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