Emergency Medicine

ACUTE ABDOMEN

266 Surgical Emergencies

Ischaemic colitis

DIAGNOSIS

1 This usually occurs in an elderly patient with recurrent abdominal pain,

progressing to episodes of bloody diarrhoea or intestinal obstruction from

stricture formation.

2 Gain i.v. access and send blood for FBC, coagulation profile, electrolyte and

liver function tests (ELFTs), blood sugar, lipase/amylase, lactate and G&S.

3 Record an ECG.

4 Request a plain AXR that may reveal ‘thumb-printing’ of the colonic wall, or

proximal colon dilation, intramural gas, and the most ominous sign of gas

within the portal vein.

5 Arrange a CT scan with i.v. contrast that may show free f luid and colonic-

wa ll oedema or air, a lt hough many of t he features are non-specif ic.

MANAGEMENT

1 Commence an i.v. inf usion of norma l sa line.

2 Give analgesia and keep the patient nil by mouth.

3 Refer the patient to the surgical team.

MESENTERIC INFARCTION

DIAGNOSIS

1 This may be due to embolism from atrial fibrillation or a myocardial infarc-

tion, or due to arterial or venous thrombosis, or arterial occlusion such as

following an aortic dissection.

2 There is sudden onset of severe, diffuse abdominal pain, usually in an elderly

patient, associated wit h vomiting and bloody diarrhoea.

3 Abdominal examination reveals distension, generalized tenderness, absent

bowel sounds and fresh rectal blood.

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

sugar and cross-match 2–4 units of blood. Send a lactate as a marker of lactic

acidosis.

5 Record the ECG.

MANAGEMENT

1 Commence an i.v. infusion of normal saline or Hartmann’s (compound

sodium lactate) to treat shock.

2 Refer the patient to the surgical team, who will determine the need for

angiography to confirm the diagnosis. However, the prognosis is poor.