common surgical presentations phil polson urology registrar clinical teaching fellow

49
Common Surgical Common Surgical Presentations Presentations Phil Polson Phil Polson Urology Registrar Urology Registrar Clinical Teaching Fellow Clinical Teaching Fellow

Upload: walter-gilbert

Post on 26-Dec-2015

230 views

Category:

Documents


4 download

TRANSCRIPT

Page 1: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Common Surgical Common Surgical PresentationsPresentations

Phil PolsonPhil Polson

Urology RegistrarUrology Registrar

Clinical Teaching FellowClinical Teaching Fellow

Page 2: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

IntroductionIntroduction

Abdominal PainAbdominal Pain Abdominal PainAbdominal Pain Abdominal PainAbdominal Pain Abdominal PainAbdominal Pain BleedingBleeding Leg PainLeg Pain Leg PainLeg Pain

General SurgeryGeneral Surgery UrologyUrology VascularVascular TraumaTrauma T&OT&O

Page 3: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

The AbdomenThe Abdomen

Page 4: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

The AbdomenThe Abdomen

Page 5: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

RUQ painRUQ pain

Biliary colicBiliary colic Acute cholecystitisAcute cholecystitis CholangitisCholangitis Acute HepatitisAcute Hepatitis HepatomegalyHepatomegaly PneumoniaPneumonia

Page 6: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Acute CholecystitisAcute Cholecystitis

Murphy’s SignMurphy’s Sign

Page 7: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Acute CholecystitisAcute Cholecystitis

InvestigationsInvestigations• BloodsBloods• eCXReCXR• USSUSS• MRCPMRCP

ManagementManagement• AnalgesiaAnalgesia• IV fluidsIV fluids• AntibioticsAntibiotics• ERCP +/- ERCP +/-

sphincterotomysphincterotomy• CholecystectomyCholecystectomy

Page 8: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

CholangitisCholangitis

Features:Features:• Charcot’s Triad (60%)Charcot’s Triad (60%)

1) Fever and rigors1) Fever and rigors 2) RUQ pain2) RUQ pain 3) Jaundice3) Jaundice ShockShock Altered consciousnessAltered consciousness

Page 9: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

CholangitisCholangitis

InvestigationsInvestigations• BloodsBloods• USSUSS

ManagementManagement• ResuscitationResuscitation• AntibioticsAntibiotics• HDU/ITUHDU/ITU• ERCP / Percutaneous drainageERCP / Percutaneous drainage

Page 10: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

ERCPERCP

Page 11: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Epigastric PainEpigastric Pain

All RUQ pain All RUQ pain Perforated ulcerPerforated ulcer PancreatitisPancreatitis

• AcuteAcute• ChronicChronic

DyspepsiaDyspepsia

Page 12: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Perforated gastro-duodenal ulcerPerforated gastro-duodenal ulcer

Causes:Causes:• H. pyloriH. pylori• DrugsDrugs• AlcoholAlcohol• Physiological stressPhysiological stress• MalignancyMalignancy

Presentation:Presentation:• Sudden, severe Sudden, severe

painpain• Shoulder painShoulder pain• Rebound Rebound

tendernesstenderness• RigidityRigidity• Shock / SepsisShock / Sepsis

Page 13: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Perforated UlcerPerforated Ulcer

Investigations:Investigations:• eCXReCXR• BloodsBloods• CTCT

Management:Management:• ResuscitationResuscitation• NGNG• AnalgesiaAnalgesia• AntibioticsAntibiotics• PPIPPI• Surgery – upper Surgery – upper

midline laparotomymidline laparotomy

Page 14: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Acute PancreatitisAcute Pancreatitis Middle-aged menMiddle-aged men

CausesCauses• GallstonesGallstones• AlcoholAlcohol

Presentation:Presentation:• PainPain• Nausea/VomitingNausea/Vomiting• PeritonismPeritonism• ShockShock

Investigations:Investigations:• AmylaseAmylase• PANCREASPANCREAS

pO2 (<8kPa)pO2 (<8kPa) Age (>55)Age (>55) Neutrophils (WCC > Neutrophils (WCC >

15)15) Calcium (<2)Calcium (<2) uRea (>16)uRea (>16) Enzymes – Enzymes –

AST/ALT/LDHAST/ALT/LDH Albumin (<32)Albumin (<32) Sugar (>10)Sugar (>10)

• eCXReCXR• USSUSS• CTCT

Page 15: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Acute PancreatitisAcute Pancreatitis

ManagementManagement• ResuscitateResuscitate• Fluid +++Fluid +++• AnalgesiaAnalgesia

Page 16: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

LUQ painLUQ pain

Gastric ulcerGastric ulcer Splenic injurySplenic injury PneumoniaPneumonia PericarditisPericarditis

Page 17: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

RIF painRIF pain

AppendicitisAppendicitis Inflammatory bowel diseaseInflammatory bowel disease Testicular torsionTesticular torsion Renal colicRenal colic PerforationPerforation HerniaHernia Psoas abscessPsoas abscess GynaecologicalGynaecological

Page 18: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Acute AppendicitisAcute Appendicitis

22ndnd/3/3rdrd decades decades PresentationPresentation• Central Central RIF pain RIF pain• Off food, N&VOff food, N&V• Low grade feverLow grade fever• PeritonismPeritonism• DiarrhoeaDiarrhoea• Urinary frequencyUrinary frequency• Bent overBent over• RIF guardingRIF guarding• Rovsing’s SignRovsing’s Sign

Page 19: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Acute AppendicitisAcute Appendicitis InvestigationsInvestigations

• BloodsBloods• Urine dipUrine dip• (USS / CT)(USS / CT)

ManagementManagement• AnalgesiaAnalgesia• IV fluidsIV fluids• AntibioticsAntibiotics• AppendicectomyAppendicectomy• (Percutaneous drainage)(Percutaneous drainage)

Page 20: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Testicular TorsionTesticular Torsion

1 in 4000 males <25yrs old1 in 4000 males <25yrs old 90% of acutely painful scrotums (13-90% of acutely painful scrotums (13-

21yr olds)21yr olds)

History:History:• Sudden onset, severe, unilateral painSudden onset, severe, unilateral pain• Nausea/VomitingNausea/Vomiting• Scrotal swelling, erythema, warmthScrotal swelling, erythema, warmth• High, horizontal lieHigh, horizontal lie

Page 21: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Testicular TorsionTesticular Torsion

Management:Management:• Theatre immediatelyTheatre immediately

Page 22: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

LIF PainLIF Pain

DiverticulitisDiverticulitis PerforationPerforation Inflammatory bowel diseaseInflammatory bowel disease HerniaHernia Testicular TorsionTesticular Torsion Renal ColicRenal Colic Psoas abscessPsoas abscess GynaecologicalGynaecological

Page 23: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

DiverticulitisDiverticulitis

Diverticulosis = Pouches within bowel wallDiverticulosis = Pouches within bowel wall Diverticulitis = Inflammation of pouchesDiverticulitis = Inflammation of pouches

Presentation:Presentation:• LLQ pain and tendernessLLQ pain and tenderness• FeverFever• DiarrhoeaDiarrhoea• PR BleedPR Bleed

Page 24: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

DiverticulitisDiverticulitis

Investigations:Investigations:• BloodsBloods• CTCT• Colonoscopy?Colonoscopy?

Management:Management:• Low fibre dietLow fibre diet• AntibioticsAntibiotics• Surgery for Surgery for

complicationscomplications

Complications:Complications:• Bowel obstructionBowel obstruction• PeritonitisPeritonitis• AbscessAbscess• FistulaFistula• StricturesStrictures• BleedingBleeding

Page 25: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Renal ColicRenal Colic

One of most painful conditionsOne of most painful conditions Can be life threateningCan be life threatening

Presentation:Presentation:• Colicky pain – where?Colicky pain – where?• Nausea / VomitingNausea / Vomiting• Tender flank – otherwise normalTender flank – otherwise normal

Page 26: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Renal ColicRenal Colic

Investigations:Investigations:• Bloods inc Calcium / Bloods inc Calcium /

UrateUrate• Urine dipUrine dip• CT KUBCT KUB

Management:Management:• NSAIDNSAID• IVI / IV antibioticsIVI / IV antibiotics• ? Stent ? Stent • ? Nephrostomy? Nephrostomy

Other treatment Other treatment options:options:• ESWLESWL• PCNLPCNL• Ureteroscopy +/- Ureteroscopy +/-

LASER +/- basketLASER +/- basket

Size matters!Size matters!• <4mm 90% pass<4mm 90% pass• 4-5.9mm 50% pass4-5.9mm 50% pass• >6mm 20% pass>6mm 20% pass

Page 27: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Diffuse PainDiffuse Pain Acute PancreatitisAcute Pancreatitis Bowel obstructionBowel obstruction AAAAAA AppendicitisAppendicitis GastroenteritisGastroenteritis Inflammatory Bowel DiseaseInflammatory Bowel Disease IBSIBS Mesenteric ischaemiaMesenteric ischaemia PeritonitisPeritonitis Sickle-cell crisisSickle-cell crisis

Page 28: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Bowel ObstructionBowel Obstruction

Page 29: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Large vs. SmallLarge vs. Small

CausesCauses• CarcinomaCarcinoma• VolvulusVolvulus• Diverticular diseaseDiverticular disease• Pseudo-obstructionPseudo-obstruction

CausesCauses• AdhesionsAdhesions• HerniaHernia• MalignancyMalignancy

Page 30: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Large vs. SmallLarge vs. Small

Colicky painColicky pain Absolute constipationAbsolute constipation Vomit – ‘faeculent’Vomit – ‘faeculent’ Abdo distensionAbdo distension TenderTender ResonanceResonance Reduced bowel Reduced bowel

soundssounds Empty rectumEmpty rectum

Colicky painColicky pain Absolute constipationAbsolute constipation Vomit – food, bileVomit – food, bile Abdo distensionAbdo distension Visible peristalsisVisible peristalsis TenderTender ResonanceResonance High-pitch bowel High-pitch bowel

soundssounds Normal PRNormal PR

Page 31: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Large vs. Small - InvestigationsLarge vs. Small - Investigations

AXRAXR BloodsBloods CTCT

AXRAXR BloodsBloods Contrast study Contrast study

(gastrograffin)(gastrograffin) CTCT

Page 32: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Large vs. Small - TreatmentLarge vs. Small - Treatment

ResuscitationResuscitation Treat cause:Treat cause:

• Malignancy – Malignancy – SurgerySurgery

• Volvulus – Volvulus – decompressdecompress

Nutritional supportNutritional support

‘‘Drip & Suck’Drip & Suck’ SurgerySurgery Nutritional supportNutritional support

60-85% settle 60-85% settle spontaneouslyspontaneously

Page 33: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Mesenteric IschaemiaMesenteric Ischaemia

Risk factors:Risk factors:• AFAF• >50yrs>50yrs• PVDPVD

Presentation:Presentation:• Pain ‘out of Pain ‘out of

proportion’proportion’• Distension, nausea, Distension, nausea,

vomitingvomiting• PR bleedPR bleed

Investigations:Investigations:• BloodsBloods• ABGABG• eCXReCXR• ECGECG• CT with IV contrastCT with IV contrast• CT angiographyCT angiography

Page 34: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Mesenteric IschaemiaMesenteric Ischaemia

Management:Management:• OxygenOxygen• AnalgesiaAnalgesia• FluidsFluids• LaparotomyLaparotomy

Mortality = 45-80%Mortality = 45-80%

Page 35: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

OtherOther

AAAAAA Urinary retentionUrinary retention

Page 36: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Leaking Abdominal Aortic AnerysmLeaking Abdominal Aortic Anerysm

Kills 5000 a year.Kills 5000 a year. 7500 emergency operations a year.7500 emergency operations a year.

Presentation:Presentation:• Back/Abdo/Flank/Groin painBack/Abdo/Flank/Groin pain• Haemodynamically unstableHaemodynamically unstable• CollapseCollapse• 5% history of AAA5% history of AAA• Leg ischaemiaLeg ischaemia

Page 37: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Leaking AAALeaking AAA Investigations:Investigations:

• Bloods (X-match)Bloods (X-match)• ?CT?CT

Management:Management:• ResuscitationResuscitation• Surgery – open vs. EVARSurgery – open vs. EVAR

Prognosis:Prognosis:• 50% die before hospital50% die before hospital• 50% of those who make it to hospital will die 50% of those who make it to hospital will die

whilst inpatient.whilst inpatient.

Page 38: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Urinary RetentionUrinary Retention

Acute vs ChronicAcute vs Chronic Causes:Causes:

• BPHBPH• Prostate cancerProstate cancer• Urethral stricturesUrethral strictures• Post-opPost-op• ClotsClots• DrugsDrugs• StonesStones• PhimosisPhimosis

Page 39: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Urinary RetentionUrinary Retention

PresentationPresentation• Suprapubic painSuprapubic pain• Can’t wee!Can’t wee!• LUTSLUTS• Suprapubic massSuprapubic mass• Dull to percussDull to percuss• DREDRE• Neuro assessmentNeuro assessment

InvestigationsInvestigations• BloodsBloods• USSUSS• CSUCSU• ? PSA? PSA

Page 40: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Urinary retentionUrinary retention

Management:Management:• Catheter (Residual volume)Catheter (Residual volume)• Observe for diuresisObserve for diuresis• ? Tamsulosin? Tamsulosin• TWOC vs LTC vs TURPTWOC vs LTC vs TURP

Page 41: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

BleedingBleeding

Page 42: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

GI BleedingGI Bleeding

Upper GI = MedicalUpper GI = Medical Lower GI = SurgicalLower GI = Surgical

Presentation:Presentation:• Bright red bloodBright red blood• Dark clotted bloodDark clotted blood• ? Pain? Pain• ? Change in bowel habit? Change in bowel habit• PR EXAM ESSENTIALPR EXAM ESSENTIAL

Page 43: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Lower GI BleedingLower GI Bleeding

Causes:Causes:• Diverticular disease Diverticular disease

60%60%• Inflammatory bowel Inflammatory bowel

disease 13%disease 13%• Colorectal cancerColorectal cancer• Infective colitisInfective colitis• Post-opPost-op

Management:Management:• ResuscitationResuscitation• BloodsBloods• Rigid Rigid

sigmoidoscopysigmoidoscopy• ColonoscopyColonoscopy• AngiographyAngiography

Page 44: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

Lower GI BleedingLower GI Bleeding

Surgery:Surgery:• Persistent bleeding / shockPersistent bleeding / shock• >6 units transfused>6 units transfused

Mortality = 2-4%Mortality = 2-4% Rebleeding = 14-38%Rebleeding = 14-38%

Page 45: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

HaematuriaHaematuria

Risk of clot retentionRisk of clot retention Visible vs Non-visibleVisible vs Non-visible History / ExaminationHistory / Examination Investigations:Investigations:

• BloodsBloods• MSUMSU• CT Urogram CT Urogram • USS / X-ray KUBUSS / X-ray KUB• Flexible cystoscopyFlexible cystoscopy

Page 46: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

HaematuriaHaematuria

Management:Management:• 3-way catheter3-way catheter• Bladder washouts +/- irrigationBladder washouts +/- irrigation• GA cystoscopyGA cystoscopy

Page 47: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

AbscessesAbscesses

PerianalPerianal Ischio-rectalIschio-rectal PilonidalPilonidal

AnalgesiaAnalgesia Surgical DrainageSurgical Drainage Pack woundPack wound

Page 48: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

OthersOthers

TraumaTrauma• #’s, abdominal#’s, abdominal

OrthopaedicsOrthopaedics• Septic arthritis, back painSeptic arthritis, back pain

UrologyUrology• Priapism, Paraphimosis, Epididymo-orchitisPriapism, Paraphimosis, Epididymo-orchitis

ENTENT• Epistaxis, foreign bodiesEpistaxis, foreign bodies

VascularVascular• Acute limb ischaemiaAcute limb ischaemia

Page 49: Common Surgical Presentations Phil Polson Urology Registrar Clinical Teaching Fellow

SummarySummary

Plus plenty of Plus plenty of others!others!

Any questions?Any questions?