Ben Johnson
Surgical Sieve Exercise
• VITAMIN DC
Presentation
•History, examination & site of pain
Causes
•Medical
•Gynaecological
•Surgical
Cases
• 1-4
Summary & References
……………..Vascular
……………..Infective/inflammatory
……………..Traumatic
……………..Autoimmune
……………..Metabolic
……………..Iatrogenic
……………..Neoplastic
……………..Degenerative
……………..Congenital
OHGP 3 Ed
OHGP 3 Ed
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MI
Lower lobe pneumonia
PE
Aortic dissection
Acute hepatitis
DKA
UTI / pyelonephritis
Herpes zoster
IBS/IBD
Gastroenteritis
Hypercalcaemia
Constipation
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Mesenteric adenitis
Subphrenic abscess
Addison’s Disease
Porphyria
Lead poisoning
Spinal arthritis
Muscular
HSP
Gastritis
Diverticular disease
Liver disease
Iatrogenic
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Ectopic pregnancy
PID
Rupture/torsion of ovarian cyst
Endometriosis
Mittleschmertz
Placental abruption, uterine
rupture
Dysmenorrhoea
Gynae malignancy
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Non-specific abdominal pain
Acute appendicits
Cholecystitis and biliary colic
Pancreatitis
Peptic ulcer disease
Abdominal aortic aneurysm
Mesenteric ischaemia
Diverticulitis
Large bowel perforation
Intestinal obstruction eg
herniae, volvulus, adhesions
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Ureteric calculi
Urinary retention
Testicular torsion
Intussusception / Meckel’s
diverticulum
Cancer
Trauma/other causing rupture
of abdominal viscera e.g.
spleen
Spinal artery occlusion
Dylan is a 6 year old American
boy who presents looking
unwell with severe abdominal
pain. He looks pale and is
clutching his tummy. His
parents say they have just
arrived this morning from the
US and shortly after landing
Dylan woke up distressed and
in pain.
1.
Assessment
Call for help, manage in resus, ABCDE.
Low O2 sats, abdo pain , cool peripheries, looks dry
2.
Management
Oxygen, analgesia, keep the patient warm, iv access, blds for FBC, U&E,
CRP, blood culture, VBG, ivf – fluid bolus 20ml/kg then maintenance fluids
+/- %dehydration. Once stable CXR, MSU.
FBC phoned through Hb 8.0, film pending……..possible diagnosis ?
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Sickle cell disease occurs in Africa, the Middle East,
Caribbean, USA and Mediterranean populations
Due to genetic defect in one of the Hb chains
normal genotype produces HbA; heterozygote =sickle cell trait is HbAS
in the homozygote HbS.
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The HbS molecule polymerizes in deoxygenated or
acidic conditions causing RBC sickling.
The sickle cells are fragile and haemolyse or block small vessels
causing ischemia, infarction and further sickling.
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Can occur de novo or follow infection, cold, dehydration or
any condition where tissue hypoxia or ischaemia occur
The crisis may involve thrombosis, haemolysis or acute
hepatosplenic sequestration.
A crisis can mimic any acute medical/surgical emergency eg
PE, stroke, acute abdomen, bone pain and low grade fever
deoxygenation
or acidosis
sickling
increased
blood
viscosity
stasis
sludging
Kaycee-Leigh is an 8 year old
who has presented with
abdominal and leg pain.
She is normally fit and well but
has recently been treated for a
throat infection by her GP. She
is alert but grumpy and has a
temperature of 38.2C.
1.
Assessment
Make a quick judgement as to whether you need
help straight away. Observations. ABCDE. Is this a
meningitic child ?
E – exposure…rash on buttocks and both legs, nonblanching, some petechiae, some purpuric.
1.
Assessment
cont…
Make a quick judgement as to whether you need
help straight away. Observations. ABCDE. Is this a
meningitic child ?
E – exposure…rash on buttocks and both legs, nonblanching, some petechiae, some purpuric.
She has no meningism but has vomited twice.
Her abdomen is soft but she has voluntary guarding
and is in discomfort when examined. Her parents tell
you the abdominal pain comes and goes.
Her ankles look oedematous and she has an antalgic gait.
Her observations are P127, RR32, O2 99%A, T38.2C, Avpu,
2.
Pertinent questions
….meningism. Foreign travel. Contact illnesses
….meleana / haematemesis
….recent infection
….haematuria
3.
Management
Providing you are sure this is not meningitis
Analgesia +/- antipyretic
Refer Paeds.
Will need
urinalysis
FBC, U&E
BP (hypertension is a sign of renal involvement)
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Combination of a characteristic skin rash, arthralgia, periarticular
oedema, abdominal pain and glomerulonephritis.
Usually occurs between 3-10yrs, 2♂:1♀, peaks during winter months,
often preceded by URTI
Cause unknown; postulated to involve genetic predisposition and
antigen exposure increasing serum IgA. Complexes of IgA and IgG
are deposited in the affected organs precipitating an inflammatory
response with vasculitis.
Rash in 50%, joint pain 66%, abdominal pain in many children (if
severe Rx corticosteroids; can also get intussusception, ileus &
protein losing enteropathy), renal involvement is common with >80%
having proteinuria/haematuria. Renal involvement can progress over
several years
Malcolm is a 82 year old retired farmer. He
presents with progressively worsening
abdominal pain over the course of the day.
He has had some vomits and looks
uncomfortable. He is apyrexial, tachcardic
at 120 and has a respiratory rate of 28. He
says he has not opened his bowels for one
week.
His only medical history is a bladder ca. 3
years ago. He is awaiting a TURP.
1.
Assessment
GCS 15/15. P120. O2 95%A. BP 105/51. In pain – had
10mg morphine with YAS. Feels nauseated. Looks pale.
Abdomen very tender, reluctant to move.
What next…?
2.
Management
?Resus
ABCDE
iv access x2
Monitoring
Blds (FBC, U&E, LFT, Amylase, G&S, coag), VBG, iv fluids
E-CXR, AXR
ECG
Urinary catheter
Senior/Surgical review ………..?FAST scan / CT scan
Results
VBG :
pH 7.26, PaO2 3.5, PaCO2 5.4, Hb 10.2,
Glu 12.1, Na 133, K 3.3, HCO 19.1,
BE -3.8
FBC :
U&E, LFT :
Hb 11.4, WCC 13.2, Plt 335
Na 130, K3.1, urea 7.8, creat 154
LFT normal except ALT 144, amylase 210
Coag :
ECG :
normal
sinus tachycardia 120
….Likely diagnosis ?
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Following resection of the bladder cancer this man
had chemotherapy and radiotherapy
The radiotherapy had caused fibrosis within the
rectum requiring lifelong laxative treatment
Another complication of radiotherapy to the abdomen
can be damage to microvasculature of the mesentery.
This in turn can lead to bowel ischaemia
Due to his prostatic symptoms this man had become
constipated because he drank less and omitted his
laxative to manage his urinary frequency
Tallula is a 30 year old lady who is 30/40
pregnant. She is G1 P0 and has until now had
an uneventful pregnancy with some light
spotting in the early stages. She has had
normal scans at 10/40 and 19/40. The SFH
record shows the baby is growing well. She
has no PMH of note.
She presents with a 6 hour history of generalised
Abdominal pain, nausea and has vomited once.
1.
Assessment
GCS 15/15. P105. O2 100%A. T 37.5C. BP 112/78.
Uncomfortable but mobilising ok. Nauseated but only
one vomit. CVS & RS normal. Abdomen is not peritonitic
but has generalised tenderness over her abdomen, more
so on RUQ and Right loin. No PV discharge/bleeding. No
headache or visual changes.
Thoughts as to what is going on…….?
2.
Management
Analgesia……what ?
Full observations including BP
Blds, FBC, U&E, CRP, LFT, amylase, iv access
Urinalysis…..(NB consider pre-eclampsia / UTI)
Obstetric / surgical review ?
3.
Differentials
Onset of early labour
Renal colic
Cholestasis / gallstones
Pancreatitis
Appendicitis
UTI / pyelonephritis
Constipation
Gastroenteritis
Pre-eclampsia
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Results :
Urinalysis :
Leu +, Nit -ve, Ket –ve, Glu –ve, Pro -ve
Blds :
Hb 11.2, Plt 222, WCC 12.1, LFT and
U&E normal, amylase 54, CRP 38
Most likely diagnosis……...?
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Most common surgical emergency
UK lifetime incidence of ~6%. Peak age 10-30yrs
Differentials include : mesenteric adenitis, UTI, IBD,
gastroenteritis, Meckel’s, intussusception, Gynae/Obs,
DKA/pneumonia etc
Affects 1:1000 pregnancies. Maternal mortality is high and
perforation more common (15-20%).
Foetal mortality is 5-10% in simple appendicitis and 30% with
perforation.
Note the position of the appendix is different in pregnancy so
signs may not be of classical RIF pain.
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Abdominal pain is a frequent PMC to the Emergency
Department.
As illustrated, the causes are many but common things are
common.
Most people will require analgesia, urinalysis +/-PT, FBC,
U&E, LFT, CRP and amylase, BM +/- imaging.
Non-specific abdominal pain accounts for a significant
proportion of surgical admissions with most pain resolving
spontaneously.
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Oxford Handbook of Emergency Medicine 3rd
Edition
Oxford Handbook of General Practice 3rd
Edition
Browse’s Introduction to the Symptoms and
Signs of Surgical Disease 4th Edition
Illustrated Textbook of Paediatrics 3rd Edition