O. N. M. Panton, MB, BS, FRCSC, FACS, Head, UBC Division of General Surgery, VGH/UBCH.

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CATASTROPHIC ABDOMINAL EMERGENCIES O. N. M. Panton, MB, BS, FRCSC, FACS, Head, UBC Division of General Surgery, VGH/UBCH

Transcript of O. N. M. Panton, MB, BS, FRCSC, FACS, Head, UBC Division of General Surgery, VGH/UBCH.

Page 1: O. N. M. Panton, MB, BS, FRCSC, FACS, Head, UBC Division of General Surgery, VGH/UBCH.

CATASTROPHIC ABDOMINAL EMERGENCIES

O. N. M. Panton, MB, BS, FRCSC, FACS,Head, UBC Division of General Surgery,

VGH/UBCH

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WHAT ARE ABDOMINAL CATASTROPHIES?

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CATASTROPHIC EMERGENCIES

HAEMORRHAGE SEPSIS

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HAEMORRAHGE

Upper GI Small Bowel Colorectal Solid organ

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Massive UGI Bleed

Gastric or duodenal ulcer Varices Mallory-Weiss tear Oesophageal ulcer

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Oesophageal Bleeding

Varices Mallory-Weiss tear Esophagitis/ulcer – acid reflux, infection Neoplasia Trauma

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Gastric Bleeding

Gastritis Superficial Stress ulceration Mechanical

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Gastric Bleeding

Gastric Ulcer Benign or malignant

(10%) Initial biopsy if safe Repeat OGD to assess

healing & repeat bx Benign: drug-induced,

hypersecretors +/- H. pylori infection

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Duodenal Bleeding

Duodenitis Benign ulcer Crohn’s Neoplasia Vascular Malformation Dieulafoy

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Duodenal Bleeding

Haemobilia Aortoduodenal fistula

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Duodenal Bleeding

Benign ulcer May have all the

same etiology as stomach

Major bleeding usually gastroduodenal artery

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SB Haemorrhage accounts for 2-3% of GI bleeds

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Jejunal diverticulosis

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Meckel’s Diverticulum

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CLINICAL SCENARIO MASSIVE UGI BLEED

32 year old male found at home in a pool of blood & still vomiting blood

VGH ER pulse140 BP 60/0 Hb 32 Massive resuscitation/transfusion protocol Codes x 2 in ER OGD bleeding ++++

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UGI BLEED

OR STAT laparotomy Codes shortly after laparotomy Duodenotomy/gastrotomy Watermelon stomach torrential

haemorrhage Blood gushing from duodenum Died on table

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Colon Bleeding

Angiodysplasia Diverticular disease Neoplasia: Adenocarcinoma, GIST’s Ischemia Hemmorhoids IBD Infection: Campylobacter, Shigella,

Salmonella, Enteropathogenic E. coli

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LGI Bleed

Acute bleeding occurs in 20-30 cases/100,000 annually

20-30% of GI bleeds

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Angiodysplasia

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Diverticulosis

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Barium enema - diverticulosis

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Lower gi bleed red cell scan

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CLINICAL SCENARIO MASSIVE LGI BLEED

67 year old female found down at home in a pool of blood passed per rectum

VGH ER pulse 156 BP 50/0 Hb 36 Resuscitated/massive transfusion

protocol Previous LAR/TME rectal ca neoadjuvant

short course radiorx Leak/Hartmann

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LGI BLEED

STAT OR Pre-sacral ulcer communicating with

rectal stump Packed/controlled ICU plan for IR angio/embolization DIC ICU & died

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SOLID ORGAN HAEMORRHAGE

56 year old male presents VGH ER sudden (R) flank pain

Pulse 148 BP 210/110 Hb 88 Resuscitated then STAT laparotomy (R) suprarenal ruptured tumour

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SEPSIS

Perforated appendicitis Colonic perforations Gasrtro-duonenal perforations Mesenteric ischaemia with infarcted gut Gangrenous cholecystitis Necrotizing pancreatitis Ascending cholangitis

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INTRA-ABDOMINAL SEPSIS

47 male HIV + 24 hour hx severe abdominal pain

CT dx terminal ileitis Rx IV antibiotics GS consulted next night Temp 39 pulse 120 BP 115/68 Generalized peritonitis WBC 18 creatinine

110-169

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SEPSIS

DL RLQ abscess Laparotomy: gangrenous

appendicitis/faecolith Appendectomy & drainage of abscess