Emergency General Surgery

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Emergency General Surgery Peter Mitchell SpR
General Surgery South Manchester University
Hospitals NHS Trust Sept 2008
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Emergency General Surgery Topics

• Can you talk through these topics??

• Acute abdomen
• Biliary Emergencies / pancreatitis
• Swallowed FBs
• GI bleeding
• Appendicitis and RIF pain
• Abdominal pain in children
• Peritonitis
• Intestinal obstruction
• Pseudo-obstruction
• Strangulated hernia

• Intestinal ischaemia
• Superficial sepsis and abscesses
• Acute anorectal sepsis
• Ruptured AAA
• Acutely ischaemic limb
• Acute urological emergencies
• Acute gynae presentations

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Emergency General Surgery Procedures

• Large bowel obstruction
• Colonic perforation
• Hartmanns Procedure
• Colostomy
• Appendicectomy
• Drainage ano-rectal sepsis
• Laparotomy for trauma
• Laparotomy post-op complications
• Exploration of scrotum
• Paraphimosis
• Embolectomy
• Fasciotomy

• Can you talk through these ??

• Abscess drainage
• Tracheostomy
• Catheterisation (inc suprapubic)
• Thoracotomy
• Laparoscopy
• Perf DU
• Upper GI bleed endoscopy / surgery
• Cholecystectomy
• Splenectomy
• Hernia
• Small bowel obstruction / resection
• Ileostomy

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Acute Abdomen

• Abdo pain lt1w duration, requiring admission, not
  previously investigated
• CEPOD senior involvement
• 35 NSAP
• Care with labelling, esp. older patients
• Careful history and examination
• Early resuscitation and analgesia
• Careful and appropriate Ix

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Acute abdomen Early Investigations

• Blood tests
• Specific diagnostic tests
• Baseline
• Indicators of areas of pathology
• X-rays
• Erect CXR
• Supine AXR only when indicated (obstr, perf,
  ?renal stones)
• Contrast studies
• Large bowel obstruction
• ?Upper GI perf
• ?Small bowel obstruction

Regular active re-assessment is as important as
any investigation in influencing management
decisions
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Acute abdomen Other Investigations

• Ultra-sonography
• Early diagnosis of gallstones, gynae pathology,
  ?appendicitis
• CT scanning
• Increasingly important in early and continuing
  assessment
• Laparoscopy
• Early laparoscopy is beneficial in improving
  diagnosis and outcomeDecadt et al. Br J Surg
  1999861383-6

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Case One

• 55yr old male
• Hx - Epigastric pain severe, Vomit x 1, Recent
  Shoulder injury.
• O/E Unwell, Guarding Epigastrium. No BS.
• Ix Bloods, X rays. ??
• Differential Diagnosis.
• DU Perforation Resuscitation Surgery.

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Gastroduodenal Perforation

• Symptoms Abdo pain severe, constant, sudden
  onset.
• Nausea and Vomiting
• Collapse
• Hx of Peptic Ulcer disease (20-50 no Hx of PUD)
• Drugs- NSAIDS, Steroids.
• SIGNS- Pale, Clammy, Tachycardia, Hypotension,
  Tachypnoeic ,Peritonitis .
• INVESTIGATIONS - Erect CXR,FBC,U/E, LFTs,
  Clotting, Cross-match. Amylase, ECG.
• 80 have pneumoperitoneum on erect CXR.

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Gastroduodenal Perforation

• MANAGEMENT ABC, Resuscitation, Catheter, Plan
  for theatre.
• SURGERY - Thorough lavage of peritoneal cavity.
  Omental patch repair. Partial gastrectomy if
  duodenum destroyed, biopsies of gastric ulcers ?
  Malignant.
• PPI Therapy, Antibiotics, DVT prophylaxis,
  eradication therapy.
• Conservative Management - Elderly if too unfit
  for surgery.
• ? In patients who are well with no tenderness
  up to 30 will need surgery. May miss other
  pathology.

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Case Two

• 65yr old male
• Hx Severe epigastric and chest pain, vomiting
  x10, Alcohol
• O/E Unwell, shocked, Guarding in upper abdomen,
  ?creps Left lung base.
• Ix- Bloods, Xrays, ?CT
• Differential Diagnosis.
• Oesophageal Perforation.

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Oesophageal Perforation

• Symptoms Macklers Triad Chest pain,
  vomiting/retching and subcutaneous emphysema.
• Signs Shock, unwell.
• Mediastinits Fever, AF, Tachypnoea
• Respiratory Distress.
• Symptoms can be vague and difficult to assess
  therefore think of diagnosis.

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Oesophageal Perforation

• Spontaneous rupture (Boerhaaves syndrome)
• Post-emetic (80-90) Alcohol excess
  
  Hyperemesis
  gravidarum
• Barogenic Parturition
  
  Heimlich manouvre Heavy weight
  lifting
• Neurology Seizures
• Underlying disease Malignancy, ulceration
• Traumatic Perforation
• Penetrating
• Blunt
• Ingestion injuries
• Corrosive agents
• Foreign bodies

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Oesophageal Perforation

• Iatrogenic Perforation
• Intraluminal injury Flexible/rigid endoscopy
  
  Post-dilatation
  Variceal
  sclerotherapy
  Laser/PDT
  
  Endoprosthesis/stent
  
• Operative injury Antireflux surgery
  
  Cardiomyotomy
  Thoracic aneurysm repair

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Oesophageal Perforation

• Spontaneous affects usually lower third
• comparatively thinner and weaker mural structure
• along longitudinal axis
• left postero-lateral (lack of support/longitudinal
  muscle fibres)
• 0.6 to 9 cm
• mucosal tear longer than muscle tear

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Differentials?

• Acute MI
• Pancreatitis
• Perforated DU
• Dissecting aortic aneurysm
• Pneumonia
• Spontaneous pneumothorax
• Pericarditis
• Gastric volvulus
• Diaphragmatic hernia
• Mesenteric thrombosis

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Investigations

• Erect CXR pleural effusions
  pneumo-mediastinum subcutaneous
  emphysema hydrothorax
  hydropneumothorax pneumo-peritoneum
• Contrast XR
• CT scan
• Endoscopy
• Thoracocentesis

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Management

• Supportive Resuscitation, analgesia, Catheter,
  Oxygen, Antibiotics, PPIs, HDU care/input, Chest
  drainage. Strict NBM.
• Conservative vs Surgery.
• Conservative has limited role in unfit patients,
  minimal contamination, late diagnosis, small
  ruptures, Iatrogenic perforations.

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• Surgery
• Lavage
• ? Repair
• ? Resection
• ? Create Fistula
• Nutrition
• ? Covered Stent

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Surgery for oesophageal perforation
Repair
T tube
Chest drain
Diaphragm
Gastrostomy
Feeding Jejunostomy
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Case Three

• 75yr old woman
• Hx 9 days -Abdo pain, vomiting, constipated.
• O/E Dehydrated, distended, mild tenderness.
• Ix WCC13, Creat 260, X rays SB loops.
• Differential Diagnosis.
• SBO Gallstone Ileus.

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Small Bowel Obstruction

• Symptoms of Obstruction
• Colicky abdo pain
• Distension
• Vomiting
• Bowels not open.
• Previous surgery ?
• Difference between SBO and Ileus??

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Small Bowel Obstruction

• Extra luminal Adhesions
• Hernia
• Volvulus
• Intussuception
• Inflamm/neoplastic mass
• Congenital bands
• Within bowel Wall Crohns
• Cancer
• TB
• Luminal Gallstones
• FB
• Parasites

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Small Bowel Obstruction

• On examination Scars?, Distension, Peristalsis,
  hernia orifices. Bowel sounds.
• Investigations AXR
• Difference between SB and LB on AXR?
• Anatomy Question difference between jejunum and
  ileum??
• Contrast Studies Gastrograffin films, CT scan.

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Management

• Conservative Drip and Suck - Fluid balance,
  catheter, DVT prophylaxis, NG tube.
• Surgery Laparotomy.
• Case three patient Gallstone removed through
  enterotomy. GB? left alone.

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Case Four

• 66yr old male
• Hx 5 days post CABG, abdo pain, distension,
  difficulty in breathing.
• O/E Distension , Tender RIF.
• Ix bloods, Xrays. CE CT scan
• Differential diagnosis.
• Pseudo Obstruction.

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Large Bowel Obstruction

• Mechanical
• Outside Bowel, Within bowel wall, In the bowel.
• Common causes in colon
• Cancer
• Strictures DD, IFB.
• Volvulus sigmoid.
• Pseudo Obstruction presents as colonic
  obstruction but no cause found. Risk factors
  recent Major surgery (Cardiac and orthopaedic),
  Retroperitoneal disease, elderly, bed bound,
  electrolyte disturbances.
• Closed Loop.

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Large bowel Obstruction

• Change in bowel habit
• /- vomiting ? Closed loop
• Weight loss
• Management
• Drip and Suck
• Imaging
• CE CT scan.
• Contrast enema.

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Surgery for Large bowel obstruction

• Can you talk through
• Right hemicolectomy
• Hartmanns Procedure
• How would you anastomose bowel?
• Consent Patient for Laparotomy for large bowel
  obstruction.
• Blood supply to colon
• Colonic Stenting

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Mx of Pseudo Obstruction

• Correct Electrolyte abnormalities
• Treat possible underlying causes e.g. chest
• Oxygen
• Nutritional support
• Fluid balance
• Flatus tube/ Sigmoidoscopy
• Colonoscopy
• Neostigmine
• Surgery-tender caecum, competent valve.

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Case Five

• 45yr old female
• Hx Severe abdo pain. NV. Not managing
  diet/fluids. Pain radiates into back.
• O/E Guarding epigastrium. Unwell. Dry.
• Ix Bloods, Amylase, ABG, eCXR, AXR.
• Differential Diagnosis.
• Acute pancreatitis.

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Acute Pancreatitis- What to know?

• Definition
• Epidemiology and aetiology
• Pathogenesis
• Scoring systems / severity
• Antibiotics
• CT scanning
• ERCP
• Diagnosis of infection
• Surgical treatment indications and techniques
• Outcome and further management
• Timing of cholecystectomy

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Acute pancreatitis-definition
An acute inflammatory process of the pancreas,
with variable involvement of other regional
tissues or remote organ systems. Atlanta
Classification, 1992 Classification
Mild AP Associated with minimal organ
dysfunction and uneventful recovery Severe
AP Associated with organ failure or local
complication
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Causes
Alcohol Hypercalcaemia Gallstones Postopera
tive Tumours Trauma ERCP Ischaemia Infection
CMV, mumps Drugs Anatomical abnormalities Scorpion
venom Lipid abnormalities Idiopathic Hypotherm
ia
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Acute pancreatitis - pathophysiology

• Acinar damage by enzymes
• Maybe due to hypersecretion and ductal
  obstruction or reflux of duodenal contents.
• Proteolytic enzymes cause ischaemia and
  haemorrhage.
• Systemic effects
• Main enzymes released trypsin, amylase, lipase
• Oedematous, Haemorrhagic, Necrotizing.

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Acute pancreatitis - pathophysiology

• Systemic Inflammatory Response Syndrome
• SIRS
• Two of four
• Temp gt38 or lt36
• RR gt22
• HR gt90
• WCC gt14 or gt4
• Multiple Organ Failure
• ARDS
• Renal Failure
• Cardiac Failure
• GI compromise

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Acute pancreatitisinvestigation and management

• Initial resuscitation and management
• Assessment of severity of disease
• Identification management of precipitating
  factors
• Specific aspects of management

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Acute pancreatitisInitial resuscitation and
management
General supportive care Analgesia Intravenous
fluids Support cardiovascular, Renal and
respiratory systems.
Investigations FBC U/E, glucose serum amylase
clotting LFT ABG CXR AXR USS CT scanning
Monitoring Pulse, BP Hourly Urine
Output BMs Sats CVP/Arterial line HDU / ITU
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Acute pancreatitis - Assessment of severity of
disease
On admission At 48 hours age gt 55y Hct
decrease gt 10 glucose gt 200mg serum Ca2 lt
8mg WCC gt 16000/mm3 base deficit gt 4mEq/L LDH
gt 700 IU/L urea increase gt 5mg GOT gt 250
IU/L fluid sequestration gt 6L arterial
pO2 lt 60mmHg Ranson et al 1974
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Modified Glasgow Score

• P PaO2 lt8KPA
• A Albuminlt32
• N Neutrophils (WCC gt15)
• C Calcium lt2mmol/L
• R uRea gt16mmol/L
• E Enzymes LDHgt600
• A AST gt200
• S Sugar- Glucosegt10mmol/L
• Validated for Gallstone and Alcohol
  Pancreatitis. Ransons for alcohol induced only.

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Acute pancreatitis - Assessment of severity of
disease

• Clinical Assessment
• Ranson Criteria
• Imrie / Glasgow Score
• APACHE II
• CT scanning
• Individual markers
• CRP(gt200, or persists gt150)
• IL 6 gtResearch setting
• TAP gtResearch setting

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Acute pancreatitis Identification management
of precipitating factors
Cholelithiasis ERCP ES, cholecystectomy Alcohol
Abstention, counselling. Ischaemia Careful
support, Correct cause Malignancy Resection or
bypass Hyperlipidaemia Diet, lipid lowering
drugs Anat. Abnormalities Correction if
possible Drugs Stop or change
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Acute pancreatitis Specific aspects of management

• CT scanning
• Antibiotics
• Diagnosis of infection
• ERCP in gallstone pancreatitis
• Nutrition
• Manipulation of the inflammatory response

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Acute pancreatitis - CT scanning

• Occasionally helpful in diagnosis
• Useful in severe disease
• Days 4-10 to identify necrosis
• Not useful in predicting severity
• Useful for complications
• Acute fluid collections
• Abscess
• Necrosis
• Monitoring progress of disease

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Acute pancreatitis - Antibiotics

• Imipenem reduced sepsis in severe pancreatitis,
  but not operation rate or mortality.
• Pederzoli et al. 1993 Multicentre randomised
  control trial 74 patients
• Cefuroxime reduced mortality from severe
  disease.
• Sainio et al. Lancet 1995 single centre ,
  randomised 60pts.
• However most in the cefuroxime arm had a change
  in antibiotic therapy.
• Selective gut decontamination- to prevent
  translocation.
• Recent evidence of severe fungal infections in
  those
• administered antibiotics
• Antibiotics can reduce the risk of infected
  pancreatic necrosis but may not influence
  mortality.
• If used they should be restricted to patients
  with proven pancreatic necrosis/ severe
  pancreatitis.

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Acute pancreatitis - Diagnosis of infection
? Sepsis or systemic inflammatory response
syndrome ?
CT guided FNA of pancreatic necrosis in the
context of SIRS is recommended to diagnose actual
infection but is still not universally practised

• Until then no antibiotics until specifically
  indicated
• Infected necrosis is an indication for surgery

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Acute pancreatitis - ERCP ES

• Controversial ?
• Reduces complications LOS in severe gallstone
  AP
• Neoptolemos Lancet 1988,
• Fan New Eng J Med1993,
• Nowak 1995
• Definitely indicated in those with gallstone
  pancreatitis
• jaundice and cholangitis

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Acute pancreatitis - Nutrition

• Nutrition vitally important, despite previous
  theories
• about resting the gland
• Enteral feeding is superior to parenteral
  feeding
• Kalfarentzos et al., Br J Surg 1997
• Nasogastric feeding is tolerable in most cases,
  and
• not associated with any increase in
  complications

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Acute pancreatitis - Outcome

• Variable outcome
• Mortality 9-20
• Mortality higher with
• severe disease
• age
• ERCP-induced or post-op. pancreatitis

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Questions