ACUTE SURGICAL

EMERGENCIES
GAVIN CALPIN
DYLAN VIANI WALSH
LEARNING OBJECTIVES

• Demonstrate understanding of initial assessment of acute

unwell surgical patients, inc. history and clinical examination
findings
• Formulate a differential diagnosis
• Outline investigations - taking into account relevant exam
findings.
• Outline a management plan – based on findings
“Interactive discussion”

Department of Surgery
RCSI
 …BUT FIRST…

• …understand the impact of inflammation on surrounding tissues.

• If no inflammation the abdominal organs are easily identifiable:
arteries are red, veins blue, gallbladder green, etc…
and they slide easily on peritoneal surfaces…
• When inflammation <6 days all is red, sticky but easily dissected
• When inflammation 6 days – 6 weeks all is stuck together, difficult to
identify and may be impossible to separate
NO INFLAMMATION
EARLY INFLAMMATION – 7 DAYS
INFLAMMATION AT 3 WEEKS
MOST COMMON SURGICAL
PRESENTATIONS

1. Inflammatory problems:
2. Bleeding: UGIB, LGIB
3. Vascular: Ischemic bowel, AAA
4. Soft tissue infections: Cellulitis, abscess
5. Trauma: ATLS
MANAGEMENT OF THE COMMON
SURGICAL PRESENTATIONS

Management of ALL acute

abdominal presentations is THE
SAME
ALMOST
So you only need to remember the
variations
Department of Surgery
RCSI
BASIC MANAGEMENT ALGORITHM
• Admit to Hospital
• Airway, Breathing, Circulation, Disability, Exposure
• Oxygen – if in doubt - until blood gasses (ABG) available
• IV Fluids – 100ml/hour until you work out losses etc
• Intake and output chart – consider urinary catheter
• Analgesia – opiates usually necessary but BEWARE…
• Anti-emetics – if indicated
• Antibiotics – for ALL except pancreatitis
• NPO for ALL - [NG if vomiting]
• Type and screen
• DVT prophylaxis
Department of Surgery
RCSI
 CASE 1
History: 18 ♀
PC:
• Sudden onset right side lower abdominal since last night.
• Vomited x 2
• BO yesterday
• No urinary symptoms
• LMP 2 weeks ago
Past Med/Surg Hx: Diagnostic laparoscopy 2 years ago
Meds: Nil, NKDA
Review Of Systems:
- Nil of note Department of Surgery
RCSI
CASE 1
Physical Examination:
Abdomenal
General Inspection:
Examination:
- Face flushed
- Uncomfortable on bed • Soft + Tender RIF
Vitals:
• HR 96
• Guarding
• BP 114/70 • No Rebound
• RR 15
• Rovsing’s Sign Negative
• Temperature 37.8
• O2 sat 98% on Room Air

Department of Surgery
RCSI
CASE 1
Differential Diagnosis:
1.Acute appendicitis
2.Ovarian Torsion – absent blood flow
3.Ruptured ovarian cyst
4.Ectopic Pregnancy
5.Mid cycle pain - Mittelschmerz
6.Small bowel obstruction (?Meckel’s diverticulum)
7.UTI

Department of Surgery
RCSI
CASE 1
Investigation:
LABS:
• FBC: Hb 13.1, WCC 12.9
• CRP: 19
• U&E: Ur 6.5, Cr 101, Na 139, K 4.1
• Lactate: 1
Urinalysis:
• Clear
• β-HCG: negative
Radiology: ?Scan

Department of Surgery
RCSI
CASE 1
Ultrasound Pelvis :

Department of Surgery
RCSI
CASE 1

Management:
• Admit
• Airway, Breathing, Circulation, Disability, Exposure
• Oxygen – until gasses available
• IV Fluids
• Analgesia
• Anti-emetics
• Antibiotics
• NPO [NG if vomiting]
• Type and screen
• DVT prophylaxis
Department of Surgery
RCSI
DEFINITIVE
MANAGEMEN
T:
• Diagnostic Laparoscopy

• Detorsion and conservation vs. salpingo-

oophorectomy
• Give a little time after detorsion to see if blood supply
returns
WHICH CANNULA?

• Cannula colour and size?

Orange 14 G Can deliver 1L in 3.5 min
Grey 16 G
Green 18 G
Pink 20 G
Blue 22 G Can deliver 1L in 22 min
Yellow 25 G Only in infants

Department of Surgery
RCSI
INTRAVENOUS CANNULAE
• Become familiar with canula color
and size

Department of Surgery
RCSI
CASE 2
History: 53 ♀
•Rapid onset severe upper abdominal pain x 2 days
•Progressively worsening, previously intermittent, now
constant
• 1st presentation
• Nauseated, no vomiting
• Last BO 2 days ago
• No urinary symptoms
Meds: nil & NKDA ROS: NAD
Social Hx:
•Non-smoker No C2H5OH Department of Surgery
RCSI
CASE 2
Physical Examination:
Abdomen:
General:
• Increased BMI • Soft
• Uncomfortable • RUQ tenderness - severe
Vitals: • Guarding ++
• HR 110 • Murphy’s sign positive
• BP 110/70
• RR18
• Temp 38.3
• O2 sat 98% Department of Surgery
RCSI
 CASE 2
Differential Diagnosis: If she had rigors
Differential Diagnosis would now include:
1. Acute cholecystitis 1. Acending Cholangitis
2. [Pyelonephritis]
2. PUD 3. [Lobar pneumonia]
4. [Malaria]
3. Acute Pancreatitis
4. Gastritis
5. Myocardial infarction
6. LowerLobe Pneumonia
7. UTI

Department of Surgery
RCSI
CASE 2
Labs Investigation:
• FBC: Hb 11.5, WCC 13
• U&E: Ur 6, Cr 73, Na 137, K 4.0
• LFT’s: Bilirubin 10, AST 99, ALP, 195
• Amylase: 62
• CRP: 59
• Lactate: 1.5
Urinalysis:
• Clear
• β-HCG: negative
What’s next?

Department of Surgery
RCSI
IMAGING?

• Erect CXR – Why?

• U/S gallbladder – Looking for what?

 CASE 2
Investigation:
US abdomen
• GB wall thickening (>4-5 mm) or oedema (double wall sign)
• Acoustic shadowing
• No CBD dilation (CBD not often seen – or reliable)
• “Sonographic Murphy's sign“ positive

Department of Surgery
RCSI
 CASE 2
Management:
• Admit
• Oxygen
• IV Fluids – which fluids? What rate?
• Analgesia
• Anti-emetics
• Antibiotics – What abx?
• NPO [+/- NG]
• Type and screen
• DVT prophylaxis
• Role of Surgery? - What surgery?
Department of Surgery
RCSI
 MANAGEMENT :

• Antibiotics and Observe

Vs Cholecystectomy
• Early vs delayed
Vs Cholecystostomy
IR v Surgical
Which one, why and when would
be used?
WHAT IV FLUIDS?
a. Normal Saline 0.9%? NACL – if
electrolytes ok

b. Hartmann’s Solution? (Compound

Sodium Lactate) - if electrolyte imbalance

c. 8.4% Sodium Bicarbonate?

c. 5% Dextrose????

Department of Surgery
RCSI
 MAINTENANCE FLUIDS :

• 100 ml per hour if no cardiac failure

IV FLUIDS
Bolus of fluid “fluid challenge”:
• 10 - 20mL/kg over 5-30 minutes
Volume will depend on age and co-morbidity:
1. 20 yrs old man: 80kg & dehydrated
2. 90 yrs old man: 70kg with CCF

Department of Surgery
RCSI
CASE 3
History: 73 ♂
Meds:
• Left lower abdo pain x 5 days
• Ventolin PRN
• “Generally unwell” x 2 days • Aspirin
• LBO 3 days ago – constipated • Amlodipine
• No nausea, vomiting, or blood PR • Ramipril
• Nursing home resident – no previous • Furosemide
diagnosis dementia
• Lactulose
PMHx:
• Metformin
• COPD • Gliclazide
• IHD, CCF, HTN Allergies:
• T2DM • Penicillin - Anaphylaxis
• Lap appx at 30, lap chole at 54
Department of Surgery
RCSI
CASE 3
Physical Examination:
Abdomen:
• Uncomfortable, agitated
Tender LIF
• Disoriented time and place
Moderate guarding
Vitals:
No rebound tenderness
• HR 115
• BP 105/70
PR:
• RR 16
Empty rectum
•T 38.6
No masses palpable
• O2 sat 99% on 4L

Department of Surgery
RCSI
CASE 3

Differential Diagnosis: Giving pros and cons.

1. Diverticulitis
2. Volvulus
3. UTI/pyelonephritis
4. Mesenteric ischaemia
5. Colitis – infective vs inflammatory
6. Neoplasm

Department of Surgery
RCSI
CASE 3
Lab Investigation:
• FBC: Hb14.1 WCC 13.1

• CRP 155

• U&E: Ur 5.1 Cr 69 Na141 K3.5

• LFT: Bil 12 AST 42 ALP 98

• Amylase: 12

• Coag: INR 1.1

• Lactate: 1.8
Urinalysis: 10 pus cells

What Radiology?
Department of Surgery
RCSI
 CASE 3

Management:
• CT Abdomen
• Segmental thickening of bowel.
• Pericolic Abscess/Distant abscess

Department of Surgery
RCSI
 CASE 3
Management:
• Admit
• Oxygen
• IV Fluids – which fluids? What rate?
• Analgesia
• Anti-emetics
• Antibiotics – What abx?
• NPO [+/- NG]
• Type and screen
• DVT prophylaxis
• Role of Surgery? - What surgery?
Department of Surgery
RCSI
CASE 3

Management:
• CT Abdomen:
“Uncomplicated left colon
diverticulitis”
Treatment:
• Uncomplicated
diverticulitis: IV antibiotics

Department of Surgery
RCSI
Complicated Diverticulitis:
Management based on Hinchey
Classification

• Hinchey I Localised Abscess Risk of Death 5%

• Hinchey II Pelvic Abscess Risk of Death 5%
• Hinchey III Purulent peritonitis Risk of Death 15%
• Hinchey IV Faeculent peritonitis Risk of Death 45%
Complicated diverticulitis: Based on Hinchey classification
Hinchey I: IV antibiotics
Hinchey II: IV antibiotics + abscess drainage (IR - Perc. drainage)
Hinchey III: Laparoscopy and wash out
Hinchey IV: Hartmann’s Procedure
COMPLICATIONS OF
DIVERTICULITIS
 WHICH ANALGESIA?
• “WHO pain ladder”
• But it will depend on the
severity of pain and the
circumstances
• Recognise overdosage
• Narcotic antidote and
dosage

Department of Surgery
RCSI
CASE 4
History: 39 ♂
• Severe rapid “plateau-like” onset epigastric pain x 8 hours
• Radiating through to back – like a band across upper abdomen
• Pain relieving by leaning forward
• Vomiting x3 today
• LBO today – loose
PMHx:
• Renal calculus - 3 years ago
• Gastritis – 1 year ago on OGD
• C2H5OH 70 units/ week
Meds: Omeprazole 20mg OD
NKDA
Department of Surgery
RCSI
CASE 4

Physical Examination:
General: Abdomen:
Soft
Uncomfortable
Epigastric tenderness ++
Distressed
Guarding
Asking for painkillers
No rebound tenderness
Vitals:
Bowel sound present
HR 110
BP 95/55 Chest: Slightly reduced air entry
bilaterally, no crepitations
RR 17
T 37.6
O2 sat 97% RA Department of Surgery
RCSI
CASE 4
Differential Diagnosis: Give pros and cons.
1. Acute Pancreatitis
2. Cholecystitis
3. PUD
4. Perforated DU
5. Gastritis/duodenitis
6. Ruptured AAA
7. Ureteric calculus

Department of Surgery
RCSI
CASE 4
Lab Investigation:
FBC: Hb 12.4, WCC 14.3
CRP 35
U&E: Ur 7.9, Cr 102, Na 141, K 3.1
LFT: Bili 15, AST 30, ALP 121, GGT 720
Amylase: 1183
Coag: INR1.1
Lactate 1.3
Urinalysis: clear

Imaging?
Department of Surgery
RCSI
CASE 4 - IMAGING

•Ultrasound – why?

•No CBD dilation – not gallstone pancreatitis

 CASE 4
Management:
• Admit
• Oxygen
• IV Fluids? What rate? Pancreatitis may be high demand
• Analgesia
• Anti-emetics
• Antibiotics – ????? Pancreatitis different
• NPO [+/- NG] - ? Need for bowel rest
• Type and screen
• DVT prophylaxis
• Role of Surgery?
Department of Surgery
RCSI
 CALCULATE PROGNOSTIC
SCORES:
Modified GLASGOW Score:
Pa02 <8Kpa
Age >55
Neutrophils – (WCC) >15
Calcium < 2mmol
Renal Function – Urea >16
Enzymes (Liver) – LDH >600 :
AST/ALT >200
Albumin <32
Sugars – Glucose >10mmol/l

3 or more criteria positive = Severe Pancreatitis!! Transfer to

ICU/HDU
PANCREATITIS COMPLICATIONS:
• Early:
1. ARDS
2. SIRS
3. Hypovolaemic/septic shock
4. Acute kidney injury
5. Disseminated intravascular
coagulation
6. Hypocalcaemia
7. Hyperglycaemia
8. Metabolic acidosis
• Late(>1 week):
1. Pancreatic pseudocyst
2. Pancreatic necrosis
3. Peri-pancreatic necrosis
4. Infected necrosis/abscess
5. Pancreatic fistula
6. Splenic vein thrombosis
7. Abdominal compartment
syndrome
ANTIBIOTICS - GENERAL

Bowel: Augmentin (co-amoxiclav)

Flagyl (metronidazole) + Zinacef (cefuroxime)

Cellulitis: Flucloxacillin
Benzylpenicillin

Pneumonia: Community: Augmentin/Clarithromycin

Hospital: Tazocin (piperacillin/tazobactam)

MRSA: Vancomycin + cover for relevant system Department of Surgery

RCSI
CASE 5

History: 33 ♀
PC:
• Sudden onset severe RUQ pain 8 hours previously
• Shoulder-tip pain
• Nauseated, no vomiting
• Bowels opened earlier today
• Intermittent RUQ pain worsening last 2 years
PMHx: Chronic back pain
Meds: Diclofenac
Allergies: Penicillin
Department of Surgery
RCSI
CASE 5
Examination:
• Severely distressed Abdomen:
• Restless • Rigid
• Diaphoretic • Generalised tenderness
• Tachypnoeic
• Guarding
Vitals:
• No distension
• HR: 119 • Absent bowel sounds
• BP: 97/65
• RR: 15
• T: 37.9
• O2 sat 98% on room air Department of Surgery
RCSI
CASE 5

Differential Diagnosis: Give pros and cons

1. Perforated Duodenal/Gastric Ulcer (DU more common)

2. Acute cholecystitis
3. Ascending Cholangitis
4. Acute Pancreatitis
5. Inferior wall MI
6. LRTI
7. Colitis – inflammatory vs infective
8. Perforated appendicitis
Department of Surgery
RCSI
CASE 5
Lab Investigations
FBC: Hb 13.2, WCC 22.1 , Plt 632
CRP 210
U&E: Ur 5.1, Cr 96, Na+ 139, K+ 4.3
LFT: normal
Amylase 61
Coag: INR 1.0
Urinalysis: clear
Radiology: Which scan?
Department of Surgery
RCSI
CASE 5

Erect CXR

Department of Surgery
RCSI
CASE 5

Investigation:

• CT Abdomen

Department of Surgery
RCSI
 CASE 5
Management:
• Admit
• Oxygen
• IV Fluids? What rate? Pancreatitis may be high demand
• Analgesia
• Anti-emetics
• Antibiotics – Cefuroxime and metronidazole
• NPO [+/- NG]
• Type and screen
• DVT prophylaxis
• Role of Surgery?+ IV PPI
Department of Surgery
RCSI
IV PPI

Indication:
• Major haematemesis or UGIB
• Severe PUD

• UGIB: Bolus 80mg followed by maintenance infusion at

8mg/hr
• Everything else: 40mg or 20mg

Department of Surgery
RCSI
ANTI EMETICS

Dopamine antagonist
• Stemetil (prochlorperazine)
Antihistamine (central H1 histamine receptor antagonist)
• Cyclizine
5-HT3 antagonist – also centrally acting
• Ondansetron

Department of Surgery
RCSI
CASE 5

Management:
• Laparoscopy vs
Laparotomy:

- Vigorous peritoneal lavage

- Omental patching

Department of Surgery
RCSI
PERF DU REPAIR
 Break
(10 min)
Optional
Department of Surgery
RCSI
CASE 6

History: 62 ♂ farmer
PC:
• Shortness of breath
• Kick from a horse - left lower chest/upper abdomen an hour ago
• Severe pain overlying left chest and upper abdomen
PMHx: nil
Meds: nil
NKDA

Department of Surgery
RCSI
 CASE 6
Circulation:
Physical Examination •Hypotensive, tachycardic
Vitals:
•Weak radial pulses
• HR 102
• BP 90/45
•Cap refill approx. 3 seconds
• RR 26 •HS present - no added sounds.
• T 36.5 •2x IV 14G cannulae inserted into
• O2 sat 89% on RA Antecubital fossae, bloods taken
Airway: Talking i.e. airway patent and IV Fluid Bolus initiated
Breathing: Disability:
• Bruising on LHS chest
•GCS 15/15
• Left lower base dull to percussion
•Blood glucose normal
• Reduced air entry left bas
• Tachypnoea Exposure –Abdominal Bruising
• On 100% O2 via non-rebreather Department of Surgery
RCSI
 CASE 6
Lab Investigation:
• FBC: Hb 9.5 WCC 12
• CRP: 8
• U&E: Ur 7.6 Cr 89 Na 140 K 4.6
• LFT: normal
• Amylase: 21
• Coag: INR 1.0
• Cross match – 4-6 units
• ABG:
• Pa02: 8.2KPa
• PaC02: 5KPa
- Ph 7.36
- O2 sats 92% on 100% non- rebreather
- Lactate 1.2 Department of Surgery
RCSI
CASE 6

Investigation?

• CXR

Department of Surgery
RCSI
 CASE 6
• Left chest drain inserted
• Haemothorax: 400mL blood drains
BUT
- Remains Hypotensive despite fluids
- Hb dropping
- What next?
Secondary Survey:
- Abdomen Tender LUQ ++
- Guarding
Differential Diagnosis …?
Department of Surgery
RCSI
EFAST SCAN & CT
 CASE 6
Management:
• Admit
• Oxygen
• IV Fluids? What rate? What Temp? What proportions 1:1:1
• Analgesia
• Anti-emetics
• Antibiotics
• NPO [+/- NG]
• Type and Cross match 4-6 units
• DVT prophylaxis
• Role of Surgery?What Surgery
Department of Surgery
RCSI
CASE 6 – Management Ruptured
Spleen
• Oxygen
Interventional Radiology:
• Embolization – for minor
lacerations
Surgical:
• Laparotomy
• Splenectomy
Department of Surgery
RCSI
CASE 7
History: 74 ♂
PC: BIBA following severe epigastric pain and haematemesis
Med Hx:
HTN, Benign Prostatic Hyperplasia, Type 2 Diabetes, osteoarthritis, recently
completed triple therapy H-Pylori infection

Meds:
Aspirin, Bisoprolol, Amlodipine, Metformin, Tamsulosin, Ibuprofen,
Esomeprazole

NKDA

Department of Surgery
RCSI
 Abdomen:
CASE 7 • Soft
Physical Examination: • Tender epigastrium
Vitals: • No rebound tenderness

• HR 86
DRE:
• BP 90/40
• Dark coloured soft stool
• RR 18 • No fissure/mass/active
• T 37.0 bleeding
• FOB: +VE
• O2 sat 96%

Department of Surgery
RCSI
CASE 7
Differential Diagnosis: Give Pros and cons for each

1. Bleeding gastric/duodenal ulcer

2. Oesophageal varices
3. Mallory-Weiss tear
4. Oesophagitis/Gastritis
5. Oesophageal/Gastric carcinoma
6. Aorto-enteric fistula

Department of Surgery
RCSI
CASE 7

Lab Investigation:
FBC: Hb 6.6 WCC 12 plt 252
CRP: 15
U&E: Ur 21.1 Cr 167 Na132 K 5.0
LFT: normal
Amylase 19
Coag: INR 1.21
Lactate 2.2

Type and Screen 4 units.

Department of Surgery
RCSI
 CASE 6
Management:
• Admit
• Oxygen
• IV Fluids? What rate? What Temp? What proportions 1:1:1
• Analgesia
• Anti-emetics
• Antibiotics
• NPO [+/- NG]
• Type and Cross match 4-6 units
• DVT prophylaxis
• Role of Surgery?Endoscopic Surgery?
Department of Surgery
RCSI
CASE 7

• AIV PPI
• Urinary catheter & I/O chart
• Transfusion.
• Any intervention?
Step 1 – OGD Diagnostic and Therapeutic

Department of Surgery
RCSI
CASE 7

OGD

• Injection with adrenaline

• Clipping

• Banding

Department of Surgery
RCSI
BLEEDING DU
FORREST CLASSIFICATION –
PREDICTING REBLEED RISK
 CASE 7
• OGD unsuccessful.

• Embolization vs. Surgery.

• Surgery:
• Under running of bleeding duodenal ulcer.

• [Distal gastrectomy + loop gastrojejunostomy.]

Department of Surgery
RCSI
CASE 8
History: 74 ♂ Meds:
PC: Sudden onset severe peri-umbilical pain, Aspirin
nausea and vomiting, no BO last 3 hours Ticagrelor
PMHx: Amlodipine
• Hypertension
Warfarin
NKDA
• Atrial Fibrillation

• Previous Stroke

• Recently discharged from hospital after a

Myocardial Infarction

• Smoker 30 pack year

Department of Surgery
RCSI
 Abdominal Exam: Early
CASE 8 • Soft
• May have hyperactive bowel sounds.
EXAMINATION:
• Non tender,
- Visibly in pain - clutching his
• No rebound
abdomen

Vitals:
• HR 102 and Irregular Abdominal Exam: Later
• BP 130/66 • Tender in periumbilical region

• RR 20
• Guarding
• Rebound tenderness +/-
• Temp: 36.5 • Bowel sounds absent
• O2 sat 93% RA

Department of Surgery
RCSI
CASE 8
Differential Diagnosis: Give pros and cons
1. Acute mesenteric Infarction (Embolus vs.Thrombus)
2. Ruptured AAA
3. Pancreatitis
4. Appendicitis
5. Perforated DU

Department of Surgery
RCSI
CASE 8 Imaging:
• Erect Chest X-ray/Plain
Lab Investigation: Film Abdomen
• FBC: Hb 14.7, WCC 10.4, PLT • High resolution CT
254.
angiography of the
• CRP: 4
mesentery
• Renal Profile: Urea 12.1, Cr 144.
• LFT: Normal
• Coags Profile: INR 1.4
• Lactate: 3

Department of Surgery
RCSI
CASE 8

Investigation:

• CT Angiogram

Department of Surgery
RCSI
 CASE 6
Management:
• Admit
• Oxygen
• IV Fluids? What rate? What Temp? What proportions 1:1:1
• Analgesia
• Anti-emetics
• Antibiotics
• NPO [+/- NG]
• Type and Cross match 4-6 units
• DVT prophylaxis
• Role of Surgery?What Surgery
Department of Surgery
RCSI
CASE 8
Management:
• IV Fluids - to maintain adequate intravascular volume and visceral perfusion

• Urinary catheter & Monitor urine output

• Avoid vasopressors - can exacerbate ischemia.

• Antithrombotic therapy - anticoagulation (unfractionated heparin, weight-based

protocol) - limits thrombus propagation and alleviates arteriolar vasoconstriction
with or without antiplatelet therapy.

• .

Department of Surgery
RCSI
 CASE 8
Interventional management
1. Interventional Radiology/Cardiology
To attempt to aspirate the clot
2. Embolectomy 
Open superior mesenteric artery (SMA) embolectomy
3. Surgical Resection
If ischaemic bowel (sepsis, pneumatosis intestinalis)
4 Pharmacomechanical thrombolysis
For patients who can undergo arteriography within 8 hours of abdominal
pain onset and have no evidence of advanced ischemia or a contraindication to
thrombolytic therapy.
Department of Surgery
RCSI
CASE 9 (FINAL CASE)
History: 82 ♀
3 days history of crampy abdominal pain & absolute constipation
Nausea & vomiting – 2 episodes today

Attended A&E 2 days prior with same – sent home on lactulose &
movicol
PMHx:

CVA 2007, HTN

Diverticulitis
Open repair of Intussusception as a child
Allergies: Penicillin

Meds: Amlodipine, losartan, aspirin, atorvastatin Department of Surgery

RCSI
 CASE 9

Physical Examination:
• Vitals:
• HR 108
• BP 136/90
• RR 15
• T 35.9
• O2 sat 97%

• Abdomen:
• Soft,
• Distended,
• Generalised tenderness but no guarding
• Bowel sounds hyperactive Department of Surgery
RCSI
CASE 9

Differential Diagnosis:
Small bowel obstruction
Large bowel obstruction
Constipation
UTI/pyelonephritis
Diverticulitis

Department of Surgery
RCSI
CASE 9

Investigation:
Bloods:

• FBC: Hb 11 , WCC 12.5.

• CRP 85
• Renal Profile: Urea 9 , Creatinine 110, Na 138 , K 3.4.
• LFTs: Bili 15
• Amylase: 41
• Coags profile: INR 1.1
• Lactate 0.8
Urinalysis: clear
Imaging: Which?
Department of Surgery
RCSI
CASE 9

Investigation:
• PFA
• Distended loops
• Central bowel
• Little/no air in colon
• No air in rectum
• Thickening of the bowel wall

• Erect abdomen
• Air fluid levels
• As above

Department of Surgery
RCSI
CASE 9

Investigation:
• CT Abdo/Pelvis

Department of Surgery
RCSI
 CASE 9

Management:
• Admit
• Oxygen
• IV Fluids
• Analgesia
• Antibiotics
• +/- Anti-emetics
• NPO [+ NG tube]
• Urinary catheter & Monitor UO
• DVT prophylaxis
• ? Role for TPN
• Surgery – What Surgery

Department of Surgery
RCSI
CASE 9
Surgical Management:
• Laparoscopy + division of adhesions

Department of Surgery
RCSI
SI ADHESIONS
THE END

Coffee!

Department of Surgery
RCSI