1. Common Surgical Presentations
Phil Polson
Urology Registrar
Clinical Teaching Fellow

2. Introduction Abdominal Pain Bleeding Leg Pain General Surgery Urology
Vascular
Trauma
T&O

3. The Abdomen

4. The Abdomen

5. RUQ pain Biliary colic Acute cholecystitis Cholangitis Acute Hepatitis
Hepatomegaly
Pneumonia

6. Acute Cholecystitis
Murphy’s Sign

7. Acute Cholecystitis Investigations Management Bloods eCXR USS MRCP
Analgesia
IV fluids
Antibiotics
ERCP +/- sphincterotomy
Cholecystectomy

8. Cholangitis Features: Charcot’s Triad (60%) 1) Fever and rigors
2) RUQ pain
3) Jaundice
Shock
Altered consciousness

9. Cholangitis Investigations Management Bloods USS Resuscitation
Antibiotics
HDU/ITU
ERCP / Percutaneous drainage

10. ERCP

11. Epigastric Pain All RUQ pain Perforated ulcer Pancreatitis Dyspepsia
Acute
Chronic
Dyspepsia

12. Perforated gastro-duodenal ulcer
Causes:
H. pylori
Drugs
Alcohol
Physiological stress
Malignancy
Presentation:
Sudden, severe pain
Shoulder pain
Rebound tenderness
Rigidity
Shock / Sepsis

13. Perforated Ulcer Investigations: Management: eCXR Bloods CT
Resuscitation NG
Analgesia
Antibiotics
PPI
Surgery – upper midline laparotomy

14. Acute Pancreatitis Middle-aged men Causes Presentation:
Gallstones
Alcohol
Presentation:
Pain
Nausea/Vomiting
Peritonism
Shock
Investigations:
Amylase
PANCREAS
pO2 (<8kPa)
Age (>55)
Neutrophils (WCC > 15)
Calcium (<2)
uRea (>16)
Enzymes – AST/ALT/LDH
Albumin (<32)
Sugar (>10)
eCXR
USS CT

15. Acute Pancreatitis
Management
Resuscitate
Fluid +++
Analgesia

16. LUQ pain
Gastric ulcer
Splenic injury
Pneumonia
Pericarditis

17. RIF pain Appendicitis Inflammatory bowel disease Testicular torsion
Renal colic
Perforation
Hernia
Psoas abscess
Gynaecological

18. Acute Appendicitis 2nd/3rd decades Presentation Central  RIF pain
Off food, N&V
Low grade fever
Peritonism
Diarrhoea
Urinary frequency
Bent over
RIF guarding
Rovsing’s Sign

19. Acute Appendicitis Investigations Management Bloods Urine dip
(USS / CT)
Management
Analgesia
IV fluids
Antibiotics
Appendicectomy
(Percutaneous drainage)

20. Testicular Torsion 1 in 4000 males <25yrs old
90% of acutely painful scrotums (13-21yr olds)
History:
Sudden onset, severe, unilateral pain
Nausea/Vomiting
Scrotal swelling, erythema, warmth
High, horizontal lie

21. Testicular Torsion
Management:
Theatre immediately

22. LIF Pain Diverticulitis Perforation Inflammatory bowel disease Hernia
Testicular Torsion
Renal Colic
Psoas abscess
Gynaecological

23. Diverticulitis Diverticulosis = Pouches within bowel wall
Diverticulitis = Inflammation of pouches
Presentation:
LLQ pain and tenderness
Fever
Diarrhoea
PR Bleed

24. Diverticulitis Investigations: Management: Complications: Bloods CT
Colonoscopy?
Management:
Low fibre diet
Antibiotics
Surgery for complications
Complications:
Bowel obstruction
Peritonitis
Abscess
Fistula
Strictures
Bleeding

25. Renal Colic One of most painful conditions Can be life threatening
Presentation:
Colicky pain – where?
Nausea / Vomiting
Tender flank – otherwise normal

26. Renal Colic Investigations: Management: Other treatment options:
Bloods inc Calcium / Urate
Urine dip
CT KUB
Management:
NSAID
IVI / IV antibiotics
? Stent
? Nephrostomy
Other treatment options:
ESWL
PCNL
Ureteroscopy +/- LASER +/- basket
Size matters!
<4mm 90% pass
4-5.9mm 50% pass
>6mm 20% pass

27. Diffuse Pain Acute Pancreatitis Bowel obstruction AAA Appendicitis
Gastroenteritis
Inflammatory Bowel Disease
IBS
Mesenteric ischaemia
Peritonitis
Sickle-cell crisis

28. Bowel Obstruction

29. Large vs. Small Causes Causes Carcinoma Volvulus Diverticular disease
Pseudo-obstruction
Causes
Adhesions
Hernia
Malignancy

30. Large vs. Small Colicky pain Absolute constipation Vomit – ‘faeculent’
Abdo distension
Tender
Resonance
Reduced bowel sounds
Empty rectum
Colicky pain
Absolute constipation
Vomit – food, bile
Abdo distension
Visible peristalsis
Tender
Resonance
High-pitch bowel sounds
Normal PR

31. Large vs. Small - Investigations
AXR
Bloods CT
AXR
Bloods
Contrast study (gastrograffin) CT

32. Large vs. Small - Treatment
Resuscitation
Treat cause:
Malignancy – Surgery
Volvulus – decompress
Nutritional support
‘Drip & Suck’
Surgery
Nutritional support
60-85% settle spontaneously

33. Mesenteric Ischaemia Risk factors: Presentation: Investigations: AF
>50yrs
PVD
Presentation:
Pain ‘out of proportion’
Distension, nausea, vomiting
PR bleed
Investigations:
Bloods
ABG
eCXR
ECG
CT with IV contrast
CT angiography

34. Mesenteric Ischaemia Management: Mortality = 45-80% Oxygen Analgesia
Fluids
Laparotomy
Mortality = 45-80%

35. Other
AAA
Urinary retention

36. Leaking Abdominal Aortic Anerysm
Kills 5000 a year.
7500 emergency operations a year.
Presentation:
Back/Abdo/Flank/Groin pain
Haemodynamically unstable
Collapse
5% history of AAA
Leg ischaemia

37. Leaking AAA Investigations: Management: Prognosis: Bloods (X-match)
?CT
Management:
Resuscitation
Surgery – open vs. EVAR
Prognosis:
50% die before hospital
50% of those who make it to hospital will die whilst inpatient.

38. Urinary Retention Acute vs Chronic Causes: BPH Prostate cancer
Urethral strictures
Post-op
Clots
Drugs
Stones
Phimosis

39. Urinary Retention Presentation Investigations Suprapubic pain
Can’t wee!
LUTS
Suprapubic mass
Dull to percuss
DRE
Neuro assessment
Investigations
Bloods
USS
CSU
? PSA

40. Urinary retention Management: Catheter (Residual volume)
Observe for diuresis
? Tamsulosin
TWOC vs LTC vs TURP

41. Bleeding

42. GI Bleeding Upper GI = Medical Lower GI = Surgical Presentation:
Bright red blood
Dark clotted blood
? Pain
? Change in bowel habit
PR EXAM ESSENTIAL

43. Lower GI Bleeding Causes: Management: Diverticular disease 60%
Inflammatory bowel disease 13%
Colorectal cancer
Infective colitis
Post-op
Management:
Resuscitation
Bloods
Rigid sigmoidoscopy
Colonoscopy
Angiography

44. Lower GI Bleeding Surgery: Mortality = 2-4% Rebleeding = 14-38%
Persistent bleeding / shock
>6 units transfused
Mortality = 2-4%
Rebleeding = 14-38%

45. Haematuria Risk of clot retention Visible vs Non-visible
History / Examination
Investigations:
Bloods
MSU
CT Urogram
USS / X-ray KUB
Flexible cystoscopy

46. Haematuria Management: 3-way catheter Bladder washouts +/- irrigation
GA cystoscopy

47. Abscesses Perianal Ischio-rectal Pilonidal Analgesia Surgical Drainage
Pack wound

48. Others Trauma Orthopaedics Urology ENT Vascular #’s, abdominal
Septic arthritis, back pain
Urology
Priapism, Paraphimosis, Epididymo-orchitis
ENT
Epistaxis, foreign bodies
Vascular
Acute limb ischaemia

49. Summary
Plus plenty of others!
Any questions?