O. N. M. Panton, MB, BS, FRCSC, FACS, Head, UBC Division of General Surgery, VGH/UBCH.
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Transcript of 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
WHAT ARE ABDOMINAL CATASTROPHIES?
CATASTROPHIC EMERGENCIES
HAEMORRHAGE SEPSIS
HAEMORRAHGE
Upper GI Small Bowel Colorectal Solid organ
Massive UGI Bleed
Gastric or duodenal ulcer Varices Mallory-Weiss tear Oesophageal ulcer
Oesophageal Bleeding
Varices Mallory-Weiss tear Esophagitis/ulcer – acid reflux, infection Neoplasia Trauma
Gastric Bleeding
Gastritis Superficial Stress ulceration Mechanical
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
Duodenal Bleeding
Duodenitis Benign ulcer Crohn’s Neoplasia Vascular Malformation Dieulafoy
Duodenal Bleeding
Haemobilia Aortoduodenal fistula
Duodenal Bleeding
Benign ulcer May have all the
same etiology as stomach
Major bleeding usually gastroduodenal artery
SB Haemorrhage accounts for 2-3% of GI bleeds
Jejunal diverticulosis
Meckel’s Diverticulum
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 ++++
UGI BLEED
OR STAT laparotomy Codes shortly after laparotomy Duodenotomy/gastrotomy Watermelon stomach torrential
haemorrhage Blood gushing from duodenum Died on table
Colon Bleeding
Angiodysplasia Diverticular disease Neoplasia: Adenocarcinoma, GIST’s Ischemia Hemmorhoids IBD Infection: Campylobacter, Shigella,
Salmonella, Enteropathogenic E. coli
LGI Bleed
Acute bleeding occurs in 20-30 cases/100,000 annually
20-30% of GI bleeds
Angiodysplasia
Diverticulosis
Barium enema - diverticulosis
Lower gi bleed red cell scan
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
LGI BLEED
STAT OR Pre-sacral ulcer communicating with
rectal stump Packed/controlled ICU plan for IR angio/embolization DIC ICU & died
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
SEPSIS
Perforated appendicitis Colonic perforations Gasrtro-duonenal perforations Mesenteric ischaemia with infarcted gut Gangrenous cholecystitis Necrotizing pancreatitis Ascending cholangitis
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
SEPSIS
DL RLQ abscess Laparotomy: gangrenous
appendicitis/faecolith Appendectomy & drainage of abscess