Emergency Abdominal Surgery
Emergency and acute abdominal pain is a very common condition that often leads to hospital admission. There are a variety of reasons that cause abdominal pain and lead to patients being admitted with a surgical problem. The most common situations are as follow:
Acute cholecystitis: is usually caused by stones in the gallbladder that lead to upper abdominal pain associated with nausea and vomiting and sometimes that leads to a temperature when the infection is established. In a situation like that there is a complication of stones in the gallbladder. The patient usually needs an emergency admission to the hospital and they will need a removal of the gallbladder which is done laparoscopically on the same admission. Untreated problems with cholecystitis, particularly in older people can lead to a variety of complications such as pancreatitis, formation of an abscess within or just outside the gallbladder and also stones can block the bile duct and there can be a variety of other unusual complications that can happen. Symptoms of the gallbladder that lead to pain will come back if left untreated, therefore an operation is highly recommended.
Acute appendicitis: is a very common surgical problem which is a sudden onset or slight gradually increasing abdominal pain in the central part of the abdomen associated with nausea. The patient might vomit once and then the pain usually moves to the right iliac fossa. It is a particularly common disease in young adults and adolescents and inflammation of the appendix is a common condition with no predisposing factors or dietary causes. Whenever the appendix becomes inflamed the patient will need to be admitted to the hospital and the appendix is usually removed via keyhole surgery.
Occasionally other abdominal emergencies and other causes of abdominal pain can lead to a pain similar to acute appendicitis and these conditions in particular are common to be confused with appendicitis. Conditions in young females such as mid cycle pain and a ruptured ovarian follicle or ruptured ovarian cyst are commonly confused as are a variety of other pelvis infections and inflammatory bowel disease. That also includes endometriosis.
Diagnosis of acute appendicitis is not 100% accurate and there will be about 30% of patients who are suspected to have appendicitis who will turn out to have a different pathology. The only definite test is to either a camera via keyhole into the abdomen or a CT scan. We don’t routinely perform a CT scan for young adults and children and on clinical suspicion of acute appendicitis we usually take them to theatre for a direct look with the camera and then the appendix will usually be removed. If there is alternative pathology that will be dealt with at the same time. Removal of the appendix is usually a straight forward operation from which the patient will recover quickly. They might spend a couple of nights in the hospital and they should be able to resume their usual duties or go back to school in a matter of about one week.
Peptic ulcers and their complications: Peptic ulcer disease is not a common disease anymore since the eradication of the responsible bacteria that was found to cause it. However, we do see ulcer disease and its complication for a variety of reasons. If you are taking Voltaren or Brufen for a long time you should ask you Doctor to get some medication to protect your stomach because the non steroidal anti inflammatory medications can lead to an ulcer that could perforate. A perforated ulcer usually manifests in the form of a sudden acute abdominal pain in the upper part of the abdomen and the patient will become quite unwell. The diagnosis of that is based on a clinical suspicion and usually on a CT scan to look for evidence of perforation. The treatment is an emergency operation to fix the ulcer. Usually the patient will recover quickly from that.
Bleeding from the gastrointestinal tract: You could be bleeding from the gastrointestinal tract which could manifest in the form of fresh blood per rectum or altered blood. Also, if there is bleeding from the upper part of the gastrointestinal tract which is the stomach and the duodenum it could manifest in the form of what is called haematemesis (vomiting of blood). Alternatively if there is a bleeding ulcer the patient could be passing tarry dark bowel motions which is called melena and that is because the blood gets altered by the digestive enzymes and the acid that gets secreted by the stomach to change the colour of the blood. If there is a suspicion of gastrointestinal bleeding usually the patient will be admitted to hospital. They might need a blood transfusion and very often they need an endoscopy for the upper and lower gastrointestinal tract (a gastroscopy and a colonoscopy).
Diverticulitis: is inflammation of pockets in the colon that is called diverticular and this is a very common problem in adult people. Almost 50% above the age of 5o might have some of these. They can get infected, particularly if the patient is constipated. They usually manifest in the form of lower abdominal pain more centered in the left side of the lower abdomen associated with feeling unwell and a temperature. The majority of these situations will settle down on antibiotics but the patient will be in the hospital for a few days for intravenous antibiotics and then they continue to have oral antibiotics at home until everything settles down. In a situation like that, usually the patient will require a colonoscopy in order to rule out other pathology, other than diverticular disease, particularly cancers and inflammatory bowel disease.
Complication of diverticular disease: although most cases settle down with antibiotics there can be a complication that might require emergency surgery or other forms of intervention. Emergency surgery is indicated for a patient who is unwell with perforated diverticulitis. In that situation the surgeon will remove the infected part of the colon and usually the patient will end up having a colostomy which in this situation is usually temporary and can be reversed after at least three months of full recovery.
Other forms of complication are formation of abscess in the vicinity of the diverticulitis and that abscess can often be drained under a CT scan guidance with local anaesthesia without the need for surgery.
Bowel obstruction: generally bowel obstruction is a common condition and when ever the patient is admitted to the hospital with bowel obstruction most of them will settle down without surgical intervention. Bowel obstruction can be divided into two categories; small bowel obstruction and large bowel obstruction. Large bowel obstruction is a more sinister situation and usually it is caused by cancers and whenever a large bowel obstruction is diagnosed the treatment is an emergency operation which might entail putting a colostomy on a temporary basis that can be reversed two to three months after recovery. The more common form of bowel obstruction is small bowel obstruction. Small bowel obstruction is related to adhesions that will occur in the abdominal cavity as a result of usually previous surgery. However, adhesions can happen as a result of previous inflammation like appendicitis and diverticulitis. Scar tissue can kink the small bowel and lead to bowel blockage which usually settles down without an operation. However, the patient will have to be in the hospital where a tube will be inserted in the stomach to decompress the gastrointestinal tract. Some patients will not resolve and they will need an operation and that will involve usually division of the adhesions and occasionally part of the small bowel will have to removed, usually a small part. In that situation it is very unlikely that the patient will need a stoma as the small bowel heals well and it can be joined together at the time of the operation. There are other causes for small bowel obstruction and these include hernias in the groin and ventral hernias or incisional hernias that happen as a result of previous abdominal operations and bowel obstruction from hernias is a surgical emergency that needs to be fixed with operative treatment, to fix the hernia, reduce the small bowel and occasionally the surgeon may need to remove part of the small bowel.
Other conditions that we treat as an emergency admission: are infections of the skin and subcutaneous tissues in the form of abscesses and cellulitis. That can be abscess formation any where in the body and also pilonidal abscess and acute perianal abscess which is a particular condition that is relatively common where there will be pain around the area of the anus associated with feeling unwell. In that case the patient needs to be admitted to the hospital and the abscess needs to be drained under a general anaesthesia. Usually the patient will go on some antibiotics and they recover pretty quickly.