Upper Gastrointestinal

CASE 25: abDominal trauma

history

You are called urgently to the resuscitation room for a trauma call. An 18-year-old girl has fallen from her horse. During her descent, the horse kicked her, and she is now complaining of generalized abdominal pain and left shoulder-tip pain.

examination

She is talking and examination of her chest is normal. The oxygen saturations are 100 per cent on 24 per cent oxygen. Initially, her pulse rate is 110/min with a blood pressure of 84/60 mmHg. She is slightly drowsy and her Glasgow Coma Score (GCS) is 14. On examination of the abdomen, there is an abrasion on the left side beneath the costal margin with tenderness in the left upper quadrant. There is no evidence of any other injuries and the urinalysis is clear. The patient is given 2 L of intravenous fluids and the blood pressure improves to 130/90 mmHg. As the patient has now become stable, a CT scan of the chest and abdomen is obtained. The CT image is shown in Figure 25.1.

Figure 25.1 Computerized tomography of the abdomen.

On returning to the emergency department, the patient becomes increasingly agitated. The nurse informs you that her blood pressure is now 80/60 mmHg and the pulse rate is 130/min.

Questions

•What does the CT scan show?

•Are there any alternative investigations to CT?

•What special requirements may this patient have postoperatively?

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100 Cases in Surgery

ANSWER 25

The patient has sustained a tear to the splenic capsule, causing intraperitoneal bleeding. The CT scan shows the fractured spleen with surrounding haematoma. The shoulder-tip pain described is known as Kehr’s sign, and is indicative of blood in the peritoneal cavity causing diaphragmatic irritation. Unstable patients suspected of splenic injury and intra-abdominal haemorrhage should undergo exploratory laparotomy and splenic repair or removal. Blunt trauma, with evidence of haemodynamic instability that is unresponsive to fluid challenge, should be considered a life-threatening solid organ (splenic) injury. Those patients who respond to an initial fluid bolus, only to deteriorate again with a drop in blood pressure and increasing tachycardia, are also likely to have a solid organ injury with ongoing haemorrhage. Transfer to the CT scanner can be extremely dangerous for an unstable patient.

Focused abdominal sonographic technique (FAST) is helpful in diagnosing the presence or absence of blood in the peritoneal cavity without transfer to a CT scanner. Diagnostic peritoneal lavage may be a valuable adjunct if time permits and multiple other injuries are present. In a haemodynamically stable trauma patient, CT scanning provides an ideal non-invasive method for evaluating the spleen. The decision for operative intervention is determined by the grade of the injury and the patient’s current or pre-existing medical conditions. Splenic embolization is a safe alternative depending on the grade and location of the splenic injury. Those patients who undergo splenectomy have a lifetime risk of septicaemia and should receive immunizations against pneumococcus, haemophilus and meningococcus.

KEY POINTS

•Whenever possible, the spleen should be conserved.

•patients require lifelong prophylactic antibiotics after splenectomy.

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Upper Gastrointestinal

CASE 26: hepatomegaly

history

A GP refers an 87-year-old woman to the surgical outpatient department. The patient has had a 6-week history of constant right-sided abdominal pain which radiates up under the ribs and into her right shoulder. There are no relieving or exacerbating factors. She was fit and well up until 4 years ago, when she had a right hemicolectomy for a Dukes’ B caecal adenocarcinoma. She did not want any postoperative oncological treatment and there was no evidence of metastatic disease at the time of her operation. Recently, she feels she has lost weight and has felt tired. She describes no recent change in her bowel habit or rectal bleeding.

examination

There is no evidence of pallor, jaundice, clubbing or lymphadenopathy. The chest is clear and heart sounds are normal. Examination of the abdomen reveals a palpable irregular liver border about 3 cm below the costal margin. There are no other palpable masses in the abdomen and digital rectal examination is normal.

INVESTIGATIONS

in view of this woman’s history, a Ct scan of the abdomen is organized (Figure 26.1).

Figure 26.1 Computerized tomography of the abdomen.

Questions

•What does the CT scan show?

•What investigation would confirm the diagnosis in this patient?

•Give six other causes of hepatomegaly.

•What are the options for managing this patient?

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100 Cases in Surgery

ANSWER 26

The CT scan shows metastatic deposits within the liver. It is likely this is recurrent disease after her previous colonic resection. A CT-guided biopsy would confirm the possible origin of these lesions.

!Causes of hepatomegaly

Smooth generalized enlargement

•hepatitis

•Congestive cardiac failure

•micronodular cirrhosis

•hepatic vein obstruction (budd–Chiari syndrome)

•amyloidosis

Craggy generalized enlargement

•metastatic secondaries

•macronodular cirrhosis

localized swelling

•hepatocellular carcinoma

•riedel’s lobe

•hydatid cyst

•liver abscess

A CT scan may demonstrate recurrence of the bowel malignancy. Tumour markers such as carcinoembryonic antigen (CEA) may be raised, and a CT-guided biopsy of the liver deposits may confirm the source of the recurrence. It is important to send a full blood count as she has been feeling tired recently and may be anaemic. The patient should be brought back to the clinic, with her relatives, to discuss the options for further management. The number of metastases in the liver and their distribution would make local resection unfeasible. Chemotherapy may be discussed, but may not be appropriate in this patient. It is unlikely to prolong the patient’s life significantly and indeed may worsen her quality of life. The most important factor is to control the patient’s symptoms. A palliative care team should be involved in her continued management.

KEY POINT

•Colorectal liver metastases can be surgically resected, depending on their number, anatomical distribution and the fitness of the patient.

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