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CHAPTER 7 Upper gastrointestinal surgery
302302
Acute abdominal pain
Acute abdominal pain is the commonest emergency presentation to hospitals in the UK. It is often a daunting challenge to the admitting team
because of the huge differential diagnosis possible, and the wide range
of tests available to try and establish a diagnosis. Be methodical and
remember some simple rules.
• Take a proper history and examination; do not work to the diagnosis
given to you by the referring doctor.
• Resuscitate the patient properly and give adequate analgesia; this often
helps to clarify the diagnosis. There is no reason to withhold analgesia
prior to ‘senior’ clinical examination.
• Try to clarify if you think the patient has signs of peritonitis (localized
or generalized); this will narrow the differential and may require
surgery as part of the diagnostic work-up.
Causes
Causes approximate to the fact that pathology of underlying structures
in each region tend to give rise to abdominal pain maximal in that
region (see Box 7.1). Although a good guide, it is wise to remember that
viscera are often mobile and pain often radiates to adjacent sections of
the abdomen.
Clinical features
Each condition has its own clinical features, but here are some rules to
follow.
Symptoms and signs
• Constant pain, gradual in onset, but progressive worsening suggests an
underlying infl ammatory cause.
• Intermittent pain that is poorly localized suggests colic arising from a
visceral structure.
• Central and lower abdominal pain in children (under the age of 12) is
self-limiting (non-specifi c) in 70%, from benign gynaecological causes in
25% (girls), and only pathological in 10–20%.
• Severe pain out of proportion to the clinical signs suggests ischaemic
bowel until proven otherwise.
• Pain in the loin or back arises from (at least partially) retroperitoneal
structures; consider the pancreas, renal tract, and abdominal aorta.
Emergency management
Resuscitation
• Establish IV access.
• Catheterize and place on a fl uid balance chart only if hypotensive.
• Give adequate analgesia. If renal pathology is suspected, diclofenac
• Send blood for FBC (Hb, WCC), U&E (Na, K), amylase, LFTs, CRP,
®
(Voltarol
disease). If intra-abdominal pathology is suspected, 5–10mg morphine
iv is reasonable. Morphine IV never hides established clinical signs; it
often helps to clarify the diagnosis by its anxiolytic effect on patients.
group and save.
) 100mg pr is very effective (avoid in asthma and renal
ACUTE ABDOMINAL PAIN
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Box 7.1 Causes of acute abdominal pain arranged
according to abdominal region
Right hypochondriac Epigastric Left hypochondriac
• Right lower lobe
pneumonia/
embolism
• Cholecystitis
• Biliary colic
• Pancreatitis
• Gastritis
• Peptic ulcer
• Myocardial
infarction
• Left lower lobe
pneumonia/
embolism
• Large bowel
obstruction
• Hepatitis
Right lumbar Umbilical Left lumbar
• Renal colic
• Appendicitis
• Intestinal
obstruction
• Intestinal ischaemia
• Renal colic
• Large bowel
obstruction
• Aortic aneurysm
• Gastroenteritis
• Crohn’s disease
Right iliac Hypogastric Left iliac
• Appendicitis
• Crohn’s disease
• Right tubo-ovarian
pathology
• Cystitis
• Urinary retention
• Dysmenorrhoea
• Endometriosis
• Sigmoid
diverticulitis
• Left tubo-ovarian
pathology
Establish a diagnosis
The time frame for the diagnosis of acute abdominal pain varies according
to the presentation. It is not uncommon for 12–24h of ‘masterful inactivity’ to be used to allow the diagnosis to be clarifi ed. Young patients
with central and mild RIF pain are typical of this sort of management. Do
not assume this is normal. Some causes of acute abdominal pain require
diagnosis and management immediately upon admission or within 6–8h or
less. Try to be thoughtful in diagnostic tests; many may be requested, but
usually only one or two are really useful.
• Blood investigations are very rarely diagnostic. Serum amylase more than
3x normal maximum is very highly suggestive of acute pancreatitis.
• Plain abdominal radiographs are very rarely diagnostic.
• Always request a plain erect chest radiograph; it is the fi rst-line test of
choice for free abdominal air.
• Upper abdominal ultrasound is an excellent investigation for suspected
hepatobiliary pathology.
• Pelvic ultrasound (transabdominal or transvaginal) is a good test for
suspected tubo-ovarian disease.
• CT scanning may well be indicated and is a good ‘general survey ‘
of the abdomen, but exposes the patient to signifi cant radiation and
should not be routinely requested.
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CHAPTER 7 Upper gastrointestinal surgery
304304
Early treatment
• IV antibiotics are inappropriate without a clear diagnosis; they will
suppress, but may not adequately treat, developing infection.
• Until a defi nitive management plan is established, concentrate on fl uid
balance, analgesia, and monitoring vital signs.
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CHAPTER 7 Upper gastrointestinal surgery
306306
Gynaecological causes of lower
abdominal pain
Gynaecological pathologies are a common cause of lower abdominal
pain, not only in women of childbearing age, but they can also affect
post-menopausal women.
Causes
• Complications of menstruation. Retrograde menstruation, mid-cycle
ovulation pain (‘Mittelschmerz’).
• Ovarian cyst. Acute swelling, rupture, torsion.
• Tubo-ovarian infection, including PID, abscess.
• Ectopic pregnancy, including rupture.
Clinicopathological features
Complications of menstruation
• Commonest during development of regular periods.
• Typically cyclical pains, often sharp and sudden in onset.
• May have marked tenderness bordering on peritonitis.
• Normal blood investigations; self-limiting.
Ovarian cyst complications
• Commonest in mid-childbearing years.
• May have severe pain with few clinical signs.
• Normal blood investigations.
Tubo-ovarian infection
• Commonly caused by Escherichia coli, Bacteroides fragilis,
Streptococcus sp.
• Associated with cervical disease or instrumentation.
• Sexually-transmitted infections can cause tubo-ovarian sepsis, which
may be more chronic and recurrent (Neisseria gonorrhoeae,
Chlamydia trachomatis).
• Associated with multiple sexual partners and unprotected intercourse.
• Pyrexia, mild tachycardia, occasional purulent vaginal discharge.
• Often affects both sides causing bilateral pain and tenderness.
Ectopic pregnancy
• May occur at any age.
• Commonest site is the Fallopian tube (ampulla, tube, or isthmus).
• Associated with previous tubal disease or surgery.
• Menstrual irregularity or a ‘late’ period is common, but not uniform.
• May give rise to symptoms whilst enlarging with unilateral pelvic pain.
• Symptoms increase with complications (bleeding into site of
pregnancy, free rupture with bleeding into pelvis and peritoneal cavity).
• Typifi ed by lower abdominal pain without fever.
• Hypotension with tachycardia suggests active intra-abdominal bleeding,
but is fortunately rare at presentation.
GYNAECOLOGICAL CAUSES OF LOWER ABDOMINAL PAIN
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Emergency management
Resuscitation
• Establish large calibre IV access if an ectopic pregnancy is suspected.
• Catheterize and place on a fl uid balance chart only if hypotensive.
• Give adequate analgesia (5–10mg morphine IV is reasonable).
• Send blood for FBC (Hb, WCC), U&E (Na, K), CRP, group and save.
Establish a diagnosis
• Urine B-HCG (and serum B-HCG where urine test is positive since
this is more reliable). All women of childbearing age should be assumed
to be pregnant until proven otherwise. Pregnancy testing may be
negative in ectopic pregnancy if the fetus is already dead by the time of
presentation.
• High vaginal swabs should be taken if tubo-ovarian sepsis is suspected.
• Pelvic ultrasound (transabdominal or transvaginal) is the diagnostic
investigation of choice unless the patient is acutely unstable. It has a
high sensitivity and good specifi city.
• Laparoscopy is a very common diagnostic investigation. It allows a fi rm
diagnosis of most gynaecological pathology and may be therapeutic
(e.g. pelvic lavage, cyst treatment).
Early treatment
• IV antibiotics for a clear diagnosis of pelvic infection.
• If ruptured or bleeding ectopic pregnancy is seriously considered,
make sure the surgical and gynaecological teams are aware. Direct
transfer to theatre may be necessary.
Defi nitive management
• Complications of menstruation. Conservative management—pelvic
lavage if laparoscopy is performed.
• Ovarian cyst complications. Ovarian preservation if below the age of
menopause; cystectomy or drainage where possible.
• Tubo-ovarian infection. Cephradine 500mg tds PO and metronidazole
400m PO tds for non-sexually transmitted infections; metronidazole
400mg PO for chlamydia; IV penicillin for neisserial infections.
• Ectopic pregnancy. Conservation or reconstruction of the affected
tube/ovary wherever possible. If not salvageable, unilateral salpingooophrectomy.
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CHAPTER 7 Upper gastrointestinal surgery
308308
Intra-abdominal abscess
Key facts
Intra-abdominal sepsis can present as an intra-abdominal abscess if the
sepsis is contained by tissues or anatomy. Common locations are:
• Alongside the organ of origin (e.g. paracolic in diverticulitis,
parapancreatic after infected pancreatitis).
• Pelvic (especially after pelvic sepsis such as appendicitis or after
generalized peritoneal infection).
• Subphrenic (e.g. after upper GI perforation).
Causes
• Sigmoid diverticulitis (see b p. 404).
• Acute appendicitis (see b p. 298).
• Severe acute cholecystitis (see b p. 316).
• Upper GI perforation (see b p. 296).
• Post-anastomotic leakage (see b p. 420).
• Infected acute pancreatitis (see b p. 332).
• Post-trauma.
Clinical features
Depending on the source, the preceding pathology may have specifi c clinical features, but the development of an abscess gives rise to certain common features independent of the origin.
Symptoms
• Malaise, anorexia.
• Localized abdominal pain—constant.
Signs
• Swinging fever, typically peaks in excess of 38.5*C occurring twice a
day.
• Tachycardia tends to follow the temperature.
• Localized abdominal tenderness with a possible mass if abscess in an
accessible position (e.g. paracolic).
Emergency management
Resuscitation
• Establish large calibre IV access if the patient is unwell.
• Catheterize and place on a fl uid balance chart only if hypotensive.
• Give adequate analgesia (e.g. 5–10mg morphine IV).
• Send blood for FBC (Hb, WCC), U&E (Na, K), CRP, group and save.
Establish a diagnosis
• Helical CT scanning is the diagnostic investigation of choice.
• Pelvic ultrasound (transabdominal or transvaginal) is occasionally
useful if a pelvic abscess is suspected and CT scanning is to be avoided
due to age.
INTRA-ABDOMINAL ABSCESS
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Early treatment IV antibiotics are appropriate if the patient is septic and
should be given according to the most likely underlying diagnosis and
organisms.
Defi nitive management
• Radiologically guided drainage by ultrasound or CT scanning wherever
possible. Limitations include retroperitoneal or intermesenteric
abscesses with dangerous access or complex multiloculated abscesses.
• Open surgical drainage usually only indicated if:
Radiological drainage not possible or safe.•
Radiological drainage fails to deal with the clinical symptoms or •
abscess recurs.
Surgical treatment is required for the primary underlying pathology.•
309309
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Chapter 8
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Liver, pancreatic, and
biliary surgery
Jaundice—causes and diagnosis 312
Jaundice—management 314
Gall bladder stones 316
Common bile duct stones 318
Chronic pancreatitis 320
Portal hypertension 322
Cirrhosis of the liver 324
Pancreatic cancer 326
Cancer of the liver, gall bladder, and biliary tree 328
Acute variceal haemorrhage 330
Acute pancreatitis 332
311
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