Emergency Medicine

ACUTE ABDOMEN

264 Surgical Emergencies

Biliary colic

DIAGNOSIS

1 This presents with discrete episodes of colicky pain in the right hypo-

chondrium, referred to t he scapula.

2 Look for right upper quadrant tenderness on examination. The patient may

be jaundiced if the common bile duct is obstructed, with yellow sclera, and

bilirubin in the urine.

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

4 Request an upper abdominal ultrasound.

MANAGEMENT

1 Treat pain with i.v. analgesia such as morphine 0.1 mg/kg i.v. with an

antiemetic such as metoclopramide 10 mg i.v.

2 Refer the patient to the surgical team if the pain is severe or acute chole-

cystitis is suspected.

3 Otherwise, advise the patient to eat a diet low in saturated fats and refer them

to the GP or surgical outpatients for follow-up.

Acute cholecystitis

DIAGNOSIS

1 This causes acute, constant right upper quadrant pain referred to the scapula,

with anorexia, nausea and vomiting.

2 Look for localized tenderness, with involuntary guarding and rebound

tenderness. Painful splinting of respiration on deep inspiration and right

upper quadrant palpation is frequent (Murphy’s sign). Fever is common.

3 Occasionally a gall bladder may be palpable in association with jaundice,

although more commonly the gall bladder is not felt as it is shrunken and

contracted.

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

amylase, and blood culture.

5 Request an upper abdominal ultrasound.

MANAGEMENT

1 Give analgesia such as morphine 0.1 mg/kg i.v. with an antiemetic such as

metoclopramide 10 mg i.v., and commence an i.v. infusion of norma l sa line.

2 Give gentamicin 5 mg/kg i.v., and ampicillin 1 g i.v. q.d.s.

3 Refer the patient to the surgical team for bed rest, analgesia, antibiotics and

cholecystectomy.