• Mx surg emerg - recognise emerg + Tx accordingly
• Dire emerg - Tx B4 knowing definite Dx (but w/ Q's + prelim P/E - working hypothesis)
• Mx - Hx, P/E, Ix, definitive Tx

1. Acute abdomen
2. Bleeding: haematuria; per rectal bleeding; haematemesis
3. Acute retention of urine
4. Acute limb ischaemia
5. Infections: quinsy; perianal abscess; Fournier's gangrene (rapid, invasive)
6. Trauma: not discussed in this lecture

1. Appendicitis
2. Acute cholecystitis
3. Pancreatitis
4. Perforated ulcer: GU + DU
5. UG causes: eg. Stones
6. "Medical" abdomen

1. Ectopic pregnancy
2. Rupture spleen, liver, AAA
3. Mesenteric thrombosis
4. Massive peritoneal sepsis

1. Haemorrhagic pancreatitis
2. MI

1. Blood (least irritating)
2. Urine
3. Bile
4. Pus
5. Pancreatic juice
6. Intestinal juice
7. Gastric juice: board-like rigidity (most irritating)

• Pancreatitis; 30 hours
• Appendicitis: faster

1. Full UB
2. Fluid
3. Fibroid
4. Faces
5. Foetus
6. Flatus
7. Fat

1. Crampy pain
2. Constipation
3. Distension
4. Vomiting

• Liver, spleen, and central diaphragm - phrenic nerve (C3-5) - upper ab pain
• Peripheral diaphragm, stomach, pancreas, gallbladder, ST - celiac plexus + greater splanchnic nerve (T6-9) - upper ab pain/ mid-ab pain
• Appendix, colon, pelvic viscera - Mesenteric plexus + lesser splanchnic nerve (T10-11) - mid-ab pain
• Sigmoid colon, rectum, kidney, ureters, and testes - lower splanchnic nerve (T11-L1) - lower ab pain
• Bladder and rectosigmoid - Hypogastric plexus (S2-4) - perineal pain

• Sudden/ Abrupt severe - biliary colic, urethral colic, MI, perforated ulcer, ruptured aneurysm
• Gradual, steady pain - acute cholecystitis, acute cholangitis, acute hepatitis, appendicitis, diverticulum, acute salpingitis
• Rapid onset of severe constant pain - acute pancreatitis, mesenteric thrombosis, strangulated bowel, ectopic pregnancy
• Intermittent, colicky pain - early pancreatitis, SI obstruction, IBD

• Irritation diaphragm - shoulder pain (phrenic nerve C3-5) - eg. Perforated peptic ulcer, gastric juice initially in subphrenic area, but may travel to dome of diaphragm
• Kidney + urethral lesion - scrotum or groin (kidney retroperitoneal - testis initially retroperitoneal but then migrates to scrotum and takes nerve supply with it)
• Pancreatic disease - backache (retroperitoneal organ)

• Appendicitis: initially over central ab (epigastric region) due to irritation of mid-gut - as inflammation progresses, peritoneal peritoneum over RLQ involved (pain in RLQ)
• Perforated peptic ulcer: gastric juice travels to RLQ- therefore pain moves from central ab (epigastric region) to RLQ

• CVS - MI, RF, Pneumonia, heart failure
• Collagen: periarteritis nodosa, lupus erythematosis, RA
• Neuro - herpes zoster, abd epilepsy, spinal tumour, taves dorsalis
• Genetic - stickle cell, Mediterranean fever
• Toxic - lead poisoning, archnidism, uremia
• Metabolic - hypercalcaemia

• Non-abdominal causes of abdominal pain: myocardial ischaemia, pleurisy, zoster
• Acute exacerbation of chronic problems: chronic pancreatitis, inflammatory bowel diseases
• Previous surgery, medications, recent fall or accident, menstrual history (ectopic pregnancy?)

• Overall appearance, facial expression, nail-beds, vital signs, intra-oral examination, cervical lymphadenopathy, carotid bruits, fundoscopic signs of emboli, chest examination and auscultation, note for blisters of herpes zoster, Grey-Turner sign

• Inspection for distension, hernias, abdominal pulsation, mass effect, and pattern of movement with ventilation. Palpation for guarding, rebound tenderness, point of maximum tenderness, organomegaly, or mass effect. Auscultation for bowel sound and bruits. Per-rectal examination for detection of pelvic collection or mass. Pelvic examination of female adults. Exclusion of testicular torsion or inflammation in males.

• Perforated ciscus - scaphoid, tense ab, less bowel sounds, loss of liver dullness, guarding or rigidity
• Peritonitis - motionless, absent bowel sounds, cough and rebound tenderness, guarding or rigidity
• Inflamed mass of abscess - tender mass, punch tenderness, special signs (Murphy's, psoas)
• Intestinal obstruction
• Paralytic ileus
• Ischaemic or strangulated bowel
• Bleeding

Also: inguinal and femoral rings, male genitalia, rectal examination, pelvic examination

• To aid in the diagnosis of the patient and to assist in readying the patient for an operation.

• CBC, Liver function tests, serum electrolytes, Renal function tests, amylase, pregnancy test and urine analysis.
• Hb, haemtocrit, WBC
• Serum electrolytes, urea, creatinine
• Arterial blood gas conc
• Serum amylase (pancreatitis)
• Liver function test
• Clotting profiles

• X-ray erect - pneumonia
• Plain ab X-ray (erect + supine)
• Free intraperitoneal air
• Air in the retroperitoneum
• Air in the structures that do not normally contain air (bile duct, veins, intestinal walls, soft tissues.. etc.)
• Pattern of gas distribution should be noted eg. Presence or absence of gas in small bowel, colon, stomach and rectum
• Presence of air-fluid levels
• Psoas shadows
• Presence of stones or calcification.

• Contrast X-ray: barium enema/ follow-through, IV urogram
• CAT scan
• US
• Radionuclide imaging
• Angiography: bleeding
• Endoscopy: lesion from UGIT or LGIT
• Laparoscopy: cannot make Dx, suspect ectopic pregnancy/ salpingitis/ appendicitis (pump up ab with CO2, insert camera to view inside)
• Peritoneal lavage - eg. Wash with normal saline and see what comes out (eg. Haemoperitonium after trauma)
• Paracentesis

PRE-OP MX

• Pain relief
• Resuscitation
• ABX
• Nasogastric tube
• Informed consent

1. Surgery
2. Possibility of multiple staged operates (eg. LI obstruction)
3. Temporary of permanent stoma (allow diversion of faeces)
4. Impotence or sterility (eg. Pelvic trauma, sphincter damage)
5. Post-op intubation or mechanical ventilation

• Peptic ulcer 80%
• Mallory Weiss syndrome: tear of lower oeso
• Acute gastric erosion
• Portal hypertension: oeso varices, haematemesis

• Perianal condition (haemorrhoid): minimal bleeding but alarms Pt; occasionally can cause torrential bleeding + shock
• Large bowel: diverticulosis, tumour
• Small bowel

• Time of onset
• Amount of bleeding
• Presence + absence of haematemesis
• Change in colour or the stools'
• Previous bleeding episodes
• Ab pain or dyspepsia
• Jaundice
• Exposure to drugs (esp. aspirin, anticoagulants)
• Alcohol intake
• Wt loss
• Bowel symptoms (bowel change, cramps, diarrhoea)
• Previous GI X-rays
• Other members of family with bleeding problems

• Endoscopy

• Endoscopy
• Barium enema
• Angiography
• RBC scan (Cr51 labelled red cells)
• Meckel's scan: for Meckel's diverticulum

• Overlooking lesion in nasopharynx
• Confusing haemoptysis with GI bleeding
• Minimising importance of occult bleeding
• Dx haemorrhoids without bothering to look for more serious lesion
• Confusion UGIT with LGIT bleeding
• Treating iron deficiency anaemia without investigating GIT
• Assuming that the cirrhotic Pt is bleeding from varices before excluding an ulcer
• Giving barium before doing an angiogram

• Endoscopic haemostasis
• Sngstaken tube for oesophageal varices
• Laparotomy

• Nephritis
• Calculi
• Trauma
• Infection: acute and chronic
• Tumour
• BPH

Management: most patients can be investigated selectively

• Benign prostatic hyperplasia
• Bladder tumour/calculi
• Prostate tumour
• Urethral stricture
• Neurogenic bladder

• For relief of symptoms
• Urethral catheterisation
• Suprapubic catheterisation (if cannot catheterise due to stricture)
• Investigate and treat after thorough investigation

• Cardiac decompensation
• Organised heart thrombus dislodged
• Atrial fibrillation (50%)
• MI (33%)
• Previous embolism (25%)
• Rheumatic heart
• Subacute bacterial endocarditis
• Prosthetic heart valves

• History, examination

• XRC, ECG, blood sugar
• Electrolytes
• Doppler ultrasound
• Angiography (selective)

• Treat underlying heart problem
• Heparisation: prevent coagulation
• Limb salvage
• Fasciotomy
• Amputation

• Early: penicillin
• Abscess: incision and drainage