common surgical presentations phil polson urology registrar clinical teaching fellow

Common Surgical Common Surgical PresentationsPresentations

Phil PolsonPhil Polson

Urology RegistrarUrology Registrar

Clinical Teaching FellowClinical Teaching Fellow

IntroductionIntroduction

Abdominal PainAbdominal Pain Abdominal PainAbdominal Pain Abdominal PainAbdominal Pain Abdominal PainAbdominal Pain BleedingBleeding Leg PainLeg Pain Leg PainLeg Pain

General SurgeryGeneral Surgery UrologyUrology VascularVascular TraumaTrauma T&OT&O

The AbdomenThe Abdomen

The AbdomenThe Abdomen

RUQ painRUQ pain

Biliary colicBiliary colic Acute cholecystitisAcute cholecystitis CholangitisCholangitis Acute HepatitisAcute Hepatitis HepatomegalyHepatomegaly PneumoniaPneumonia

Acute CholecystitisAcute Cholecystitis

Murphy’s SignMurphy’s Sign

Acute CholecystitisAcute Cholecystitis

InvestigationsInvestigations• BloodsBloods• eCXReCXR• USSUSS• MRCPMRCP

ManagementManagement• AnalgesiaAnalgesia• IV fluidsIV fluids• AntibioticsAntibiotics• ERCP +/- ERCP +/-

sphincterotomysphincterotomy• CholecystectomyCholecystectomy

CholangitisCholangitis

Features:Features:• Charcot’s Triad (60%)Charcot’s Triad (60%)

1) Fever and rigors1) Fever and rigors 2) RUQ pain2) RUQ pain 3) Jaundice3) Jaundice ShockShock Altered consciousnessAltered consciousness

CholangitisCholangitis

InvestigationsInvestigations• BloodsBloods• USSUSS

ManagementManagement• ResuscitationResuscitation• AntibioticsAntibiotics• HDU/ITUHDU/ITU• ERCP / Percutaneous drainageERCP / Percutaneous drainage

ERCPERCP

Epigastric PainEpigastric Pain

All RUQ pain All RUQ pain Perforated ulcerPerforated ulcer PancreatitisPancreatitis

• AcuteAcute• ChronicChronic

DyspepsiaDyspepsia

Perforated gastro-duodenal ulcerPerforated gastro-duodenal ulcer

Causes:Causes:• H. pyloriH. pylori• DrugsDrugs• AlcoholAlcohol• Physiological stressPhysiological stress• MalignancyMalignancy

Presentation:Presentation:• Sudden, severe Sudden, severe

painpain• Shoulder painShoulder pain• Rebound Rebound

tendernesstenderness• RigidityRigidity• Shock / SepsisShock / Sepsis

Perforated UlcerPerforated Ulcer

Investigations:Investigations:• eCXReCXR• BloodsBloods• CTCT

Management:Management:• ResuscitationResuscitation• NGNG• AnalgesiaAnalgesia• AntibioticsAntibiotics• PPIPPI• Surgery – upper Surgery – upper

midline laparotomymidline laparotomy

Acute PancreatitisAcute Pancreatitis Middle-aged menMiddle-aged men

CausesCauses• GallstonesGallstones• AlcoholAlcohol

Presentation:Presentation:• PainPain• Nausea/VomitingNausea/Vomiting• PeritonismPeritonism• ShockShock

Investigations:Investigations:• AmylaseAmylase• PANCREASPANCREAS

pO2 (<8kPa)pO2 (<8kPa) Age (>55)Age (>55) Neutrophils (WCC > Neutrophils (WCC >

15)15) Calcium (<2)Calcium (<2) uRea (>16)uRea (>16) Enzymes – Enzymes –

AST/ALT/LDHAST/ALT/LDH Albumin (<32)Albumin (<32) Sugar (>10)Sugar (>10)

• eCXReCXR• USSUSS• CTCT

Acute PancreatitisAcute Pancreatitis

ManagementManagement• ResuscitateResuscitate• Fluid +++Fluid +++• AnalgesiaAnalgesia

LUQ painLUQ pain

Gastric ulcerGastric ulcer Splenic injurySplenic injury PneumoniaPneumonia PericarditisPericarditis

RIF painRIF pain

AppendicitisAppendicitis Inflammatory bowel diseaseInflammatory bowel disease Testicular torsionTesticular torsion Renal colicRenal colic PerforationPerforation HerniaHernia Psoas abscessPsoas abscess GynaecologicalGynaecological

Acute AppendicitisAcute Appendicitis

22ndnd/3/3rdrd decades decades PresentationPresentation• Central Central RIF pain RIF pain• Off food, N&VOff food, N&V• Low grade feverLow grade fever• PeritonismPeritonism• DiarrhoeaDiarrhoea• Urinary frequencyUrinary frequency• Bent overBent over• RIF guardingRIF guarding• Rovsing’s SignRovsing’s Sign

Acute AppendicitisAcute Appendicitis InvestigationsInvestigations

• BloodsBloods• Urine dipUrine dip• (USS / CT)(USS / CT)

ManagementManagement• AnalgesiaAnalgesia• IV fluidsIV fluids• AntibioticsAntibiotics• AppendicectomyAppendicectomy• (Percutaneous drainage)(Percutaneous drainage)

Testicular TorsionTesticular Torsion

1 in 4000 males <25yrs old1 in 4000 males <25yrs old 90% of acutely painful scrotums (13-90% of acutely painful scrotums (13-

21yr olds)21yr olds)

History:History:• Sudden onset, severe, unilateral painSudden onset, severe, unilateral pain• Nausea/VomitingNausea/Vomiting• Scrotal swelling, erythema, warmthScrotal swelling, erythema, warmth• High, horizontal lieHigh, horizontal lie

Testicular TorsionTesticular Torsion

Management:Management:• Theatre immediatelyTheatre immediately

LIF PainLIF Pain

DiverticulitisDiverticulitis PerforationPerforation Inflammatory bowel diseaseInflammatory bowel disease HerniaHernia Testicular TorsionTesticular Torsion Renal ColicRenal Colic Psoas abscessPsoas abscess GynaecologicalGynaecological

DiverticulitisDiverticulitis

Diverticulosis = Pouches within bowel wallDiverticulosis = Pouches within bowel wall Diverticulitis = Inflammation of pouchesDiverticulitis = Inflammation of pouches

Presentation:Presentation:• LLQ pain and tendernessLLQ pain and tenderness• FeverFever• DiarrhoeaDiarrhoea• PR BleedPR Bleed

DiverticulitisDiverticulitis

Investigations:Investigations:• BloodsBloods• CTCT• Colonoscopy?Colonoscopy?

Management:Management:• Low fibre dietLow fibre diet• AntibioticsAntibiotics• Surgery for Surgery for

complicationscomplications

Complications:Complications:• Bowel obstructionBowel obstruction• PeritonitisPeritonitis• AbscessAbscess• FistulaFistula• StricturesStrictures• BleedingBleeding

Renal ColicRenal Colic

One of most painful conditionsOne of most painful conditions Can be life threateningCan be life threatening

Presentation:Presentation:• Colicky pain – where?Colicky pain – where?• Nausea / VomitingNausea / Vomiting• Tender flank – otherwise normalTender flank – otherwise normal

Renal ColicRenal Colic

Investigations:Investigations:• Bloods inc Calcium / Bloods inc Calcium /

UrateUrate• Urine dipUrine dip• CT KUBCT KUB

Management:Management:• NSAIDNSAID• IVI / IV antibioticsIVI / IV antibiotics• ? Stent ? Stent • ? Nephrostomy? Nephrostomy

Other treatment Other treatment options:options:• ESWLESWL• PCNLPCNL• Ureteroscopy +/- Ureteroscopy +/-

LASER +/- basketLASER +/- basket

Size matters!Size matters!• <4mm 90% pass<4mm 90% pass• 4-5.9mm 50% pass4-5.9mm 50% pass• >6mm 20% pass>6mm 20% pass

Diffuse PainDiffuse Pain Acute PancreatitisAcute Pancreatitis Bowel obstructionBowel obstruction AAAAAA AppendicitisAppendicitis GastroenteritisGastroenteritis Inflammatory Bowel DiseaseInflammatory Bowel Disease IBSIBS Mesenteric ischaemiaMesenteric ischaemia PeritonitisPeritonitis Sickle-cell crisisSickle-cell crisis

Bowel ObstructionBowel Obstruction

Large vs. SmallLarge vs. Small

CausesCauses• CarcinomaCarcinoma• VolvulusVolvulus• Diverticular diseaseDiverticular disease• Pseudo-obstructionPseudo-obstruction

CausesCauses• AdhesionsAdhesions• HerniaHernia• MalignancyMalignancy

Large vs. SmallLarge vs. Small

Colicky painColicky pain Absolute constipationAbsolute constipation Vomit – ‘faeculent’Vomit – ‘faeculent’ Abdo distensionAbdo distension TenderTender ResonanceResonance Reduced bowel Reduced bowel

soundssounds Empty rectumEmpty rectum

Colicky painColicky pain Absolute constipationAbsolute constipation Vomit – food, bileVomit – food, bile Abdo distensionAbdo distension Visible peristalsisVisible peristalsis TenderTender ResonanceResonance High-pitch bowel High-pitch bowel

soundssounds Normal PRNormal PR

Large vs. Small - InvestigationsLarge vs. Small - Investigations

AXRAXR BloodsBloods CTCT

AXRAXR BloodsBloods Contrast study Contrast study

(gastrograffin)(gastrograffin) CTCT

Large vs. Small - TreatmentLarge vs. Small - Treatment

ResuscitationResuscitation Treat cause:Treat cause:

• Malignancy – Malignancy – SurgerySurgery

• Volvulus – Volvulus – decompressdecompress

Nutritional supportNutritional support

‘‘Drip & Suck’Drip & Suck’ SurgerySurgery Nutritional supportNutritional support

60-85% settle 60-85% settle spontaneouslyspontaneously

Mesenteric IschaemiaMesenteric Ischaemia

Risk factors:Risk factors:• AFAF• >50yrs>50yrs• PVDPVD

Presentation:Presentation:• Pain ‘out of Pain ‘out of

proportion’proportion’• Distension, nausea, Distension, nausea,

vomitingvomiting• PR bleedPR bleed

Investigations:Investigations:• BloodsBloods• ABGABG• eCXReCXR• ECGECG• CT with IV contrastCT with IV contrast• CT angiographyCT angiography

Mesenteric IschaemiaMesenteric Ischaemia

Management:Management:• OxygenOxygen• AnalgesiaAnalgesia• FluidsFluids• LaparotomyLaparotomy

Mortality = 45-80%Mortality = 45-80%

OtherOther

AAAAAA Urinary retentionUrinary retention

Leaking Abdominal Aortic AnerysmLeaking Abdominal Aortic Anerysm

Kills 5000 a year.Kills 5000 a year. 7500 emergency operations a year.7500 emergency operations a year.

Presentation:Presentation:• Back/Abdo/Flank/Groin painBack/Abdo/Flank/Groin pain• Haemodynamically unstableHaemodynamically unstable• CollapseCollapse• 5% history of AAA5% history of AAA• Leg ischaemiaLeg ischaemia

Leaking AAALeaking AAA Investigations:Investigations:

• Bloods (X-match)Bloods (X-match)• ?CT?CT

Management:Management:• ResuscitationResuscitation• Surgery – open vs. EVARSurgery – open vs. EVAR

Prognosis:Prognosis:• 50% die before hospital50% die before hospital• 50% of those who make it to hospital will die 50% of those who make it to hospital will die

whilst inpatient.whilst inpatient.

Urinary RetentionUrinary Retention

Acute vs ChronicAcute vs Chronic Causes:Causes:

• BPHBPH• Prostate cancerProstate cancer• Urethral stricturesUrethral strictures• Post-opPost-op• ClotsClots• DrugsDrugs• StonesStones• PhimosisPhimosis

Urinary RetentionUrinary Retention

PresentationPresentation• Suprapubic painSuprapubic pain• Can’t wee!Can’t wee!• LUTSLUTS• Suprapubic massSuprapubic mass• Dull to percussDull to percuss• DREDRE• Neuro assessmentNeuro assessment

InvestigationsInvestigations• BloodsBloods• USSUSS• CSUCSU• ? PSA? PSA

Urinary retentionUrinary retention

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

BleedingBleeding

GI BleedingGI Bleeding

Upper GI = MedicalUpper GI = Medical Lower GI = SurgicalLower GI = Surgical

Presentation:Presentation:• Bright red bloodBright red blood• Dark clotted bloodDark clotted blood• ? Pain? Pain• ? Change in bowel habit? Change in bowel habit• PR EXAM ESSENTIALPR EXAM ESSENTIAL

Lower GI BleedingLower GI Bleeding

Causes:Causes:• Diverticular disease Diverticular disease

60%60%• Inflammatory bowel Inflammatory bowel

disease 13%disease 13%• Colorectal cancerColorectal cancer• Infective colitisInfective colitis• Post-opPost-op

Management:Management:• ResuscitationResuscitation• BloodsBloods• Rigid Rigid

sigmoidoscopysigmoidoscopy• ColonoscopyColonoscopy• AngiographyAngiography

Lower GI BleedingLower GI Bleeding

Surgery:Surgery:• Persistent bleeding / shockPersistent bleeding / shock• >6 units transfused>6 units transfused

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

HaematuriaHaematuria

Risk of clot retentionRisk of clot retention Visible vs Non-visibleVisible vs Non-visible History / ExaminationHistory / Examination Investigations:Investigations:

• BloodsBloods• MSUMSU• CT Urogram CT Urogram • USS / X-ray KUBUSS / X-ray KUB• Flexible cystoscopyFlexible cystoscopy

HaematuriaHaematuria

Management:Management:• 3-way catheter3-way catheter• Bladder washouts +/- irrigationBladder washouts +/- irrigation• GA cystoscopyGA cystoscopy

AbscessesAbscesses

PerianalPerianal Ischio-rectalIschio-rectal PilonidalPilonidal

AnalgesiaAnalgesia Surgical DrainageSurgical Drainage Pack woundPack wound

OthersOthers

TraumaTrauma• #’s, abdominal#’s, abdominal

OrthopaedicsOrthopaedics• Septic arthritis, back painSeptic arthritis, back pain

UrologyUrology• Priapism, Paraphimosis, Epididymo-orchitisPriapism, Paraphimosis, Epididymo-orchitis

ENTENT• Epistaxis, foreign bodiesEpistaxis, foreign bodies

VascularVascular• Acute limb ischaemiaAcute limb ischaemia

SummarySummary

Plus plenty of Plus plenty of others!others!

Any questions?Any questions?