GENERAL SURGERY AND

ABDOMINAL EMERGENCIESREVISION

Due to embryogenic development, gastrointestinal tract could be divided into three

sections. Foregut is mouth to second part of duodenum, midgut is second part of

duodenum to transverse colon and hindgut is from transverse colon to rectum. Pain

in foregut localises into epigastrium, pain in midgut localises into umbilicus and pain

in hindgut localises into suprapubic region.

Pain in different regions of abdomen can indicate different acute conditions:

- Hypogastric region: pelvic conditions such as ovarian cyst, ectopic pregnancy, pelvic

inflammatory disease, cystitis

- Left inguinal region: diverticulitis of sigmoid colon

- Right inguinal region: appendicitis, meckel’s diverticulum, diverticulitis of caecum

- Left and right lumbar regions: renal colic

- Right hypochondrium: biliary colic, cholecystitis, liver and gallbladder disorders

- Left hypochondrium: gastritis, stomach and spleen disorders

- Epigastric region: myocardial infarction, acute pancreatitis, abdominal aortic

aneurysm

Common Abdominal Emergencies

Acute Appendicitis: Place of appendix is retrocaecal in majority of people and

incidence peaks at adolescence. It usually presents as colicky pain in right inguinal

region. Pain on pressing McBurney’s point, Rovsing’s sign, obturator sign and psoas

sign are appendicitis-specific tests in examination. Gold standard diagnostic method

is laparoscopy and management could be open or laparoscopic surgery. Grid iron or

Lanz incision is made in the surgery.

Acute Gallbladder:

- Acute Cholecystitis: Involves infection with blockage. Right upper quadrant pain,

jaundice and positive Murphy’s sign are present. Treatment requires antibiotics.

- Biliary colic: Right upper quadrant pain increased by eating fatty foods and radiating

to shoulder tip is characteristic of biliary colic.

MRCP is diagnostic whereas ERCP is both diagnostic and therapeutic (extraction).

Gallbladder surgery could be done laparoscopical or open (requires Kochler’s incision).

Pancreatitis:

- Acute pancreatitis: Causes of acute pancreatitis can be listed with the mnemonic GETSMASHED (g- gallstones, e-

ethanol/alcohol, t-trauma, s-steroids, m-mumps, a-autoimmune, s-scorpions, h-hypercalcaemia/hyperlipidaemia, e-

ERCP, d-drugs such as thiazide diuretics). Acute pancreatitis presents with epigastric pain radiating to back usually

together with vomiting. Pancreatitis specific signs are Grey-Turners sign and Cullens sign. Management of acute

pancreatitis involves resuscitation followed by analgesia and treating cause. Severity could be assessed by Glasgow

criteria with the mnemonic PANCREAS (p-pO2<8kPa, a-albumin<32, n-neutrophil>15x109, c-calcium<2, urea>16, e-

enzymes, a-age>55, s-sugar>10). Pancreas is capable of autodigesting itself and several complications such as

abscess, pseudocyst or chronic inflammation of pancreas; or, involvement of endocrine, renal, cardiovascular or

respiratory systems.

- Chronic pancreatitis: Chronic pancreatitis usually presents as pain increased after eating and steatorrhea.

Management involves resuscitation, analgesia and treatment of the underlying cause.

Bowel Obstruction: Classically present as vomiting, constipation and

distension accompanied by pain. Treatment involves “nil by mouth”,

diagnosing and treating the cause; and, surgical intervention.

Ischemic Bowel: Bowel injury caused by superior mesenteric artery embolism

or thrombosis resulting in ischemia. Angiography is the gold standard

diagnostic method. There is typical “thumb printing” sign on abdominal x-ray.

Management can be achieved by anticoagulants or laparotomy followed by

bowel resection.

Diverticulitis: Inflamed outpunching of colon. Diverticulitis is seen in people consuming a

low-fibre diet and the commonest location is the sigmoid colon. Typical diagnosis involves

pyrexia, leukocytosis and left iliac fossa pain. Due to perforation risk, barium enema and

sigmoidoscopy is not used in diagnosis. It is managed by resuscitation, intravenous

antibiotics and emergency surgery requiring Hartmans procedure (temporary colostomy) or

elective surgery planned for the following 6 weeks.

Stoma

Stoma is described as an opening of gut. It can be caused by colostomy (colon), ileostomy

(ileum) and urostomy (urinary system). An ileostomy stoma and colostomy stoma could be

differentiated by various factors such as ileostomy is usually performed in right iliac fossa

whereas colostomy is usually performed in left iliac fossa, colostomy stomas are larger than

ileostomy stomas, colon stomas produce an intermittent semi-solid output whereas ileum

stomas produce a continuous fluid output; and, ileostomy stomas are spouted. Loop

colostomy is temporary whereas end colostomy is permanent. Complications of stoma are:

ischemia, necrosis, prolapse and retraction.

Neck Lumps

Neck lumps localised to midline are goitre, pharyngeal pouch, thyroglossal cyst; lateral

neck lumps are neurofibroma, brachial cyst, aneurysm, cystic hygroma, multinodular

goitre. Enlarged lymph nodes could present as neck lumps as well. Location non-

specific lumps are sebaceous cysts and lipomas.

Shock

Shock is an acute failure of circulation causing hypoxia and inadequate perfusion of tissue.

There are 4 main types of shock:

- Hypovoaemic (example: blood or fluid loss)

- Cardiogenic (example: cardiac tamponade)

- Distributive (example: anaphylaxis, sepsis)

- Obstructive (example: tension pneumothorax)

Shock is managed by resuscitation (A-airway, B- breathing, C- circulation, D- disability, E-

exposure/examination, F- fluids, G- don’t ever forget glucose) and treatment of the

underlying cause.