Chapter 25 Gastrointestinal emergencies
The aim of emergency department assessment of patients with gastrointestinal (GIT) emergencies is to rapidly detect and stabilise those patients requiring urgent surgical or procedural intervention. In pursuing this aim the processes of assessment, investigations appropriate to the disease and management should be followed in an orderly and purposeful manner and must be performed simultaneously in the seriously ill.
ACUTE ABDOMEN
An ‘acute abdomen’ may be defined as an acute intra-abdominal condition causing severe pain and often requiring urgent surgery. The causes may be:
The priority is to resuscitate the patient as needed and exclude a life-threatening cause of abdominal pain. In-hospital investigation and management is usually required.
Assessment
History
Remember: Only two-thirds of patients with acute surgical conditions have a ‘typical’ history of illness. Children and the elderly are more likely to have atypical presentations.
Examination
General
Appearance is apprehensive and motionless with peritonitis, unsettled and agitated with colicky pain, and pale and ‘Hippocratic’ with advanced disease. Check temperature, hydration, pulse and blood pressure (with postural drop).
Abdomen
Note: ‘Rebound’ is not pathognomonic of peritonitis. It is false positive in up to one-quarter of patients and is an observer-dependent sign. Cough and percussion tenderness are often more reliable.
Special signs
Note: Cervical excitation is a ‘classic’ sign of ectopic pregnancy and pelvic inflammatory disease but is an observer-dependent sign.
OTHER SYSTEMS
Exclude non-abdominal pathology causing abdominal pain, e.g. pneumonia, pulmonary embolus and myocardial infarction. Assess operative fitness (cardiovascular and respiratory).
Investigations
Immediate
Value of investigations
Pregnancy should be considered and excluded in all women of child-bearing years with acute abdominal pain.
White cell count is non-specific unless a marked neutrophilia (over 20 × 109/L) is present. It is often a late manifestation of significant pathology.
Serum amylase is frequently elevated in a variety of surgical conditions. Levels greater than three times normal strongly suggest pancreatitis. Lipase is more sensitive and specific for pancreatitis and is the test of choice for this disease.
Abdominal X-rays are a poor tool for diagnosing non-specific abdominal pain, but are valuable in confirming specific and serious pathology. Bowel obstruction, paralytic ileus, caecal and sigmoid volvulus have typical findings. A paucity of bowel gas may be the only clue to mesenteric infarction. Don’t forget to check the psoas shadows, the size and shape of solid organs, for calculi and for air in the biliary tree. Avoid abdominal X-rays in pregnancy if possible.
Erect chest X-ray will detect subdiaphragmatic free air, exclude pulmonary pathology and help preoperative assessment. Free air will be absent in about 20% of perforated peptic ulcers. Massive pneumoperitoneum suggests colonic perforation. The chest X-ray is the definitive investigation for Boerhaave’s syndrome (oesophageal rupture).
Abdominal ultrasound is usually indicated for right upper quadrant pain and cholelithiasis, obstructive uropathy, pelvic pathology, suspected abdominal aortic aneurysm (in stable patients) and abdominal masses. It is the investigation of choice in many paediatric patients, e.g. intussusception, pyloric stenosis, appendicitis. Pelvic ultrasound is essential for the diagnosis of gynaecological and pregnancy-related diseases.
CT scanning: spiral non-contrast CT is the initial test of choice for renal colic. Contrast CT is useful in diagnosing many acute surgical conditions, e.g. acute pancreatitis, intra-abdominal sepsis, intra-abdominal trauma. It is increasingly used to confirm the preoperative diagnosis before laparotomy.
Angiography may be both diagnostic and therapeutic in intestinal haemorrhage, mesenteric ischaemia and abdominal trauma.
Proctosigmoidoscopy is a diagnostic tool in bright rectal bleeding, rectal mass and colitis, and is therapeutic in sigmoid volvulus.
Panendoscopy is indicated urgently in life-threatening upper GIT bleeding and semi-electively in stable patients with suspected peptic ulcer or other inflammatory conditions of the upper GIT.
Management
Surgical emergency
Examples of a surgical emergency include perforated viscus, advanced peritonitis, mesenteric infarction and strangulated bowel.
Common indications for laparotomy
Most patients with an acute abdomen will undergo specific imaging prior to surgery. Adequate resuscitation and prophylactic antibiotics will allow imaging before operation.
Preoperative treatment
Note: Narcotics do not mask clinical signs in abdominal pain; they may help in assessment by reducing patient distress and anxiety. Do not deny analgesia to patients in pain.
Surgical admission
Some conditions for which admission to hospital for conservative treatment, observation and semi-elective operation is appropriate are discussed later.
Emergency department observation and discharge
Patients with mild or equivocal tenderness, minor or no laboratory abnormalities and whose condition settles can be discharged for follow-up in the community, after observation in the department. Certain diagnoses, e.g. uncomplicated renal or biliary colic and peptic ulceration, are discharged in most cases for further investigations and referral.
SPECIFIC SURGICAL CONDITIONS
Acute appendicitis
This is the most common general surgical emergency. Most problems occur with extremes of age, < 5 and > 60 years, mostly due to atypical presentation and late diagnosis.
Assessment
Investigations
Management
Acute cholecystitis
Investigations

Full access? Get Clinical Tree

