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
Assessment
History
• Who is your patient? Age and sex are two important aetiological factors.
• Patients over the age of 65 years are twice as likely as younger patients to require surgical intervention.
• Gynaecological disorders obviously need to be excluded in women, particularly in their childbearing years. Young women are also more likely to have a final ‘uncertain’ diagnosis (up to one-third of cases).
• When did the pain start? Acute onset of severe pain implies vascular events, perforated viscus or renal colic. Inflammatory causes tend to arise more slowly.
• Where is the pain? Has it moved? Initial visceral pain is usually diffuse and in the midline. Later somatic pain localises better to the site of pathology.
• What is the pain like? The colicky pain of bowel obstruction is typically episodic and gripping with pain-free intervals. In the case of biliary and renal colic, there is more constant pain rising to a crescendo. Constant severe pain indicates advanced or serious illness.
• Which other symptoms accompany this illness? The onset of nausea and vomiting after the onset of pain suggests surgical illness. Constipation is non-specific but absolute constipation (neither faeces nor flatus) indicates bowel obstruction. Diarrhoea, jaundice, haematuria, haematemesis or melaena leads to specific diagnoses.
Examination
Abdomen
Special signs
• Murphy’s sign in cholecystitis; Rovsing’s, psoas and obturator signs in appendicitis; Cullen’s and Grey-Turner’s signs in pancreatitis; costovertebral tenderness with pyelonephritis or perinephric abscess.
• Rectal examination looking for blood (bright, melaena or occult), faecal loading, local tenderness, masses, prostatomegaly.
• Pelvic examination: incorrect and uncertain diagnoses occur much more frequently in women. A careful vaginal examination will help differentiate pelvic pathology.
Note: Cervical excitation is a ‘classic’ sign of ectopic pregnancy and pelvic inflammatory disease but is an observer-dependent sign.
OTHER SYSTEMS
Investigations
Immediate
• Blood—haemoglobin; haematocrit (PCV); white cell count and differential; electrolytes, urea and creatinine (EUC); amylase/lipase (if appropriate); blood gases (if appropriate); group-and-hold serum/cross-match (if blood loss or operation likely)
Value of investigations
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.
Management
Common indications for laparotomy
• Physical findings—diffuse or spreading rigidity; tense or progressive distension; increasing or severe localised tenderness and peritonism; tender abdominal mass with high fever or sepsis; equivocal clinical signs with septicaemia, uncontrolled bleeding, suspected mesenteric ischaemia, deterioration with conservative treatment
• Radiological findings—pneumoperitoneum; gross or progressive bowel obstruction; free contrast extravasation; perforation abscess on ultrasound/CT scan
Preoperative treatment
3. Circulation—intravenous access and appropriate blood tests; volume resuscitation; urinary catheter.
4. Analgesia should be given after initial medical assessment and establishment of a working diagnosis. Small increments of intravenous narcotics greatly benefit the patient.
5. Antibiotic prophylaxis is required with diffuse peritonitis or if infective pathology is suspected. Ampicillin, gentamicin and metronidazole is the usual combination therapy.
SPECIFIC SURGICAL CONDITIONS
Acute appendicitis
Assessment
• Typical history is vague periumbilical pain, anorexia, nausea, vomiting, pain migration to right iliac fossa, fever. This only occurs in about half of cases.
• Clinical features include: mild/moderate pyrexia; anorexia; McBurney’s point tenderness and peritonism with or without mass; ruptured appendix will often have a quiet peritonitic abdomen with few localising signs.
Investigations
• Convincing clinical appendicitis—no investigations are required, other than for preoperative assessment if needed.
• Uncertain diagnosis—urine analysis/MSU to exclude urinary tract infection; white cell count is moderately raised (10 to 15 × 109/L with left shift) and is often a late indicator; AXR/CXR rarely necessary, perform only if you suspect another diagnosis or complications.
• Ultrasound is preferred for evaluating right iliac fossa pain in children and fertile female patients if the diagnosis is uncertain.
Management
1. Surgery as soon as practical. Overnight delay in the stable patient does not significantly worsen outcome.
3. Prophylactic antibiotics reduce infective complications. They should be given in the emergency department if peritonitis or abscess is suspected or if surgery will be delayed. Otherwise antibiotics can be given at induction of anaesthesia.
4. Mass/phlegmon—intravenous antibiotics and fluids; nil by mouth; ultrasound/CT scan; operation at surgeon’s discretion.
Acute cholecystitis
Investigations
• Abdominal X-ray is often not helpful but may be ordered to exclude other pathology and complications.
• Ultrasound demonstrates stones, debris within the gall bladder, wall thickening, masses or abscesses.
• Hepatobiliary iminodiacetic acid scan (HIDA) may be used if the ultrasound is non-diagnostic, e.g. acalculous cholecystitis.
