Emergency Medicine

ACUTE ABDOMEN

272 Surgical Emergencies

(i) Still refer the patient for surgery even if >6 h have elapsed, as

orchidopexy is required on the other side to prevent subsequent

torsion there.

2 Only arrange scrotal ultrasound if the diagnosis is in doubt, or the history is

prolonged to assess blood supply and to look for an alternative diagnosis.

This must never delay urgent urological assessment.

Primary peritonitis

DIAGNOSIS AND MANAGEMENT

1 Primary bacterial peritonitis occurs almost exclusively in patients with

ascites, particularly due to cirrhosis or the nephrotic syndrome.

2 Look for fever, abdominal pain and tenderness.

3 Send blood for FBC, U&Es, LFTs, blood sugar and blood cultures. Check a

urinalysis.

4 Refer the patient to the medical team for a diagnostic peritoneal tap and

culture, to exclude Mycobacterium tuberculosis and to distinguish bacterial

peritonitis from familial Mediterranean fever.

Retroperitoneal haemorrhage

DIAGNOSIS

1 This may occur following trauma to the pelvis, kidney or back, or from aortic

aneurysm rupture, or from trivial trauma – even spontaneously in those

wit h a bleeding tendency or on anticoagulants.

2 It presents with hypovolaemic shock following trauma, in the absence of an

obvious external or internal thoracic or abdominal source for haemorrhage.

A paralytic ileus may develop.

3 Insert a wide-bore i.v. cannula and send blood for FBC, coagulation profile,

ELFTs, blood sugar, lipase/amylase and cross-match blood according to the

degree of shock.

(i) Check the urine for blood.

4 Request a CT scan of the abdomen with i.v. contrast to localize the bleeding.

(i) Plain abdominal X-ray is unhelpful. It may show loss of the psoas

shadow or possibly fractures of the vertebral transverse processes

in traumatic cases, but a CT is indicated.

MANAGEMENT

1 Commence an inf usion of norma l sa line.

2 Refer to the surgical team for admission.