1. Acute GI surgical conditions Aaqid Akram MBChB (2013) Clinical Education Fellow

2. Objectives Recognise and manage appendicitis Recognise and manage biliary tree pathology Recognise and manage pancreatitis Recognise and manage bowel obstructions Recognise and manage GI bleeds Recognise and manage hernias

3. In any Patient… ABCDE!! Urinalysis Pregnancy test (females only) Allergy status + pain relief (IV opioid/PR diclofenac) + LMWH NBM until senior review – IV fluids Bloods + IV access: – FBC – U+E – CRP – Clotting / G+S if anticipating surgery

4. Case 1 24 year old female 3 day history of central abdominal pain Now pain worse in the right iliac fossa Has developed fevers overnight Has continued to pass wind Feeling nauseous but not vomited.

5. Appendicitis

6. Central abdominal pain, migrating to RIF With(out) fever – Pyrexia = cultures + Abx Clinical diagnosis Erect CXR + AXR Barn door = surgery Unsure = CT abdomen Be wary of sudden relief after excruciating pain!

7. Case 2 40 year old Caucasian female Sudden onset intermittent pain in the RUQ Worse after eating No temperature or fever No change in skin colour, bowel habit Nauseous but not vomited

8. Biliary Tree

9. Biliary Colic Gallstone impacting cystic duct / ampulla of Vater Colicky epigastrium/RUQ pain radiating to interscapular region Nausea and Vomiting No Inflammation present CCK released when eating – Gallbladder tries to release bile USS Abdomen / ERCP

10. Cholecystitis Biliary colic + inflammation May have fever – infection – Abx If stone in CBD – jaundice Murphy’s Sign USS Abdomen – Thickened wall – Not always stones present (acalculus cholecystitis) Early, day case, laprascopic cholecystectomy

11. Case 3 50 year old Caucasian male Sudden onset RUQ pain for two days Yellowing of skin Developed spiking fevers over the last day Nausea and vomiting Last opened bowels 3 hours ago

12. Charcot’s Triad Ascending Cholangitis Fevers / Chills Jaundice RUQ Pain

13. Case 4 56 year old male Alcoholic Severe epigastric pain radiating to the left upper quadrant and directly to the mid back, over the last two hours Nausea and vomiting with mild pyrexia Discolouration around the umbilical area and flanks

14. I GET SMASHED

15. Acute Pancreatitis Idiopathic / IBD Gallstones Ethanol Trauma Scorpion Bite Mumps (Coxsackie B / hepatitis) Autoimmune Steroids Hyperlipidaemia / Calcium (Metabolic) ERCP (post) Drugs (thiazides / valproate / azathioprine)

16. Investigations Amylase Lipase Bone Profile LDH ABG LFT Endoscopic USS > tansabdominal USS abdo CT abdomen (contrast enhanced) – CT severity index – Balthazar et al.

17. Glasgow Prognostic Score VariableLimit Age>55 WCC>15 Urea>16 Glucose>10 pO2<8 Albumin<32 Calcium<2 LDH>600 AST/ALT>200

18. Management Aggressive IV fluid therapy Eliminate cause Surgical intervention if significant necrosis Parenteral feeding Watch for complications and treat ASAP

19. Complications Necrosis – X3 mortality risk – IV Abx + aggressive surgical debridement + drain placement Acute fluid collections Abscess/Pseudocyst (Several weeks after) – Surgery Ascites Cholecystitis ARDS / Pleural effusions / pulmonary oedema Hypovolaemia / Shock DIC

20. Case 5 30 year old female Exploratory laparotomy for ectopic pregnancy Absolute constipation for 5 hours Mild abdominal distention Nausea and vomiting (currently non faecal) No bowel sounds No pain

21. Bowel Obstruction Small Bowel ObstructionLarge Bowel obstruction VomitingEarlyLate (faecal) ProgressFastSlow DistentionMildMarked Absolute constipationLateEarly

22. Risk Factors Small Bowel Obstruction – Adhesions (previous surgery) – Hernia (strangulated) – Malignancy – Twisting (Volvulus) Paralytic Ileus – No peristalsis – Intestinal pseudo-obstruction = Ogilvie’s syndrome Postoperative Ileus Congenital / Hirschprungs / Bezoars / Body Packers

23. Management Uncomplicated – Drip (IV fluids) – Suck (NG tube + aspiration) – Allow bowel to rest, will restart with time – Endoscopy Decompression Dilatation Stent insertion Complicated – Surgery Exploratory laparotomy Prophylactic Abx

27. Case 6 40 year old male 2 day history of diarrhoea and vomiting Sudden onset haematemesis Now light headed BP 80 systolic

28. Upper GI bleed Peptic ulcer disease Oesophageal varices Oesophagitis / gastritis / duodenitis Malignancy Mallory-Weiss tear Vascular malformations

30. Risk Factors Alcohol Chronic Renal Failure NSAID use Age Lower socio-economic class Previous UGIB H Pylori

31. Bleeding Haematemesis – Fresh red blood – ACTIVE BLEEDING Haematochezia – Passage of fresh/altered blood per rectum – Colonic bleeding – Profuse upper GI bleeding Coffee ground vomit – Ceased bleeding – Relatively modest bleeding Malaena – Black tarry stools – Digestion of upper GI bleed

32. Management – non variceal If failed first attempt Repeat endoscopyInterventional radiologySurgery Endoscopy Mechanical (clips) +/- adrenaline Thermal coagulation + adrenaline Fibrin/Thrombin + adrenalineProton Pump Inhibitor Blatchford Bleeding Score HbUreaBPPulseMalaenaSyncope Hepatic disease Cardiac Failure Resuscitation Fluid ChallengeBlood TransfusionPPI only after endoscopy If Unstable - Interventional radiology / Surgery

33. Blatchford score

34. Management - variceal Resuscitation Endoscopy Band ligation Stent Insertion Transjugular intrahepatic portosystemic shunts (TIPS) Gastric: N-butyl-2-cyanoacrylate injection Blatchford Bleeding Score HbUreaBPPulseMalaenaSyncope Hepatic disease Cardiac Failure Resuscitation Fluid ChallengeBlood TransfusionTerlipressin/octreotideAbx If Unstable - Interventional radiology / Surgery

35. Case 7 70 year old female 6 week history of intermittent fresh rectal bleeding, with darker stools Increasing with time Reduced appetite, but no significant weight loss Recently started Ferrous Sulphate for tiredness

38. Rectal Bleeding Benign ano-rectal disease – Haemorrhoids – Anal fissure – Anal fistula Diverticular disease IBD Colonic Polyps Colorectal / anal Cancer

39. Investigations Rectal Exam is essential Faecal calprotectin – IBD screen in young patients Stool MC+S Proctoscopy (haemorrhoids) Flexible sigmoidoscopy Colonoscopy Virtual colonoscopy (CT colonoscopy)

40. Management Resuscitation if required Secondary care referrals, if required (Cancer) Treat underlying cause (IBD / diverticular disease / Upper GI bleed) Haemorrhoids – Conservative Increase fluid/fibre intake – Medical Laxatives Topical therapies (antipruritics/steroids) – Non-surgical Rubber band ligation Photocoagulation/diathermy Injection sclerotherapy – Surgical Haemorrhoidectomy Haemorrhoidal artery ligation

42. Objectives were Recognise and manage appendicitis Recognise and manage biliary tree pathology Recognise and manage pancreatitis Recognise and manage bowel obstructions Recognise and manage GI bleeds Recognise and manage hernias