Emergency Medicine

ACUTE ABDOMEN

260 Surgical Emergencies

Acute appendicitis

DIAGNOSIS

1 Acute appendicitis causes poorly localized central abdominal pain, worse on

coughing or moving, which classically shifts to the right iliac fossa. There is

associated anorexia, nausea, vomiting, and diarrhoea or constipation.

2 Low-grade pyrexia, localized abdominal tenderness, rebound and guarding

are found.

3 A rectal examination is commonly performed to help diagnose a retrocaecal

or pelvic appendix, but really has little true discriminatory value.

4 Always perform a urinalysis to look for glycosuria, white cells, and a -hCG

pregnancy test. Even if positive, none of these rules out appendicitis.

5 Gain i.v. access.

(i) FBC is frequently performed, but rarely influences decision

making alone.

6 Request an ultrasound in females to rule out pelvic pathology, or a CT scan

for doubtful cases only.

7 Diagnosis is most dif f icult in ver y young, elderly or pregnant patients.

MANAGEMENT

1 Commence a norma l sa line inf usion and administer i.v. ana lgesia.

2 Keep the patient nil by mouth. Give gentamicin 5 mg/kg i.v., ampicillin 1 g

i.v. q.d.s. and metronidazole 500 mg i.v. t.d.s. if rupture is suspected with

peritonitis.

3 Admit all patients under the surgical team, whether the diagnosis appears

clear or is just suspected in an at y pica l case, such as:

(i) Confused elderly patient, infant with diarrhoea, or older child off

his or her food, any of whom could have appendicitis.

Intestinal obstruction

DIAGNOSIS

1 The causes are many, including adhesions, an obstructed hernia, carcinoma,

diverticulitis, volvulus, intussusception, mesenteric infarction, and Crohn’s

disease.

2 Intermittent colicky abdominal pain occurs with abdominal distension and

vomiting in high obstruction, and constipation with failure to pass f latus in

low obstruction.

3 Visible peristalsis may be seen, associated with tinkling bowel sounds and

signs of dehydration.