Emergency Medicine

ACUTE ABDOMEN

268 Surgical Emergencies

6 Record the ECG, which may show diffuse T wave inversion, in the absence of

myocardial ischaemia.

7 Request an erect CXR to exclude viscus perforation or lobar pneumonia as a

cause of the pain.

8 Perform a CT scan of the abdomen in severe cases that provides both

diagnostic and prognostic information.

MANAGEMENT

1 Commence an i.v. infusion of normal saline and pass a nasogastric tube.

Give morphine 5–10 mg i.v. with an antiemetic such as metoclopramide

10 mg i.v.

2 Refer the patient to the surgical team.

3 Admit patients with hypoxia, shock, metabolic acidosis, hypocalcaemia or

renal impairment to ICU.

Renal and ureteric colic

DIAGNOSIS

1 Renal and ureteric calculi may cause pain, haematuria, hydronephrosis or

infection.

2 Symptoms are caused by obstruction of one or more calyces, the renal pelvis

or ureter.

3 Characteristically these include sudden, severe colicky pain radiating from

the loin to the genitalia, restlessness, vomiting and sweating. There may also

be urinary frequency and haematuria.

4 Look for loin tenderness in the costovertebral angle, and remember to

consider a possible ruptured abdominal aortic aneurysm in men >45 years,

especially with a first episode of renal colic, and/or if haematuria is absent

(see p. 265).

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

and uric acid.

6 Perform a bedside urinalysis for macroscopic or microscopic haematuria,

which occurs in 90%.

(i) Send a formal midstream urine (MSU) for microscopy and

culture.

7 Request a plain AXR KUB (kidneys, ureters, bladder), as most renal calculi

are radio-opaque. This is of greatest value in subsequently tracking the

course of a calculus.

8 Request a non-contrast abdominal CT scan of the renal tract in all patients

>40 years with acute f lank pain, to rule out other retroperitoneal pathology

at the same time.