CATASTROPHIC ABDOMINAL EMERGENCIES

O. N. M. Panton, MB, BS, FRCSC, FACS,Head, UBC Division of General Surgery,

VGH/UBCH

WHAT ARE ABDOMINAL CATASTROPHIES?

CATASTROPHIC EMERGENCIES HAEMORRHAGE SEPSIS

HAEMORRAHGE Upper GI Small Bowel Colorectal Solid organ

Massive UGI Bleed Gastric or duodenal ulcer Varices Mallory-Weiss tear Oesophageal ulcer

Oesophageal Bleeding Varices Mallory-Weiss tear Esophagitis/ulcer – acid reflux, infection Neoplasia Trauma

Gastric Bleeding Gastritis

Superficial Stress ulceration Mechanical

Gastric Bleeding Gastric Ulcer

Benign or malignant (10%)

Initial biopsy if safe Repeat OGD to assess

healing & repeat bx Benign: drug-induced,

hypersecretors +/- H. pylori infection

Duodenal Bleeding Duodenitis Benign ulcer Crohn’s Neoplasia Vascular Malformation Dieulafoy

Duodenal Bleeding Haemobilia Aortoduodenal fistula

Duodenal Bleeding Benign ulcer

May have all the same etiology as stomach

Major bleeding usually gastroduodenal artery

SB Haemorrhage accounts for 2-3% of GI bleeds

Jejunal diverticulosis

Meckel’s Diverticulum

CLINICAL SCENARIO MASSIVE UGI BLEED

32 year old male found at home in a pool of blood & still vomiting blood

VGH ER pulse140 BP 60/0 Hb 32 Massive resuscitation/transfusion protocol Codes x 2 in ER OGD bleeding ++++

UGI BLEED OR STAT laparotomy Codes shortly after laparotomy Duodenotomy/gastrotomy Watermelon stomach torrential

haemorrhage Blood gushing from duodenum Died on table

Colon Bleeding Angiodysplasia Diverticular disease Neoplasia: Adenocarcinoma, GIST’s Ischemia Hemmorhoids IBD Infection: Campylobacter, Shigella,

Salmonella, Enteropathogenic E. coli

LGI Bleed Acute bleeding occurs in 20-30

cases/100,000 annually 20-30% of GI bleeds

Angiodysplasia

Diverticulosis

Barium enema - diverticulosis

Lower gi bleed red cell scan

CLINICAL SCENARIO MASSIVE LGI BLEED

67 year old female found down at home in a pool of blood passed per rectum

VGH ER pulse 156 BP 50/0 Hb 36 Resuscitated/massive transfusion

protocol Previous LAR/TME rectal ca neoadjuvant

short course radiorx Leak/Hartmann

LGI BLEED STAT OR Pre-sacral ulcer communicating with

rectal stump Packed/controlled ICU plan for IR angio/embolization DIC ICU & died

SOLID ORGAN HAEMORRHAGE 56 year old male presents VGH ER

sudden (R) flank pain Pulse 148 BP 210/110 Hb 88 Resuscitated then STAT laparotomy (R) suprarenal ruptured tumour

SEPSIS Perforated appendicitis Colonic perforations Gasrtro-duonenal perforations Mesenteric ischaemia with infarcted gut Gangrenous cholecystitis Necrotizing pancreatitis Ascending cholangitis

INTRA-ABDOMINAL SEPSIS 47 male HIV + 24 hour hx severe

abdominal pain CT dx terminal ileitis Rx IV antibiotics GS consulted next night Temp 39 pulse 120 BP 115/68 Generalized peritonitis WBC 18 creatinine

110-169

SEPSIS DL RLQ abscess Laparotomy: gangrenous

appendicitis/faecolith Appendectomy & drainage of abscess