Acute Surgical Conditions & Trauma Management :

1. Acute Surgical Conditions & Trauma Management : Family Medicine Presentation By K.V. Liew & H.K. Kwong

2. Common Principles : • History & Physical Examination. • Provisional Diagnosis. • Basic investigations (e.g. blood tests, X-rays & bedside imaging). • ***Definitive Imaging (USG, CT-scan), if patient is stable & fit for transfer to Radiology department. • Resuscitation if needed, then definitive surgical treatment if possible, otherwise supportive treatment.

3. Acute Abdomen : • Abdominal Pain. • Physical Examination findings (e.g. tenderness, rebound & guarding). • Fever. • Tachycardia; haemodynamicaly unstable. • Septic-looking. • Usually implies that there is peritonitis, which if left untreated, will result in severe complications (e.g. DIC & shock) and eventually DEATH.

4. Classically, requires urgent surgical treatment, especially if the precise cause is not known (i.e. exploratory laparotomy). • Nowadays, with newer technology available, the incidence of laparotomy is reduced. • Endoscopic treatments may be used, depending on the precise pathology (e.g. ERCP, therapeutic OGD & laparoscopy). • Newer X-Ray, CT & USG can provide better image quality, enabling more precise diagnosis & treatment (e.g. interventional/therapeutic radiology).

5. Take-Home Message No. 1 : • Not all acute surgical conditions requires surgery. Some can be solved by invasive non-surgical procedures. • e.g. ERCP/papillotomy, therapeutic OGD, X-ray guided gel-foam embolisation.

6. Take-Home Message No. 2 : • How do you define “acute” ? • By time of onset or urgency for treatment ? • Acute surgical conditions actually comprise a broad spectrum of time-frame, from hyper-acute (e.g. seconds to minutes in ruptured AAA) to super-acute (e.g. minutes to tens-of-minutes in GI bleed) to normal-acute (e.g. tens-of-minutes to hours in PPU, ischaemic bowel, strangulated hernia) to hypo-acute (e.g. more than a few hours in appendicitis, cholecystitis).

7. Acute Surgical Conditions (by anatomy) : • Vascular conditions : • Ruptured or Leaking AAA. • GI Bleed. • Thrombosis of arteries (e.g. SMA).

8. Ruptured AAA : • Symptoms : • Central abdominal pain, usually of persistent & continuous nature. • ***Low Back Pain*** • Dizziness. • History of AAA. • Requires high index of suspicion, especially when did not have Hx of AAA.

9. Signs : • Ill-looking. Need not necessarily be so (maybe clinically quite well). • Hypotension, with fast pulse. • Pallor. • Abdominal tenderness, rebound & guarding. • Pulsatile, expansile abdominal mass. • Expansile, pulsatile mass may not be palpable, especially if haematoma has formed in abdomen.

10. Management : • Emphasis is on RAPID clinical diagnosis, since survival depends on it. • H’cue, ? Hx of coffee ground vomitus, PR to R/O GI bleed. Bedside USG. • ***Straight to OT, X-match, mention large amounts of blood needed. • If relatively stable, URGENT CT-Abdomen, especially if no previous Hx of AAA. • Poor prognosis with 50% mortality, some centres claim 40%.

11. GI Bleed : • Divided into upper & lower GI bleed. • Can be rapidly fatal. • ***No surgical patient should die from GI bleed, if managed promptly & properly.

12. UGI Bleed Symptoms : • Coffee ground vomitus. • Tarry stool. • Dizziness/postural dizziness. • Epigastric pain. • Hx of peptic ulcer disease.

13. UGI Bleed Signs : • Malaena (fresh/old, indication of urgency of treatment). • Haematemesis. • Pallor. • Stigmata of liver disease. • Hypotension, fast pulse.

14. Differential diagnoses : • Bleeding peptic ulcer. • Gastro-oesophageal variceal bleeding. • Meckel’s Diverticulum.

15. Management : • Try to assess volume of haemorrhage. • Urgent OGD is essential for diagnostic & therapeutic purposes. • Sengstaken-Blakemore Tube for gastro-oesophageal variceal bleed. • Close monitoring of vital signs. • Can attempt X-ray guided embolisation of arterial bleeders. • If bleeding not controlled, proceed to surgery (e.g. fundoplication; partial gastrectomy for GU).

16. Lower GI Bleed Symptoms : • PR bleed, can be with blood clots. • Usually not associated with abdominal pain. • Symptoms of hypovolaemia & shock. • Symptoms of GI tract malignancy (weight loss, decreased appetite, change of bowel habit).

17. Lower GI Bleed Signs : • Fresh PR bleed, with/without clots. • Signs of hypotension & shock. • Signs of GI Tract malignancy.

18. Differential Diagnoses : • Bleeding rectal ulcer. • Haemorrhoids. • Bleeding colonic tumours.

19. Management : • PR & Proctoscopy is essentially for diagnostic purposes & assessing volume of blood loss. • Close monitoring of vital signs. • Can attempt X-ray embolisation too. • If bleeding persists, proceed to surgery (e.g. suturing of rectal ulcer; hemicolectomy).

20. Thrombosis of arteries : • For example, SMA, resulting in acute ischaemic bowel. • Severe abdominal pain which is disproportionate to abdominal signs of tenderness/rebound/guarding. • Severe metabolic acidosis. • Embolectomy +/- endarterectomy +/- gut resection.

21. Urological conditions : • Pyelonephritis +/- hydronephrosis. • If patient is septic-looking, haemodynamiccaly unstable, degree of urgency is increased. • Percutaneous nephrostomy (PCN).

22. GI Tract Conditions : • Perforated Peptic Ulcer (PPU) : • Symptoms can overlap with those of severe Gastro-enteritis (G.E.) • Classically, sudden onset of continuous, severe epigastric/central abdominal pain. May radiate to directly to back. • P/E showed “board-like rigidity” of abdomen. • ***CXR=>free gas under diaphragm. • Omental patch repair (can be open/laparoscopic). • SIRS=>OT within 6hrs. Of onset of symptoms.

23. Ischaemic bowel : • Can be due to other causes apart from thrombosis of arterial supply. • Adhesion bands, strangulated hernia, prolonged intestinal obstruction (I.O.) • CT-Abdomen is of significant value in deciding whether to operate or not. • Laparotomy +/- gut resection +/- ileostomy or colostomy.

24. Sigmoid Volvulus : • Abdominal pain. • NBO nor flatus. • AXR findings of coffee-bean shaped large bowel, spoke-wheel shaped bowel & ? shaped bowel. • Flatus Tube can relieved obstruction and thus not necessarily need surgery.

25. Intussuception : • Right-sided abdo. Pain. • Mass in Right flank, RLQ feels empty. • Confused with appendiceal abscess. • Site of intussuception near region of ileo-caecal valve. • Barium enema can both be diagnostic & therapeutic. • Risk of ischaemic bowel/recurrence after procedure.

26. Hepato-Biliary Conditions : • Ruptured HCC. • Usually occurs in those who presents with undiagnosed HCC. • CT-Abdomen if patient is stable for transfer. • X-Ray guided embolisation of branches of hepatic artery. ?Limited value. • Segmentectomy +/- partial hepatectomy.

27. Cholangitis, Cholecystitis & Gallstone pancreatitis : • Emergency ERCP +/- EPT can be life-saving. • Treat the septic focus. • Acute cholecystitis & appendicitis.