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

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.

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.

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).

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.

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).

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

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.

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.

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%.

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

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

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

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

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).

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).

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

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

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).

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.

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

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.

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.

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.

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.

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.

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