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?