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Surgery for Finals: Surgical Emergencies - Acute abdomen Dr. Lily Wenyi Cai FY1Social Medias9 Regions of the Abdomen Case 1 Question A 18-year old woman presents to A&E with pain in the right iliac fossa. On further questioning, she reveals that the pain started in umbilical region before moving to the RIF. Her blood results show the following: Hb 125; Platelets 550; CRP 135; WCC 16.5 Which one of the following clinical signs is not indicative of the patient’s condition A/ Patent A. Cope sign E/ B/ Soft B. Rovsing’s sign Sats 95% OA C. Obturator sign RR 18 Tender in the RIF D. Tenderness over McBurney’s Voluntary guarding point C/ D/ HBP 125/73lar GCS 15 No evidence of rebound E. Boas’ sign CRT 2 seconds PEARL tenderness HS I + II + 0 Temp 37.3 Case 1 Question A 18-year old woman presents to A&E with pain in the right iliac fossa. On further questioning, she reveals that the pain started in umbilical region before moving to the RIF. Her blood results show the following: Hb 125; Platelets 550; CRP 135; WCC 16.5 Which one of the following clinical signs is not indicative of the patient’s condition? A/ Patent A. Cope sign E/ B/ Soft B. Rovsing’s sign Sats 95% OA C. Obturator sign RR 18 Tender in the RIF D. Tenderness over McBurney’s Voluntary guarding point C/ D/ HBP 125/73lar GCS 15 No evidence of rebound E. Boas’ sign CRT 2 seconds PEARL tenderness HS I + II + 0 Temp 37.3 Case 1 AcuteAppendicitis Epidemiology - Acute appendicitis is common in both adults and children. - Commonly occurs between the age of 10 to 20. Diagnosis - Clinical presentation: Shifting pain - Imaging: CT is the most commonly used imaging modality; USS - Scoring system: Alvarado Score Case 1 Appendix Positions Psoas muscle Obturator internus muscle Obturator Sign Psoas Sign / Cope’s sign Case 1 AcuteAppendicitis Classification - Obstructive: commonly by a faecolith - Non-obstructive Management - Antibiotics - Surgery - Laparoscopic - Lanz - Gridiron / McBurney Case 2 Question A 40 year old female, with a history of colicky pain in the RUQ after meals, presents to A&E with severe epigastric pain. The pain is constant and radiates to the back. Which of the following electrolyte disturbance least likely to be found in severe pancreatitis A/ Patent A. Hypocalcaemia B/ B. Hypokalaemia E/ Sats 95% OA C. Elevated urea RR 20 Abdomen distended D. Hypercalcaemia Bruising around the C/ D/ umbilicus E. Not sure HRBP 125/73ar GCS 15 CRT 2 seconds PEARL HS I + II + 0 Temp 37.3 Case 2 Question A 40 year old female, with a history of colicky pain in the RUQ after meals, presents to A&E with severe epigastric pain. The pain is constant and radiates to the back. Which of the following electrolyte disturbance least likely to be found in severe pancreatitis A/ Patent A. Hypocalcaemia B/ B. Hypokalaemia E/ Sats 95% OA C. Elevated urea RR 20 Abdomen distended D. Hypercalcaemia Bruising around the C/ D/ umbilicus E. Not sure HRBP 125/73ar GCS 15 CRT 2 seconds PEARL HS I + II + 0 Temp 37.3 Case 2 Acute Pancreatitis - Idiopathic - Gallstones - Ethanol - Trauma - Steroids - Mumps - Autoimmune - Scorpion bites - Hypercalcaemia; hyper-triglycaemia; hypothermia - ERCP - Drugs: azathioprine, thiazidesCase 2 PancreasAnatomy Case 2 Acute Pancreatitis Glasgow-Imrie Score PaO2 < 7.9kPa Age > 55 Neutrophils > 15 Calcium < 2 mmol/L Renal - Urea > 16 mmol/L Enzymes - LDH > 600 IU/L Albumin < 32 g/L Sugar > 10 mmol/L Case 2 Acute Pancreatitis Management - Resuscitation - Oxygen - NG tube - free drainage - Fluid balance + correcting electrolyte disturbances - 2 large-bore cannula; IV fluids; catheter - Bloods: FBC; U&Es; LFTs; CRP; LDH; Bone profile; magnesium; phosphate - ABG - Blood glucose - Pain relief - Avoid morphine (sphincter of Oddi spasm) - Tramadol - Involve pain team - Nutrition - Concept of ‘Pancreatic Rest’ has fallen out of fashion - Basically feed the patient whichever way is tolerated. Case 3 Question A 40 year old female presents with RUQ pain She has a history of colicky RUQ pain after meals. However, this pain is constant. An USS shows that there is a gallbladder empyema and the gallbladder is very enlarged and impending rupture. Where is the gallbladder most likely to rupture from? A/ Patent A. Body B/ B. Neck E/ Sats 94% OA C. Fundus RR 24 Scleral icterus D. Hartmann’s pouch C/ D/ E. Head HRBP 110/73lar GCS 15 CRT 3 seconds PEARL HS I + II + 0 Temp 38.6 Case 3 Question A 40 year old female presents with RUQ pain She has a history of colicky RUQ pain after meals. However, this pain is constant. An USS shows that there is a gallbladder empyema and the gallbladder is very enlarged and impending rupture. Where is the gallbladder most likely to rupture from? A/ Patent A. Body B/ B. Neck E/ Sats 94% OA C. Fundus RR 24 Scleral icterus D. Hartmann’s pouch C/ D/ E. Head HRBP 110/73lar GCS 15 CRT 3 seconds PEARL HS I + II + 0 Temp 38.6 Case 3 BiliaryAnatomy Gallbladder - Neck - Body - Fundus Left Blood supply Right hepatic hepatic artery artery - Cystic artery supplies the gallbladder, it is a Cystic artery terminal / end artery Common arteryc Case 3 Gallstones Types - Cholesterol stones (around 80%) - Pigment stones Risk factors (5Fs) - Fair - Forty - Fat - Fertile - Female Complications - Biliary colic - Acute cholecystitis - Choledocholithiasis -> acute cholangitis - Mirizzi syndrome Case 4 Question 68 year old man presents to A&E with diffuse abdominal pain and abdominal extension. On questioning, he reports that he has not opened his bowels for 5 days or passed any flatus. Electronic records reveal that he had an open appendicectomy 20 years ago. What is the most likely cause leading to his presentation? A/ Patent A. Adhesion E/ B/ B. Obstructed hernia Distended abdomen Sats 96% OA C. Colorectal cancer RR 22 Diffuse abdominal pain D. Paralytic ileus HR 80 Regular D/ High-pitched tinkling E. Stricture BP 125/73 GCS 15 bowel sounds CRT 2 seconds PEARL HS I + II + 0 Temp 36.8 Case 4 Question 68 year old man presents to A&E with diffuse abdominal pain, abdominal extension and copious amount of bilious vomiting. On questioning, he reports that he has not opened his bowels for 5 days or passed any flatus. Electronic records reveal that he had an open appendicectomy 20 years ago. What is the most likely cause leading to his presentation? A/ Patent A. Adhesion E/ B/ B. Obstructed hernia Distended abdomen Sats 96% OA C. Colorectal cancer RR 22 Diffuse abdominal pain D. Paralytic ileus HR 80 Regular D/ High-pitched tinkling E. Stricture BP 125/73 GCS 15 bowel sounds CRT 2 seconds PEARL HS I + II + 0 Temp 36.8 Case 5 Question 78 year old man presents with abdominal pain whilst waiting for a colonoscopy. The referral for colonoscopy states that he’s been having bloody stool and has had 2 months history of change in bowel habits. In addition, he also has lost 10 kg in weight. What is the most likely diagnosis? A/ Patent A. Adhesion B/ E/ B. Obstructed hernia Distended abdomen Sats 96% OA C. Colorectal cancer RR 22 Diffuse abdominal pain D. Paralytic ileus C/ D/ E. Stricture HBP 125/73lar GCS 15 High-pitched tinkling CRT 2 seconds PEARL bowel sounds HS I + II + 0 Temp 36.8 Case 5 Question 78 year old man presents with abdominal pain whilst waiting for a colonoscopy. The referral for colonoscopy states that he’s been having bloody stool and has had 2 months history of change in bowel habits. In addition, he also has lost 10 kg in weight. What is the most likely diagnosis? A/ Patent A. Adhesion B/ E/ B. Obstructed hernia Distended abdomen Sats 96% OA C. Colorectal cancer RR 22 Diffuse abdominal pain D. Paralytic ileus C/ D/ E. Stricture HBP 125/73lar GCS 15 High-pitched tinkling CRT 2 seconds PEARL bowel sounds HS I + II + 0 Temp 36.8 Case 6 Question 70 year old man presents with severe diffuse abdominal pain. X-rays were taken in ED. What is the most appropriate definitive management for this patient? A. Flexible sigmoidoscopy B. Hartmann’s procedure C. NG tube and IV fluids D. Bowel resection and primary anastomosis E. Exploratory laparoscopy Case 6 Question 70 year old man presents with severe diffuse abdominal pain. X-rays were taken in ED. What is the most appropriate definitive management for this patient? A. Flexible sigmoidoscopy B. Hartmann’s procedure C. NG tube and IV fluids D. Bowel resection and primary anastomosis E. Exploratory laparoscopyCase 6 Bowel Obstruction Small Bowel Obstruction Adhesions Hernias Rarer Causes Crohn’s stricture Gallstone ileus Large Bowel Obstruction Intussusception Foreign body Colorectal cancer Diverticular stricture Volvulus (sigmoid and caecal) Constipation Case 7 Question 73 year old woman, with a background of chronic constipation, presents with left iliac fossa pain. This was associated with 2 day history of diarrhoea and some PR bleeding. Her blood results are: Hb 120; Platelets 500; WCC 15.6; CRP 100; Which of the following option should not form the management plan of the patient? A/ Patent A. Low residual/fibre diet B/ E/ B. Analgesia Marked tenderness in C. IV/PO Antibiotics Sats 96% OA RR 20 LIF D. Flexible sigmoidoscopy as an inpatient C/ D/ No evidence of HR 94 Regular GCS 15 rebound tenderness E. CT abdominal pelvis scan CRT 2 seconds PEARL HS I + II + 0 Temp 37.8 Case 7 Question 73 year old woman, with a background of chronic constipation, presents with left iliac fossa pain. This was associated with 2 day history of diarrhoea and some PR bleeding. Her blood results are: Hb 120; Platelets 500; WCC 15.6; CRP 100; Which of the following option should not form the management plan of the patient? A/ Patent A. Low residual/fibre diet B/ E/ B. Analgesia Marked tenderness in C. IV/PO Antibiotics Sats 96% OA RR 20 LIF D. Flexible sigmoidoscopy as an inpatient C/ D/ No evidence of HR 94 Regular GCS 15 rebound tenderness E. CT abdominal pelvis scan CRT 2 seconds PEARL HS I + II + 0 Temp 37.8 Case 7 Diverticulitis Definition: Inflammation/infection secondary to diverticulum (outpouching of the gut wall). Location: 95% found within sigmoid and left sided colon. Diverticulum pathophysiology - High intraluminal pressure - Forces the mucosa to herniate through the muscle layers at weak points - Stage 1 - 4 (pericolic or mesenteric abscess to faecal peritonitis) Management - Mild : bowel rest, low residual/fibre diet and antibiotics - Severe: surgery Case 8 Question 80 year old man is admitted for an elective hernia repair for a right sided reducible inguinal hernia. An open approach with mesh is adopted by the surgeon, which structure listed below would be mesh be attached to? A/ Patent A. Subcutaneous tissues B/ B. External oblique muscle C. Internal oblique muscle Sats 96% OA RR 20 E/ D. Transversalis fascia C/ D/ E. Transverse abdominis HR 72 Regular GCS 15 CRT 2 seconds PEARL HS I + II + 0 Temp 36.4 Case 8 Question 80 year old man is admitted for an urgent hernia repair for a right sided incarcerated inguinal hernia. An open approach with mesh is adopted by the surgeon, which structure listed below would be mesh be attached to? A/ Patent A. Subcutaneous tissues B/ B. External oblique muscle C. Internal oblique muscle Sats 96% OA RR 20 E/ D. Transversalis fascia C/ D/ E. Transverse abdominis HR 72 Regular GCS 15 CRT 2 seconds PEARL HS I + II + 0 Temp 36.4 Case 8 Inguinal hernias Indirect hernia: passes through the internal inguinal ring and if large, through the external ring. Direct hernia: push forward through a weak point of the posterior wall of the inguinal canal. transversus abdominis Transversalis fascia externalsis of oblique muscle Inguinal ligament Case 8 Inguinal hernias Examination Deciding if it is an inguinal hernia - Inguinal hernia is medial and superior to the pubic tubercle - As opposed to femoral hernias Deciding between indirect and direct hernias - Examination can be very inaccurate - Gold standard is via surgery - No difference in management Case 9 Question 60 year old woman is admitted with worsening abdominal pain. In ED, she has had 2 episodes of large haematemesis. She has a BG of OA controlled with simple OTC analgesia. DH: Ibuprofen, simvastatin, ramipril Urgent OGD is performed. Which vessel is likely to be bleeding? A/ Patent A. Splenic artery B/ B. Common hepatic artery C. Gastroduodenal artery Sats 92% OA E/ RR 30 Pallor D. Right gastric artery C/ D/ E. Left gastric artery HR 140 Regular GCS 14 CRT 4 seconds PEARL HS I + II + 0 Temp 37 Case 9 Question 60 year old woman is admitted with worsening abdominal pain. In ED, she has had 2 episodes of large haematemesis. She has a BG of OA controlled with simple OTC analgesia. DH: Ibuprofen, simvastatin, ramipril Urgent OGD is performed. Which vessel is likely to be bleeding? A/ Patent A. Splenic artery B/ B. Common hepatic artery C. Gastroduodenal artery Sats 92% OA E/ RR 30 Pallor D. Right gastric artery C/ D/ E. Left gastric artery HR 140 Regular GCS 14 CRT 4 seconds PEARL HS I + II + 0 Temp 37Case 9 Perforated peptic ulcer O O F Feedback & Instagram + 3FC N O Please complete feedback to receive CF slides! 3 NH O Cl CH3 CH OH CH 3 3 CH OH 3 3C CH3 HC O 3