Emergency Medicine

ACUTE ABDOMEN

262 Surgical Emergencies

MANAGEMENT

1 Insert an i.v. cannula and commence careful i.v. rehydration with analgesia.

2 Refer immediately to the surgical team.

Perforation of a viscus

DIAGNOSIS

1 Perforation may occur anywhere in the gastrointestinal tract. Common sites

are a peptic ulcer, the appendix, or a colonic diverticulum.

(i) There may be an antecedent history of alcohol or NSAID

ingestion, dyspepsia, or lower abdominal pain, or

(ii) Perforation can occur de novo.

2 It presents with severe pain and signs of generalized peritonitis with board-

like rigidity. Shock soon supervenes.

3 Gain i.v. access and send blood for FBC, U&Es, blood sugar and lipase/

amylase.

4 Request an erect CXR to look for gas under the diaphragm, seen in >70% of

cases.

5 Arrange a CT scan of the abdomen with i.v. and oral contrast.

MANAGEMENT

1 Treat shock with i.v. normal saline, administer i.v. analgesia with morphine

in 2.5–5 mg increments and pass a nasogastric tube.

2 Commence broad-spectrum antibiotics such as gentamicin 5 mg/kg once

daily, ampicillin 1 g i.v. q.d.s. and metronidazole 500 mg i.v. t.d.s.

3 Refer the patient immediately to the surgical team.

Diverticulitis

DIAGNOSIS

1 This follows inf lammation of one or more colonic diverticulae.

2 It causes lower abdominal pain radiating to the left iliac fossa, and bloody

diarrhoea, sometimes with sudden profuse rectal bleeding.

3 Look for a low-grade fever, abdominal tenderness, and guarding on the left

with a palpable mass.

4 Complications of perforation, severe bleeding, fistula formation and bowel

obstruction may occur.

5 Gain i.v. access and send blood for FBC, U&Es, blood sugar and G&S.

6 Perform an ECG and request an erect CXR if perforation is suspected.

7 Organise a CT scan of the abdomen with i.v. contrast.