Common Surgical

Presentations
Phil Polson
Urology Registrar
Clinical Teaching Fellow

Introduction

Abdominal Pain
Abdominal Pain
Abdominal Pain
Abdominal Pain
Bleeding
Leg Pain
Leg Pain

General Surgery
Urology
Vascular
Trauma
T&O

The Abdomen

The Abdomen

RUQ pain

Biliary colic
Acute cholecystitis
Cholangitis
Acute Hepatitis
Hepatomegaly
Pneumonia

Acute Cholecystitis

Murphys Sign

Acute Cholecystitis

Investigations

Bloods
eCXR
USS
MRCP

Management

Analgesia
IV fluids
Antibiotics
ERCP +/sphincterotomy
Cholecystectomy

Cholangitis

Features:
Charcots Triad (60%)
1) Fever and rigors
2) RUQ pain
3) Jaundice
Shock
Altered consciousness

Cholangitis

Investigations
Bloods
USS

Management
Resuscitation
Antibiotics
HDU/ITU
ERCP / Percutaneous drainage

ERCP

Epigastric Pain

All RUQ pain

Perforated ulcer
Pancreatitis
Acute
Chronic

Dyspepsia

Perforated gastro-duodenal ulcer

Causes:

H. pylori
Drugs
Alcohol
Physiological stress
Malignancy

Presentation:
Sudden, severe
pain
Shoulder pain
Rebound
tenderness
Rigidity
Shock / Sepsis

Perforated Ulcer

Investigations:

eCXR
Bloods
CT

Management:

Resuscitation
NG
Analgesia
Antibiotics
PPI
Surgery upper
midline laparotomy

Acute Pancreatitis

Middle-aged men
Causes

Gallstones
Alcohol

Presentation:

Pain
Nausea/Vomiting
Peritonism
Shock

Investigations:
Amylase
PANCREAS

pO2 (<8kPa)
Age (>55)
Neutrophils (WCC >
15)
Calcium (<2)
uRea (>16)
Enzymes
AST/ALT/LDH
Albumin (<32)
Sugar (>10)

eCXR
USS
CT

Acute Pancreatitis

Management
Resuscitate
Fluid +++
Analgesia

LUQ pain

Gastric ulcer
Splenic injury
Pneumonia
Pericarditis

RIF pain

Appendicitis
Inflammatory bowel disease
Testicular torsion
Renal colic
Perforation
Hernia
Psoas abscess
Gynaecological

Acute Appendicitis

2nd/3rd decades

Presentation

Central RIF pain

Off food, N&V
Low grade fever
Peritonism
Diarrhoea
Urinary frequency
Bent over
RIF guarding
Rovsings Sign

Acute Appendicitis

Investigations

Bloods
Urine dip
(USS / CT)

Management

Analgesia
IV fluids
Antibiotics
Appendicectomy
(Percutaneous drainage)

Testicular Torsion

1 in 4000 males <25yrs old

90% of acutely painful scrotums (13-21yr
olds)

History:

Sudden onset, severe, unilateral pain

Nausea/Vomiting
Scrotal swelling, erythema, warmth
High, horizontal lie

Testicular Torsion

Management:
Theatre immediately

LIF Pain

Diverticulitis
Perforation
Inflammatory bowel disease
Hernia
Testicular Torsion
Renal Colic
Psoas abscess
Gynaecological

Diverticulitis

Diverticulosis = Pouches within bowel wall

Diverticulitis = Inflammation of pouches
Presentation:

LLQ pain and tenderness

Fever
Diarrhoea
PR Bleed

Diverticulitis

Investigations:

Bloods
CT
Colonoscopy?

Management:
Low fibre diet
Antibiotics
Surgery for
complications

Complications:

Bowel obstruction
Peritonitis
Abscess
Fistula
Strictures
Bleeding

Renal Colic

One of most painful conditions

Can be life threatening
Presentation:
Colicky pain where?
Nausea / Vomiting
Tender flank otherwise normal

Renal Colic

Investigations:

Bloods inc Calcium /

Urate
Urine dip
CT KUB

Management:

NSAID
IVI / IV antibiotics
? Stent
? Nephrostomy

Other treatment
options:

ESWL
PCNL
Ureteroscopy +/LASER +/- basket

Size matters!
<4mm 90% pass
4-5.9mm 50% pass
>6mm 20% pass

Diffuse Pain

Acute Pancreatitis
Bowel obstruction
AAA
Appendicitis
Gastroenteritis
Inflammatory Bowel Disease
IBS
Mesenteric ischaemia
Peritonitis
Sickle-cell crisis

Bowel Obstruction

Large vs. Small

Causes

Carcinoma
Volvulus
Diverticular disease
Pseudo-obstruction

Causes

Adhesions
Hernia
Malignancy

Large vs. Small

Colicky pain
Absolute constipation
Vomit faeculent
Abdo distension
Tender
Resonance
Reduced bowel sounds
Empty rectum

Colicky pain
Absolute constipation
Vomit food, bile
Abdo distension
Visible peristalsis
Tender
Resonance
High-pitch bowel
sounds
Normal PR

Large vs. Small - Investigations

AXR
Bloods
CT

AXR
Bloods
Contrast study
(gastrograffin)
CT

Large vs. Small - Treatment

Resuscitation
Treat cause:
Malignancy
Surgery
Volvulus
decompress

Nutritional support

Drip & Suck

Surgery
Nutritional support
60-85% settle
spontaneously

Mesenteric Ischaemia

Risk factors:

AF
>50yrs
PVD

Presentation:
Pain out of
proportion
Distension, nausea,
vomiting
PR bleed

Investigations:

Bloods
ABG
eCXR
ECG
CT with IV contrast
CT angiography

Mesenteric Ischaemia

Management:
Oxygen
Analgesia
Fluids
Laparotomy

Mortality = 45-80%

Other

AAA
Urinary retention

Leaking Abdominal Aortic Anerysm

Kills 5000 a year.

7500 emergency operations a year.
Presentation:
Back/Abdo/Flank/Groin pain
Haemodynamically unstable
Collapse
5% history of AAA
Leg ischaemia

Leaking AAA

Investigations:

Bloods (X-match)
?CT

Management:

Resuscitation
Surgery open vs. EVAR

Prognosis:

50% die before hospital

50% of those who make it to hospital will die
whilst inpatient.

Urinary Retention

Acute vs Chronic
Causes:

BPH
Prostate cancer
Urethral strictures
Post-op
Clots
Drugs
Stones
Phimosis

Urinary Retention

Presentation

Suprapubic pain
Cant wee!
LUTS
Suprapubic mass
Dull to percuss
DRE
Neuro assessment

Investigations

Bloods
USS
CSU
? PSA

Urinary retention

Management:
Catheter (Residual volume)
Observe for diuresis
? Tamsulosin
TWOC vs LTC vs TURP

Bleeding

GI Bleeding

Upper GI = Medical
Lower GI = Surgical
Presentation:
Bright red blood
Dark clotted blood
? Pain
? Change in bowel habit
PR EXAM ESSENTIAL

Lower GI Bleeding

Causes:
Diverticular disease
60%
Inflammatory bowel
disease 13%
Colorectal cancer
Infective colitis
Post-op

Management:

Resuscitation
Bloods
Rigid sigmoidoscopy
Colonoscopy
Angiography

Lower GI Bleeding

Surgery:
Persistent bleeding / shock
>6 units transfused

Mortality = 2-4%
Rebleeding = 14-38%

Haematuria

Risk of clot retention

Visible vs Non-visible
History / Examination
Investigations:
Bloods
MSU
CT Urogram
USS / X-ray KUB
Flexible cystoscopy

Haematuria

Management:
3-way catheter
Bladder washouts +/- irrigation
GA cystoscopy

Abscesses

Perianal
Ischio-rectal
Pilonidal

Analgesia
Surgical Drainage
Pack wound

Others

Trauma
#s, abdominal

Orthopaedics
Septic arthritis, back pain

Urology
Priapism, Paraphimosis, Epididymo-orchitis

ENT
Epistaxis, foreign bodies

Vascular
Acute limb ischaemia

Summary

Plus plenty of
others!

Any questions?