Surgical Emergencies

G1Gr o up

S H O C K

I M M E D I A T E

M A N A G E M E N T S

S I G N S

I N V E S T I G A T I O N S

I N F O G R A P H I C S

S U R G I C A L E M E R G E N C I E S

• ↑ HR (>100)• ↓ pO2 (< 90%)• ↑ RR (> 20)• SBP < 90 mmHg

Signs of ShockSURGICAL EMERGENCIES

CP presentation

S U R G I C A L E M E R G E N C I E S

CP presentation

S U R G I C A L E M E R G E N C I E S

What specific laboratory studies will help you?

CP presentation

These are the appropiate initial screening tests.

i. FBCii. BUSE/Criii. Blood glucoseiv. Coagulation profilev. Blood grouping/ X matchingvi. Investigate source of bleed

CP presentation

Upper Gastrointestinal Bleeding

SITI NUR AQILAH MOHD AZRY

YEE ZHEN AUN

Variceal

Non-variceal:

I. Bleeding PUD

II. CA gastric, esophagus

III. Drugs?

IV. Mallory Weiss tear

V. Others: AVM, Dielafoy syndrome

AETIOLOGYUPPER GASTROINTESTINAL BLEEDING

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PEPTIC ULCER DISEASE

ESOPHAGEAL VARICES

CARCINOMA STOMACH,

ESOPHAGUS

Managementstep-wise management of patients with upper gastrointestinal

bleeding

GENERAL MANAGEMENTUPPER GASTROINTESTINAL BLEEDING

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In addition…• Stop any aspirin, NSAID, anticoagulant, B-blockers

• Tranexamic acid

• IV Pantoprazole 80 mg bolus, 8 mg/hour continuous infusion for 72 hours

• Suspected oesophageal varices: vasoconstrictors till bleed dealt with endoscopy, gastric lavage with large (32 F) NG tube for better visualization

• IV Terlipressin 2 mg 6th hourly or

• S/C sandostatin 50-100 micrograms BD

SPECIFIC MANAGEMENTUPPER GASTROINTESTINAL BLEEDING

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In acute UGIB:

• emergency endoscopy (within 24 hours)

For bleeding PUD;

• if Forest grade I, IIa and IIb proceed with endoscopic therapy, CLO test

3 modalities (choose 2):

• Adrenaline (1:10000) 15-30 ml

OGDS ELECTROCOAGULATION

HEMOCLIP

DEFINITIVE MANAGEMENTUPPER GASTROINTESTINAL BLEEDING

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If endoscopic therapy fail…

Laparotomy and under-running of bleed gastric or duodenal ulcer with silk suture

DEFINITIVE MANAGEMENT

Duodenal ulcer: truncal vagotomy + (pyloroplasty or post. gastrojujenostomy or antrectomy)Gastric ulcer: truncal vagotomy + pyloroplasty, highly selective vagotomy, partial gastrectomy

FOR ESOPHAGEAL VARICESUPPER GASTROINTESTINAL BLEEDING

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ENDOSCOPIC BAND LIGATION ENDOSCOPIC INJECTION SCLEROTHERAPY

PREFERED IN EMERGENCY

If EBL and EIS not feasible or fail…UPPER GASTROINTESTINAL BLEEDING

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SANGSTAKEN BLAKEMOORE TUBE

Open surgery: if bleeding cannot be manage by endoscopy

• Emergency open surgery: devascularization

• Shunt surgery: porto-caval shunt, spleno-renal shunt

• TIPS

Others:

• Therapy to prevent or reduce hepatic encephalopathy

Oral neomycin 1 g QID

Oral lactulose 100g/day in divided doses, high enema

IV vitamin K 10 mg

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By Aminurulamirah and Atiqah Zayed

LOWERGASTROINTESTINALBLEEDING

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AETIOLOGY• IBD

•Colitis (amoebic colitis, typhoid)

Inflammatory

•Benign : Intestinal Polyps

•Malignant : Colorectal CANeoplastic

• Iatrogenic : post-endoscopyTraumatic

•Vascular: angiodysplasi, hemorrhoids, ischaemic colitis.

•Anal fissure

•Diverticulum :bleeding diverticulosis/meckels

•Drugs: Anticoagulant

•Radiation : Colitis

Misc

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Lower Gastrointestinal Bleed Classification

TYPES OF LGIB

WHO WE ARE

BEST SERVICE OF US

GOOD VISION

VERY USEFUL TIMELINE

EXCELLENT DIAGRAM

CONTACT US

Minor Hemorrhage

Major Hemorrhage Occult Bleed

Hemorrhoids Bleeding diverticulosis Polyps

IBD Angiodysplasia Colorectal CA

Colorectal Polyps Dieulafoy lesion of intestines

Intussusception Ischaemic cholitis

Meckel’s Diverticulum

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Schematic Presentation of

approach in LGIB

A schematic representation of proper workflow

approach towards lower GI bleed.

CP Presentation 22

•Most of LGIB are chronic cases.•Acute LGIB : 20% of GI bleed cases

Management of Acute LGIB

Resuscitation and initial assessment

Localization of the bleeding site

Therapeutic intervention to stop bleeding at the site

CP Presentation 23

Immediate Mx

i. 02, NG tube, IV fluids, CBD, CVP

ii. Correct metabolic acidosis

iii.Blood transfusioan (p.RBC,platelets, FFP)

iv.Administer hemostatic adjunct

v. IVG : all baseline IVG

ABC Protocol

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Usually LGIB source difficult to identify

Localizationof the cause

• 99mTC radionuclide/ scintigraphy• Digital Subtraction Angiogram• Arteriogram of I.M.A • Emergency colonoscopy • Unstable patient subjected to urgent laparotomy

If actively bleed vessel is identified:

Therapeutic interventions to stop bleeding at the site

Vasopressin injected = vasospasm

Injection of 1:20000 adrenaline into 4 quadrants of bleeding (bleeding diverticulum)

Laparotomy

Embolization with metal microcoil or PVA. (life-saving but need interventional radiologist)

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Management for Non-urgent Cases

Baseline blood IVG

Stools for occult blood

Endoscopy

ImagingDouble contract barium enema, CT, angiography

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referencesI. Website: gi.org/wp-content/uploads/2016/03/ACGGuideline-Acute-Lower-GI-

Bleeding-03012016.pdf

II. Website: emedicine.medscape.com/article/188478-treatment#d14

III. Manipal Manualof Surgery

IV. Clinical Companion in Surgery

●Can be detected on dipstick or FEME

●Red Blood Cell (RBC): >3 /hpf

Non-visible haematuria / dipstick-positive

CLASSIFICATIONS

Visible haematuria or gross haematuria

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CAUSES OF HAEMATURIA

Infective: Urinary infection

Non-infective: Interstitial cystitis, glomerulonephritis, pyelonephritis

Direct: Blunt/ penetrating trauma

Iatrogenic: Instrumentation/ catheterisation

Benign: Benign prostatic hyperplasia

Malignant: Renal cell carcinoma, transitional cell carcinoma of renal pelvis, ureter and bladder, carcinoma of prostate

Urinary calculi

Strenous exercise, Haemoglobinuria

Autoimmune (SLE)

Anticoagulant (Warfarin), blood thinner (Aspirin)

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• History

Pain

Blood at which stage of micturation

Ability to pass urine

Clots?

Symptoms of UTI

Bleeding disorder/ on anti-coagulant

History of trauma

Other causes of discoloured urine: beetroot, Nitrofurantoin

In Emergency Department:

• Resuscitate:

Volume replacement

Correct coagulopathy

Hemostasis

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• Baseline investigations

Blood: FBC, BUSE, coagulation profile, Bloog grouping & crossmatch

Urine: Dipstick, C&S

Imaging: X-ray KUB

In Emergency Department:

• Indications for admission:

Clot retention

Heavy hematuria

CVS instability

Uncontrolled pain

Sepsis

Acute renal failure

Coagulopathy

Severe comorbidities

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In Ward

LABORATORY

• Urine FEME

IMAGING

USG KUBIntravenous urogramCT scanMRI scan Radioactive scan

OTHERS• Cystoscopy— biospy and HPE• Ureterorenoscopy—Brushing

and cytology

Except in a case of haematuriafollowing instrumentation…

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Consist of two main components

Medical expulsive therapy (MET)

•Drink lots of fluids (>1.2 L)•Diuretic•Antispasmotic, alpha blocker,

CCB— Relax ureteric smooth muscles

Surgical

•Upper 1/3: Push and bang methodI. Cystoscopy—> pass a stent (Pigtail/

Double J stent)—> ESWLII. Prevent damage to bones.

•Middle 1/3 & Lower 1/3:I. By dormia basket or lithotripsy

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LithotripsyPigtail stentDormia basketDouble J stentESWL

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●Urethroscopy + lithotrypsy●Surgery (urethrolithotomy)

Lithotrite instrument (hendrickson lithotrite)

●ESWL●Cystoscopy and lithotrite (instrument used to

crush stone)●Cystoscopy and lithotripsy (electrohydraulic/

laser lithotrypsy)

Medical•Alpha blocker (Prazosin, Terazosin, Doxazosin

5mg ON): relax smooth muscle of bladder neck and prostate

•5-alpha reductase inhibitor (Finasteride 5 mg): reduce epithelial layer in prostate glands

Surgery

•TURP (gold standard)

•Depends on staging•Cancer not involving muscle Transurethral resection of tumour+ post-op

intravesical chemotherapy (Thiotepa/ Adriamycin/ Mitomycin)

•T2-T4 Radical cystectomy •Any nodes/ metastasis systemic radiation •Small lesion: Partial cystectomy + intravesical

chemotherapy.

•Mainly surgery, respond poorly to chemotherapy or radiotherapy. •Surgery

I. Nephron sparing surgery (T1)II. Radical nephrectomy

•Targeted therapyI. VEGF inhibitorII. ImmunotherapyIII. Interleukin-2

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EtiologySpecific Management

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Etiology

Haemoptysis is the coughing of blood from a source below theglottis. [1]

Common causes:

1. Tuberculosis (most common in southeast Asia)

2. ****Lung cancer - most common in age > 60 years.old ( bronchogenic ca)3. Pneumonia,4. Acute and chronic bronchitis 5. Bronchiectasis.

massive bleeding with life-threatening consequences

Small amount of blood-streaked sputum

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Approach to Hemoptysis

To differentiate haemetemesis /pseudo-hemoptysis /haemoptysis

Volume (in 24 hours) ●mild (15-30ml ) ● frank (>15 <600 ml) ●massive (>600 ml)

History and examination

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Specific for Lung Cancer ...

Chest x ray - to locate site of bleeding

Investigations for diagnosis:

doubt ?Flexible Bronchoscopy (4% to 22% discovered bronchogenic ca) 86% can detect site of bleeding with/ without CT thorax

Bronchoscopy sampling procedures involved several techniques including bronchial washing (BW), bronchial brushing (BB), broncho-alveolar lavage (BAL), transbronchial biopsy (TBB) and endobronchial biopsy (EBB).

* visible tumours. : BW > EBB > BB* not visible by bronchoscopy : BAL > BB > followed by TBB.

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Management

STAGE MANAGEMENT

Clinical stage I or II non-small cell lung cancer (NSCLC) Curative Surgical Resection

Stage IIIA NSCLC , T1-3 primary tumors Combined modality treatment approach

Unresectable stage IIIB NSCLC due to T4 primary tumours, N2-3

Platinum-based doublet chemotherapy (gemcitabine, paclitaxel, or vinorelbine) + -Radiotherapy

Stage IIIB disease due to the presence of a malignant pleural or pericardial effusion

Platinum-based doublet chemotherapy alone

Stage IV disease - good performance status - Poor performance

Platinum-based doublet chemotherapy or single agent chemotherapy

Supportive care

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Thank you

Reference:

The causes of haemoptysis in Malaysian patients aged over 60 and the diagnostic yield of different

investigations - Published article by Catherine Mee-Ming WONG,Kim Hatt LIM,Chong-Kin LIAM