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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2738_Библиотеки_им_академика_М_И_Перельмана
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Chapter 11: The acute abdomen 155
https://t.me/med1917
Management of acute pancreatitis
1
1. ABCDE: IV fluids, O2, catheter, analgesia
2. Identify & treat cause: e.g. cholecystectomy for gallstones
3. Close monitoring: FBC, U&Es, Ca, glucose, ABG (CRP = good indicator of
progression)
4. Consider feeding status: only keep NBM if very unwell (consider NG tube)
Complications of acute pancreatitis
Early Late
• Pain
• Hypovolaemic shock → renal failure
• Hyperglycaemia/hypocalcaemia
• DIC & sepsis
• Acute respiratory distress syndrome
PANCREATIC PSEUDOCYST = collection of necrotic tissue & fluid forming
4–6w after acute pancreatitis
Symptoms:
• Epigastric pain = deep & persistent
• N&V, anorexia, weight loss
Investigations:
• CT abdo = gold standard
• ± ERCP (to plan therapy)
Management:
1. Most = self-resolving → supportive care & monitoring
2. Drainage: percutaneous, endoscopic (ERCP), laparoscopic or open
• Pseudocyst
• Abscess
• Splenic/duodenal/SMA infarct
• Chronic pancreatitis → cancer
Prognosis
85% settle in 5–7d
15% need ICU admission
Early organ failure = poor prognostic factor
Indications for drainage :
• Symptomatic relief
• Complications (bleeding/infection)
• Concern about malignancy
1
NICE (2018, updated 2020) Pancreatitis [NG104]
Surgery
156 Chapter 11: The acute abdomen
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Meckel’s diverticulum
Remnant of embryological vitello-intestinal duct
Rule of 2s
• 2% of population
• 2 years old = peak presentation
• 2:1 ratio of M:F
• 2 inches long
• 2 feet proximal to ileocaecal valve
• 2 types of ectopic tissue
(gastric/pancreatic)
Clinical presentation / complications
→ most are asymptomatic
• Intussusception: common around 2y (painless melaena + obstruction)
• Caecal volvulus: obstruction & distension
• Peptic ulceration: epigastric pain with eating
• General inflammation: presents like acute appendicitis
Investigations
→ usually an incidental finding at diagnostic laparoscopy
→ Technetium scan: if gastric mucosa (parietal cells take up radioisotope)
→ CT: shows defect in abdo wall
Management
If asymptomatic: no intervention → otherwise surgical removal (depending on
presenting complaint)
Surgery
Chapter 11: The acute abdomen 157
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Acute appendicitis = most common surgical emergency
Pathology
→ Luminal obstruction due to: faecolith, FB or enlarged LNs
→ Bacteria proliferate in closed loop of bowel
→ Swelling → Ischaemia → Necrosis → Perforation
Clinical presentation
• Vague periumbilical pain moves to localise in RIF ( McBurney’s point )
• Nausea & anorexia ± vomiting & diarrhoea
Differentials:
• Diverticulitis/Meckel’s
• Mesenteric lymphadenitis
• Cystitis/pyelonephritis/UTI
• Cholecystitis
• IBD
• Ectopic pregnancy
• Ovarian cyst rupture
• Testicular/ovarian torsion
On examination
• Rebound & percussion tenderness
• Guarding
• +ve Rovsing’s sign – pain in RIF when LIF is pressed
• +ve psoas sign – pain on right hip extension (retrocaecal appendix)
• +ve obturator sign – pain on internal hip rotation (referred knee pain)
± fever, tachycardia, tachypnoea
*** APPENDICITIS = CLINICAL DIAGNOSIS ***
Investigations
Hx & examination: abdo (± PR exam ± pelvic exam in females if indication like
PV bleeding)
Bedside: basic obs, urine dip, blood glucose, pregnancy test (+ ECG if cardiac
history or >40y and needing surgery)
Bloods: WCC, CRP (remember amylase, U&Es, LFTs to r/o other causes of acute
abdo)
Imaging:
• USS – not always able to visualise appendix but can r/o other pathologies in
females / paediatric patients
• CT – if still unsure of Dx or anyone aged >50y to r/o malignancy
Management
Acute: ABCDE (IV ABX as per local guidelines) + urgent surgical review
Definitive: appendicectomy (within 24h)
• Pre-op ABX (as per local guidelines)
• Consider if need to be NBM
• Laparoscopic approach unless contraindicated
• Appendix sent for histology once removed
2
Consider non-operative management
(IVABX) in uncomplicated cases with
absence of appendicolith
Complications of untreated appendicitis
McBurney’s point : 1/3 of the way
between anterior, superior iliac spine
& umbilicus
Variable presentation:
• Elderly: shocked/confused
• Children: vague pain + anorexia
• Pregnancy: risk of perforation
must r/o ectopic in all women
of childbearing age
DDx of mass in RIF: Usually needs CT for
diagnosis
• Crohn’s: fibrosis & thickening
• Tumour: caecal/colonic
• Inflammatory: appendix mass, abscess, TB
granuloma
• Ovarian cyst
• Psoas abscess
• Pelvic kidney – transplanted kidney placed
in RIF
• Perforated appendix
• Peritonitis/sepsis
• Appendix abscess: can spread up paracolic gutter
• Appendix mass – inflamed appendix becomes covered in fibrotic omentum
2
Di Saverio et al. (2020) Diagnosis and treatment of acute appendicitis. World J Emerg Surg, 15:27
Management of appendix mass / abscess
1. Conservative: IV fluids + ABX
2. IR-guided drain (if suitable)
3. Delayed appendicectomy
Surgery
158 Chapter 11: The acute abdomen
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Diverticular disease
→ Diverticulum: outpouching of bowel wall (at areas of high pressure)
→ Diverticulosis: asymptomatic presence of diverticula
→ Diverticular disease: diverticulosis + symptoms
→ Diverticulitis: inflammation of diverticula (due to stagnated contents)
Pathology
Weakened bowel → stool passage s pressure → outpouching
Affects 50% of those over 50y
Often at sigmoid colon
Complications of diverticular disease:
• Perforation → peritonitic, very unwell
(abdo sepsis)
• Obstruction → constipation, distension,
vomiting
• Fistula → pneumaturia, bladder/uterus
infection
• Pericolic abscess → pus within bowel wall
(fever)
*bleed if erodes vessel
DDx of diverticular disease:
• Colorectal cancer
• IBD (or IBS)
• Ischaemic colitis
• Gynae cause: ruptured cyst, ectopic, PID
• Renal stones
Diverticular bleeds: if erodes vessel
Sx: large, painless bleed → hypovolaemic
shock
Signs: HR, RR, BP, WCC & CRP, Hb
Ix: CXR & AXR (r/o perforation & obstruction)
Mx:
1. ABCDE & urgent colonoscopy / CT angio to
find source
2. May need blood transfusion
Risk factors
• Diet: low fibre, high fat → constipation
• Age >50y & male gender
• Obesity
• CTD e.g. Marfan, Ehlers–Danlos syndrome (weak bowel wall)
3
Diverticular disease vs. diverticulitis
Diverticular disease Diverticulitis
Features • Left-sided colicky pain – relief
with defecation
• Altered bowel habit
• Sudden painless bleed*
– bright red
→ mimics colorectal cancer
Investigations Bedside: obs, abdo, DRE, urine dip
= normal
Bloods: FBC, U&Es, LFTs = normal
Imaging: flexible sigmoid-/
colonoscopy
= diagnostic (& r/o cancer)
Risks of endoscopy:
• perforation
• haemorrhage
• infection
Management3Conservative:
• Fluids & fibre
• Smoking cessation & weight loss
Medical:
• Analgesia (paracetamol)
• Bulk-forming laxatives
• Severe LIF pain – acute, worse
with movement
• Localised guarding & tenderness
– in LIF
• Systemic upset: fever, HR, N&V
→ Hinchey Class: 1–4 (small abscess
to free faeces)
Bedside: obs, abdo, DRE, urine dip
= HR & temp
Bloods: FBC, U&Es, LFTs + blood
cultures + ABG = WCC, CRP & ESR
Imaging:
1. CXR = pneumoperitoneum if
perforated
2. AXR = check for obstruction
3. CT abdo/pelvis = diagnostic
→ Avoid endoscopy in acute phase
as risk of perforation
Admission: ABCDE
• Analgesia (paracetamol)
• Broad-spectrum IV ABX
(if systemically unwell)
• IV fluids only if cannot tolerate oral
intake
Surgery: if complications
e.g. perforation
→ Hartmann’s procedure
Surgery
3
NICE (2019) Diverticular disease [NG147]
Chapter 11: The acute abdomen 159
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Gastrointestinal perforation
Loss of continuity of the gastrointestinal tract wall, allowing contents
to leak into the abdominal cavity
Causes
• Ischaemia (bowel obstruction causing necrosis)
• Infection (appendicitis, diverticulitis)
• Erosion (ulcers, malignancy)
• Direct damage (trauma, instrumentation/iatrogenic)
Symptoms
• Abdominal pain – peritonitis (guarding, rigidity)
• Nausea & vomiting
• Reduced bowel movements / constipation
• ± Fever ± septic shock
Investigations
• AXR – can show bowel obstruction
• Erect CXR – may show pneumoperitoneum
• Barium swallow – assess for UGI perforation
• CTAP – most sensitive and specific
Management
Urgent surgical referral
1. Supportive – bowel rest, IV fluids, NG tube, analgesia, catheter
2. Medical – IV ABX
3. Non-operative – collections drained by interventional radiology
4. Surgical intervention – procedure depends on type of perforation
Absence of pneumoperitoneum does not
rule out abdominal organ perforation
Surgery
160 Chapter 11: The acute abdomen
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Intestinal obstruction
*Paralytic ileus = not true obstruction, but can
present with similar symptoms
Small bowel Large bowel
Causes • Adhesions (scar tissue)
• Hernias
• Crohn’s (strictures)
• Intussusception (<3y)
• Gallstones/CF
• Malignancy (rare)
Symptoms • Colicky pain
• Vomiting (prominent, green)
• Constipation
Examination
Signs of the cause: very important to note
• Hernias
• Abdominal scars
• History of IBD
Investigations 1. History:
Types
1. Paralytic ileus*: functional problem of absent GI motility (no colicky pain)
• systemic infections
• neurological disorders
2. Mechanical obstruction: blockage of passage (intrinsic, extrinsic, intramural)
distal collapse & proximal dilation of bowel
congestion & oedema → ischaemia → necrosis
Overview of mechanical obstruction
Risk factors:
• Previous surgery
• IBD
• Biliary disease
Distension (mild) Dehydration ( urea) Tinkling bowel sounds
• Risk factors (red flags for cancer, previous surgery, IBD)
• Symptoms (last bowel movement / flatus, N&V)
→ 10% of all surgical admissions
• metabolic disturbance
• recent surgery
(inflammation & opioids)
• Colorectal cancer
• Diverticulitis
• Crohn’s/UC
• Faecal impaction (elderly)
• Volvulus
• (Adhesions/hernias)
• Abdo pain (± colicky)
• Constipation (prominent & early)
• Vomiting
Signs of the cause: very important to note
• Red flags for colorectal cancer
(weight loss, PR bleed, IDA)
Surgery
Radiology
• FBC, CRP (raised inflammatory markers, presence of anaemia)
• U&Es – deranged (electrolyte disturbance)
• Amylase, LFTs, ABG
• Erect CXR (may show free air if perforation)
• CT abdo + pelvis (shows site & cause)
→ Central dilation
→ 3–5cm
→ Valvulae conniventes (cross whole width)
Fig. 11.2
2. Bloods:
3. Imaging:
• Abdo XR
→ Peripheral dilation
→ >5cm
→ Haustra (do not cross whole width)
Fig. 11.3
Management
https://t.me/med1917
Small bowel Large bowel
4
‘Drip & suck’
1. Fluid resuscitation – IV drip + catheter
2. Decompression – NG tube
+ IV ABX if suspected sepsis
Chapter 11: The acute abdomen 161
‘Drip & suck’
1. Fluid resuscitation – IV drip + catheter
2. Decompression – NG tube
+ IV ABX if suspected sepsis
Surgery if:
→ No improvement in 48h
→ Irreducible hernia
→ Suspected perforation or ischaemia
→ No previous surgical Hx to suggest adhesions
If adhesions suspected, may try water-soluble contrast
enema before surgical intervention
Surgery usually needed:
Stent: may be possible to relieve obstruction,
depending on site & cause
Colostomy: exact procedure depends on location of
obstruction
If sigmoid volvulus: rectal insufflation (flatus
tube with gas enema pumped in)
Complications of bowel obstruction
1. Fluid & electrolyte shifts → dehydration, metabolic acidosis & hypovolaemic
shock
2. Strangulation → pain becomes severe & constant ± fever, tachycardia etc.
3. Perforation → peritonitic pain ± fever, tachycardia, raised inflammatory
markers
Faecal impaction
Risk factors: low fibre diet, dehydration,
immobility (common in elderly)
Management: fluid resuscitation, suppository/
enema, laxatives / stool softeners → manual
evacuation if needed
Fig. 11.4 Sigmoid volvulus
(‘coffee bean’ shape).
Assess competence of ileocaecal
valve
No air in small bowel = competent
valve = closed loop so risk of
perforation
4
Association of Surgeons of Great Britain and Ireland (2014) Commissioning guide emergency
general surgery
Causes of paediatric bowel obstruction:
• Intussusception
• Faecal impaction
• Hernia
• Malrotation/atresia
• Hirschsprung’s
disease
• Pyloric stenosis
• Adhesions
• Imperforate anus
Surgery
162 Chapter 11: The acute abdomen
Through defect
https://t.me/med1917
Hernias
= protrusion of an organ through a normal/abnormal opening in the wall
Usually a painless lump
Obstructed hernia = if bowel contents trapped
• Abdo pain & distension
• Constipation
• N&V
Deep ring: 1cm superior to midpoint of inguinal
ligament
Superficial ring: 1cm superior and lateral to
pubic tubercle
Classication
• Reducible: can be manipulated back through defect
• Irreducible: cannot reduce without surgery
• Incarcerated : irreducible hernia with contents trapped
• Strangulated: ischaemia of contents → necrosis → sepsis = emergency
▶ Sudden intense pain
▶ Red/purple/blue swelling = irreducible
Inguinal hernia
↳ superomedial to pubic tubercle → most common type
ANATOMY OF THE INGUINAL CANAL:
ASIS*
Inguinal ligament
Fig. 11.5
Deep ring: midpoint
of inguinal ligament
Inguinal Canal
Supercial ring
*ASIS: Anterior, superior iliac spine
*PT: Pubic tubercle
PT*
Deep ring occlusion test: differentiate
direct & indirect hernias
• Press on deep ring to reduce hernia
• Get patient to cough
• If hernia reappears =
LIKELY DIRECT
USS for
definitive Dx
CONTENTS OF INGUINAL CANAL:
• 3 arteries: testicular/ovarian, vas deferens, cremasteric
• 3 nerves: ilioinguinal, genitofemoral, sympathetic
• 3 others: vas deferens / round ligament, pampiniform plexus, lymphatics
TYPES OF INGUINAL HERNIA:
Direct (1/3) Indirect (2/3)
What?
Why? Acquired (weakened wall +
Who? Older men Younger patients (especially boys)
Features
ASIS
Fig. 11.6
in canal wall
PT
intra-abdominal pressure)
RF = chronic coughing, constipation,
obesity, heavy lifting, protein deficiency
(elderly)
→ Easily reducible
→ Rarely extends to scrotum
→ Rarely strangulates
ASIS
Fig. 11.7
Through deep
ring
Congenital
(incomplete obliteration of processus
vaginalis)
→ Harder to reduce
→ May extend to scrotum
→ More likely to strangulate
PT
Elective surgical options:
Lichtenstein open repair:
→ mesh repair under local or general
anaesthetic
Laparoscopic repair:
→ if bilateral/recurrent hernia and experienced
surgeon available
Surgery
MANAGEMENT OF INGUINAL HERNIA:
1. Reducible & asymptomatic: none
2. Symptomatic: consider elective surgery
3. Acutely irreducible / obstructed / strangulated: emergency surgery
• CT abdo to demonstrate contents of hernia & viability of bowel
• NG tube, IV fluids & catheter if obstructed
• Surgery: groin incision ± laparotomy ± bowel resection
Femoral hernia
Femoral canal
https://t.me/med1917
→ inferolateral to pubic tubercle (uncommon)
ANATOMY OF THE FEMORAL CANAL:
ASIS
Inguinal ligament
Fig. 11.8
Nerve
Inguinal Canal
Artery
Vein
PT
Femoral canal:
• Medial to vessels
• Allows expansion of vein
Femoral hernia:
• Abdominal viscera / omentum
passes through femoral canal
MANAGEMENT: operate on all within 2w of diagnosis
• Reduce hernia & narrow femoral ring with sutures or mesh plug
USS/CT for definitive Dx
Richter’s hernia
= Hernia of the bowel that only involves the bowel wall and not the lumen
• Most common at femoral ring
• May strangulate/perforate without any warning signs of obstruction
Umbilical & paraumbilical hernias
Umbilical Paraumbilical
Aetiology Herniation of bowel through
umbilical ring due to defect in
transversalis fascia
Who? Congenital (usually children) Women aged 35–50y
Risk factors Black, male, premature Obesity, multips, heavy lifting / chronic cough
Features
→ Easily reducible
→ Usually asymptomatic
→ Rarely strangulate
Management 90% close spontaneously by 2y Early surgery before obstruction
Herniation of bowel through weakness in
linea alba due to IAP (just above/below
umbilicus)
→ May become irreducible
→ Intermittent colicky pain (bowel
obstruction)
→ Higher risk of strangulation if small
defect
Chapter 11: The acute abdomen 163
Risk factors for femoral hernia:
• Female
• Pregnancy/multiparous
• Intra-abdominal pressure
Femoral hernias = high risk of strangulation
30% present as an emergency
Operate on all within 2w
DDx of groin lumps:
• Inguinal hernia
• Femoral hernia
• Lymph nodes
• Lipoma
• Ovarian cyst
• Femoral artery / iliac artery aneurysm
• Saphena varix
• Appendicular mass
• Appendicular abscess
• Tumour
Must examine regional lymph nodes for any groin
lump
Epigastric hernia
→ herniation of fat through linea alba above umbilicus
Symptoms:
• Painful abdominal mass (worse with eating)
• ± N&V, bloating
Management:
• Surgery if symptomatic (as this suggests strangulation)
DDx:
• Divarication of recti
Surgery
164 Chapter 11: The acute abdomen
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Risk factors for incisional hernia
Patient RFs Surgical RFs
• age
• Malnutrition
• Obesity
• Diabetes
• Steroids
• Smoking
• Vertical incisions
• Presence of drains
• Too loose or too tight
knots
• Emergency surgery
• Wound infection
Divarication of recti
→ separation of rectus muscles due to linea alba laxity
Risk factors: truncal obesity, pregnancy, repeated midline operations
Symptoms: painless ridge down midline
Ix: USS to r/o hernia
Management: not usually needed
Incisional hernia
→ herniation through a previous incision/scar in abdominal wall
Who: common risk after any abdominal surgery
Symptoms: bulge at scar site, local pain/erythema → can obstruct
Investigation if repairing: CT scan
Management: none / mesh repair → but high recurrence rate
↳
Prevalence:
→ 5% at 1y
→ 25% at 2y
Indications for repair:
Large, patient Sx, small
bowel obstruction
RFs for recurrence:
• Obesity
• Chronic cough
General approach to managing a hernia
1. HISTORY:
→ PCx: site, onset, duration, any pain
→ PMHx: PSHx, DHx (especially drugs which may affect surgery)
→ SHx: smoking/alcohol, BMI, independence / help at home
2. EXAMINE: remember to check for other hernias
→ General appearance
→ Observe standing & lying
→ Palpate hernia (get patient to cough & lift chin off bed) → reducible/
irreducible?
→ Deep ring occlusion test → direct / indirect?
3. SURGERY: decide if appropriate
→ depends on type/size/symptoms of hernia & fitness of patient
If unsure of Dx can
use USS or CT scan
Surgery
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