomy + pyloroplasty, highly selective vagotomy, partial gastrectomy

FOR ESOPHAGEAL VARICESUPPER GASTROINTESTINAL BLEEDING

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ENDOSCOPIC BAND LIGATION ENDOSCOPIC INJECTION SCLEROTHERAPY

PREFERED IN

EMERGENCY

If EBL and EIS not feasible or fail…UPPER GASTROINTESTINAL BLEEDING

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SANGSTAKEN BLAKEMOORE TUBE

Open surgery: if bleeding cannot be manage by endoscopy• Emergency open surgery: devascularization• Shunt surgery: porto-caval shunt, spleno-renal shunt• TIPS

Others:• Therapy to prevent or reduce hepatic encephalopathy

Oral neomycin 1 g QIDOral lactulose 100g/day in divided doses, high enemaIV vitamin K 10 mg

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By Aminurulamirah and Atiqah Zayed

LOWERGASTROINTESTINALBLEEDING BLEEDING

DISTAL TO LIGAMENT OF

TREITZ

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AETIOLOGY• IBD• Colitis (amoebic colitis, typhoid) Inflammatory

• Benign : Intestinal Polyps• Malignant : Colorectal CANeoplastic

• Iatrogenic : post-endoscopyTraumatic

• Vascular: angiodysplasi, hemorrhoids, ischaemic colitis.• Anal fissure• Diverticulum :bleeding diverticulosis/meckels• Drugs: Anticoagulant• Radiation : Colitis

Misc

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Lower Gastrointestinal Bleed ClassificationTYPES OF LGIB

WHO WE ARE

BEST SERVICE OF US

GOOD VISION

VERY USEFUL TIMELINE

EXCELLENT DIAGRAM

CONTACT US

Minor Hemorrhage

Major Hemorrhage Occult Bleed

Hemorrhoids Bleeding diverticulosis Polyps

IBD Angiodysplasia Colorectal CAColorectal Polyps Dieulafoy lesion of

intestines

Intussusception Ischaemic cholitis

Meckel’s Diverticulum

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Schematic Presentation of

approach in LGIBA schematic representation of proper workflow

approach towards lower GI bleed.

CP Presentation 30

•Most of LGIB are chronic cases.

•Acute LGIB : 20% of GI bleed cases

Management of Acute LGIB

Resuscitation and initial assessment

Localization of the bleeding site

Therapeutic intervention to stop bleeding at

the site

CP Presentation 31

Immediate Mxi.02, NG tube, IV fluids, CBD, CVPii.Correct metabolic acidosisiii.Blood transfusioan

(p.RBC,platelets, FFP)iv.Administer hemostatic adjunctv.IVG : all baseline IVG

ABC Protocol

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Usually LGIB source difficult to identify

Localizationof the cause

• 99mTC radionuclide/ scintigraphy• Digital Subtraction Angiogram• Arteriogram of I.M.A • Emergency colonoscopy • Unstable patient subjected to urgent

laparotomy

If actively bleed vessel is identified:

Therapeutic interventions to stop bleeding at the site

Vasopressin injected = vasospasm

Injection of 1:20000 adrenaline into 4 quadrants of bleeding (bleeding diverticulum)Laparotomy

Embolization with metal microcoil or PVA. (life-saving but need interventional radiologist)

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Management for Non-urgent Cases

Baseline blood

IVGStools for

occult blood

Endoscopy

ImagingDouble contract barium enema, CT, angiography

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referencesI. Website: gi.org/wp-content/uploads/2016/03/ACGGuideline-Acute-

Lower-GI-Bleeding-03012016.pdf

II. Website: emedicine.medscape.com/article/188478-treatment#d14

III. Manipal Manualof Surgery

IV. Clinical Companion in Surgery

Causes & managementHAEMATURIA

Lili syafinaz & Teo pei shin

MICROSCOPIC●Can be detected on

dipstick or FEME●Red Blood Cell

(RBC): >3 /hpf

Non-visible haematuria / dipstick-positive

HAEMATURIACLASSIFICATIONS

MACROSCOPICVisible haematuria or gross haematuria

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aetiologyCAUSES OF HAEMATURIA

CONGENITALPOLICYSTIC KIDNEY DISEASE

Infective: Urinary infection

Non-infective: Interstitial cystitis, glomerulonephritis, pyelonephritis

Direct: Blunt/ penetrating trauma

Iatrogenic: Instrumentation/ catheterisation

ACQUIRED

Benign: Benign prostatic hyperplasia Malignant: Renal cell carcinoma, transitional cell

carcinoma of renal pelvis, ureter and bladder, carcinoma of prostate

INFLAMMATORY

TRAUMATIC

NEOPLASTIC

MISCELLANEOUS

BLEEDING DISORDER

Urinary calculi Strenous exercise, Haemoglobinuria

Autoimmune (SLE) Anticoagulant (Warfarin), blood thinner (Aspirin)

39HAEMATURIA

40

• HistoryPainBlood at which stage of micturationAbility to pass urineClots?Symptoms of UTIBleeding disorder/ on anti-coagulantHistory of traumaOther causes of discoloured urine: beetroot, Nitrofurantoin

ManagementIn Emergency Department:

• Resuscitate:Volume replacementCorrect coagulopathyHemostasis

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• Baseline investigationsBlood: FBC, BUSE, coagulation profile, Bloog grouping & crossmatchUrine: Dipstick, C&SImaging: X-ray KUB

ManagementIn Emergency Department:

• Indications for admission:Clot retentionHeavy hematuriaCVS instabilityUncontrolled pain

SepsisAcute renal failureCoagulopathySevere comorbidities

42Subsequent managementIn Ward

LABORATORY• Urine FEME

IMAGINGUSG KUBIntravenous urogramCT scanMRI scan Radioactive scan

OTHERS• Cystoscopy— biospy and HPE• Ureterorenoscopy— Brushing

and cytology

General Treatment of Haematuria

Continuous Bladder IrrigationExcept in a case of haematuria

following instrumentation…

44Management of renal stoneConsist of two main components

Medical expulsive therapy (MET)•Drink lots of fluids (>1.2 L)•Diuretic•Antispasmotic, alpha blocker, CCB

— Relax ureteric smooth muscles

Surgical•Upper 1/3: Push and bang method

I. Cystoscopy—> pass a stent (Pigtail/ Double J stent)—> ESWL

II. Prevent damage to bones.•Middle 1/3 & Lower 1/3:

I. By dormia basket or lithotripsy

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Lithotripsy Pigtail stent Dormia basket Double J stentESWL

Must know (Extra)

46Bladder stone

Urethral stone●Urethroscopy + lithotrypsy●Surgery (urethrolithotomy)

Lithotrite instrument (hendrickson lithotrite)

●ESWL●Cystoscopy and lithotrite (instrument

used to crush stone)●Cystoscopy and lithotripsy

(electrohydraulic/ laser lithotrypsy)

Benign Prostatic HyperplasiaMedical•Alpha blocker (Prazosin, Terazosin, Doxazosin

5mg ON): relax smooth muscle of bladder neck and prostate

•5-alpha reductase inhibitor (Finasteride 5 mg): reduce epithelial layer in prostate glands

Surgery

•TURP (gold standard)

Bladder carcinoma•Depends on staging•Cancer not involving muscle Transurethral resection of tumour+ post-op

intravesical chemotherapy (Thiotepa/ Adriamycin/ Mitomycin)•T2-T4 Radical cystectomy •Any nodes/ metastasis systemic radiation •Small lesion: Partial cystectomy + intravesical

chemotherapy.

Renal Cell Carcinoma•Mainly surgery, respond poorly to

chemotherapy or radiotherapy. •Surgery

I. Nephron sparing surgery (T1)II. Radical nephrectomy

•Targeted therapyI. VEGF inhibitorII. ImmunotherapyIII. Interleukin-2

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HemoptysisEtiology

Specific Management

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Etiology

Haemoptysis is the coughing of blood from a source below the glottis. [1]

Common causes: 1. Tuberculosis (most common in southeast Asia)2. ****Lung cancer - most common in age > 60 years.old ( bronchogenic ca)3. Pneumonia,4. Acute and chronic bronchitis 5. Bronchiectasis.

massive bleeding with life-threatening consequences

Small amount of blood-streaked sputum

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Approach to Hemoptysis

To differentiate haemetemesis /pseudo-hemoptysis /haemoptysis

Volume (in 24 hours) ● mild (15-30ml ) ● frank (>15 <600 ml) ● massive (>600 ml)

History and examination

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Specific for Lung Cancer ...

Chest x ray - to locate site of bleeding

Investigations for diagnosis: doubt ?

Flexible Bronchoscopy (4% to 22% discovered bronchogenic ca) 86% can detect site of bleeding with/ without CT thorax

Bronchoscopy sampling procedures involved several techniques including bronchial washing (BW), bronchial brushing (BB), broncho-alveolar lavage (BAL), transbronchial biopsy (TBB) and endobronchial biopsy (EBB).* visible tumours. : BW > EBB > BB* not visible by bronchoscopy : BAL > BB > followed by TBB.

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ManagementSTAGE MANAGEMENT Clinical stage I or II non-small cell lung cancer (NSCLC) Curative Surgical Resection

Stage IIIA NSCLC , T1-3 primary tumors Combined modality treatment approach

Unresectable stage IIIB NSCLC due to T4 primary tumours, N2-3

Platinum-based doublet chemotherapy (gemcitabine, paclitaxel, or vinorelbine) + - Radiotherapy

Stage IIIB disease due to the presence of a malignant pleural or pericardial effusion

Platinum-based doublet chemotherapy alone

Stage IV disease - good performance status - Poor performance

Platinum-based doublet chemotherapy or single agent chemotherapy

Supportive care

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Thank you

Reference:The causes of haemoptysis in Malaysian patients aged over 60 and the diagnostic yield of different investigations - Published article by Catherine Mee-Ming WONG,Kim Hatt LIM,Chong-Kin LIAM