Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow.
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Transcript of Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow.
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Common Surgical Common Surgical PresentationsPresentations
Phil PolsonPhil Polson
Urology RegistrarUrology Registrar
Clinical Teaching FellowClinical Teaching Fellow
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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
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The AbdomenThe Abdomen
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The AbdomenThe Abdomen
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RUQ painRUQ pain
Biliary colicBiliary colic Acute cholecystitisAcute cholecystitis CholangitisCholangitis Acute HepatitisAcute Hepatitis HepatomegalyHepatomegaly PneumoniaPneumonia
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Acute CholecystitisAcute Cholecystitis
Murphy’s SignMurphy’s Sign
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Acute CholecystitisAcute Cholecystitis
InvestigationsInvestigations• BloodsBloods• eCXReCXR• USSUSS• MRCPMRCP
ManagementManagement• AnalgesiaAnalgesia• IV fluidsIV fluids• AntibioticsAntibiotics• ERCP +/- ERCP +/-
sphincterotomysphincterotomy• CholecystectomyCholecystectomy
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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
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CholangitisCholangitis
InvestigationsInvestigations• BloodsBloods• USSUSS
ManagementManagement• ResuscitationResuscitation• AntibioticsAntibiotics• HDU/ITUHDU/ITU• ERCP / Percutaneous drainageERCP / Percutaneous drainage
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ERCPERCP
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Epigastric PainEpigastric Pain
All RUQ pain All RUQ pain Perforated ulcerPerforated ulcer PancreatitisPancreatitis
• AcuteAcute• ChronicChronic
DyspepsiaDyspepsia
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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
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Perforated UlcerPerforated Ulcer
Investigations:Investigations:• eCXReCXR• BloodsBloods• CTCT
Management:Management:• ResuscitationResuscitation• NGNG• AnalgesiaAnalgesia• AntibioticsAntibiotics• PPIPPI• Surgery – upper Surgery – upper
midline laparotomymidline laparotomy
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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
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Acute PancreatitisAcute Pancreatitis
ManagementManagement• ResuscitateResuscitate• Fluid +++Fluid +++• AnalgesiaAnalgesia
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LUQ painLUQ pain
Gastric ulcerGastric ulcer Splenic injurySplenic injury PneumoniaPneumonia PericarditisPericarditis
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RIF painRIF pain
AppendicitisAppendicitis Inflammatory bowel diseaseInflammatory bowel disease Testicular torsionTesticular torsion Renal colicRenal colic PerforationPerforation HerniaHernia Psoas abscessPsoas abscess GynaecologicalGynaecological
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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
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Acute AppendicitisAcute Appendicitis InvestigationsInvestigations
• BloodsBloods• Urine dipUrine dip• (USS / CT)(USS / CT)
ManagementManagement• AnalgesiaAnalgesia• IV fluidsIV fluids• AntibioticsAntibiotics• AppendicectomyAppendicectomy• (Percutaneous drainage)(Percutaneous drainage)
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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
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Testicular TorsionTesticular Torsion
Management:Management:• Theatre immediatelyTheatre immediately
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LIF PainLIF Pain
DiverticulitisDiverticulitis PerforationPerforation Inflammatory bowel diseaseInflammatory bowel disease HerniaHernia Testicular TorsionTesticular Torsion Renal ColicRenal Colic Psoas abscessPsoas abscess GynaecologicalGynaecological
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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
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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
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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
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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
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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
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Bowel ObstructionBowel Obstruction
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Large vs. SmallLarge vs. Small
CausesCauses• CarcinomaCarcinoma• VolvulusVolvulus• Diverticular diseaseDiverticular disease• Pseudo-obstructionPseudo-obstruction
CausesCauses• AdhesionsAdhesions• HerniaHernia• MalignancyMalignancy
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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
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Large vs. Small - InvestigationsLarge vs. Small - Investigations
AXRAXR BloodsBloods CTCT
AXRAXR BloodsBloods Contrast study Contrast study
(gastrograffin)(gastrograffin) CTCT
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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
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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
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Mesenteric IschaemiaMesenteric Ischaemia
Management:Management:• OxygenOxygen• AnalgesiaAnalgesia• FluidsFluids• LaparotomyLaparotomy
Mortality = 45-80%Mortality = 45-80%
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OtherOther
AAAAAA Urinary retentionUrinary retention
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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
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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.
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Urinary RetentionUrinary Retention
Acute vs ChronicAcute vs Chronic Causes:Causes:
• BPHBPH• Prostate cancerProstate cancer• Urethral stricturesUrethral strictures• Post-opPost-op• ClotsClots• DrugsDrugs• StonesStones• PhimosisPhimosis
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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
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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
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BleedingBleeding
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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
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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
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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%
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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
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HaematuriaHaematuria
Management:Management:• 3-way catheter3-way catheter• Bladder washouts +/- irrigationBladder washouts +/- irrigation• GA cystoscopyGA cystoscopy
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AbscessesAbscesses
PerianalPerianal Ischio-rectalIschio-rectal PilonidalPilonidal
AnalgesiaAnalgesia Surgical DrainageSurgical Drainage Pack woundPack wound
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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
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SummarySummary
Plus plenty of Plus plenty of others!others!
Any questions?Any questions?