493 LOW BACK PAIN Investigation Check T and urinalysis. X-ray is indicated for some patients aged > 55year s, or those who are systemically unwell, with a history of trauma (except clinical coccyx f racture), or where malignancy, infection, or HIV is suspected. In the latter cases, also ch eck C-reactive protein (CRP), FBC, U&E. Treatment Refer urgently patients with lower limb weakness, altered perineal or perianal se nsation, sphincter disturbance (this is strongly suggestive of cauda equina syndrome due to central lumbar disc prolapse). An MRI scan will con \201 rm this diagnosis \200\224 in w hich case, urgent consultation with a neurosurgeon will allow emergency surgical decompress ion to be planned as appropriate. Refer patients with the following: aged <20 or > 55years, unremitting or increasing symptom s, widespread neurological signs, weight loss, systemic illness, pyrexia, chronic corticost eroids, osteoporosis, or HIV + ve patients with thoracic pain. Treat simple \200\230mechanical \200\231 back pain with regular simple analgesia and/or NS AID. Avoid the routine use of opioids. Small doses of benzodiazepines (eg diazepam 2 \200 \2235mg tds) may be useful, but tend to cause drowsiness. Advise the patient to aim to retu rn to normal activity, even if some discomfort persists. Avoid bed rest. Expect recovery in 4 \200\2236weeks. Nerve root symptoms mostly resolve over weeks to months with the above t reatment, physiotherapy or manipulation. In all cases, give written and verbal advice for i mmediate return if limb weakness, numbness, bladder, or bowel problems occur. Advise follow -up with the GP. 494 CHAPTER 9 Wounds, fractures, orthopedics Acute arthritis 1 Approach Whenever a patient presents with a painful joint, try to disting uish whether the source of pain is articular or peri-articular. Painful joints of articular origin produce warmth, tenderness, and swelling about the entire joint, with painful movem ent in all directions. Pain of peri-articular origin (outside joint capsule), such as bursi tis/tendinitis tends to result in tender- ness and swelling localized to a small area, with pain on passive movement only felt in limited planes. Consider a septic cause in every patient who presents with acute arthritis. Useful investig ations include white blood cells (WBC), erythrocyte sedimentation rate (ESR), or CRP, and j oint aspiration. Joint aspiration The most important diagnostic test in patients presenting with acute arthr itis is examination of the synovial \202 uid. When joint aspiration is per- formed, ensur e that an aseptic technique is employed. Avoid joint aspira- tion through an area of cellul itis. Send \202 uid for Gram stain, culture, crystal examination, and cell count (Table 9 .4 ). Remember that the absence of bacteria on Gram staining does not exclude septic arthri tis. Table 9.4 Normal Reactive Infectious Color Colorless/pale yellow Yellow Yellow Turbidity Clear, slightly turbid Turbid Turbid, purulent Cell count/mm 200 \200\2231000 3000 \200\22310,000 > 10,000 Predominant cell type Mononuclear Neutrophil Neutrophil Gram stain None None + ve Culture \200\223ve \200\223ve + ve Causes of polyarthritis \200 Rheumatoid arthritis. \200 Ankylosing spondylitis. \200 Reiter \200\231s disease. \200 Psoriatic arthritis. \200 Arthritis associated with in \202 ammatory bowel disease. \200 Viral arthritis. \200 Rheumatic fever. \200 Gonococ cal arthritis. \200 Gout. 495 ACUTE ARTHRITIS 1 Septic arthritis Pyogenic infection usually reaches a joint via the bloodstream, but may al so develop from adjacent osteomyelitis or external skin puncture wounds. Sepsis may progres s to complete joint destruction within 24hr. Infective agents Staph aureus, Gonococcus, Strep, TB, Salmonella. Haemophilus was the commo nest organism in babies before Haemophilus immunization, but is now rare. There is an i inc idence in patients with rheumatoid arthritis, those taking steroids, the immunosuppressed a nd at the extremes of age. Do not overlook septic arthritis superimposed on a non-infectiou s joint (eg gout, rheumatoid joints). Presentation Typically only 1 joint is affected and is red, painful, and swollen. No moveme nt is usually tolerated (but steroids and analgesics can mask many of the common features o f septic arthritis). The joint is held in position of most comfort, usually slight \202 e xion. There may be fever, shaking, and rigors. Note that hip joint infection may not produc e obvious external \201 ndings due to its deep location. Do not overlook a septic joint w ith signs obscured by concomitant antibiotic use. IV drug abusers may have involvement of u ncommon joints of the axial skeleton (eg sacroiliac, vertebral, and sterno-clavicular joint s). Investigation FBC, ESR, or CRP, blood cultures, joint aspiration (see Table 9.4 ). X-rays m ay be initially normal or show only soft tissue swelling with displacement of capsular fat planes. Later, features of bone destruction occur. Treatment Commence IV antibiotics (eg \202 ucloxacillin + benzylpenicillin). Refer urgent ly to the orthopedic team for joint irrigation/drainage, analgesia, splintage of the joint. Note: Prosthetic joint infection can be dif \201 cult to detect, but pain is typically con stant and present at rest. Early infection (within 3 months of surgery) may cause obvious w ound in \202 ammation. This is less likely to be apparent in delayed or later infections. There may be little in the way of systemic symptoms. Suggestive radiological features inclu de widening and lucency of the bone-cement interface by > 2mm, movement of the prosthesis, periosteal reaction and fractures through the cement, although X-rays may be normal. Adopt a low threshold for suspecting prosthetic joint infections and referral to the orthopedic t eam. Traumatic arthritis Joint pain, tenderness, d range of movement and haemarthrosis after inj ury implies intra-articular fracture. Note, however, that septic arthritis may occur in ass ociation with trauma, even in the absence of penetrating injury. Osteoarthritis Elderly patients with known OA may suffer acute \200\230 \202 are ups \200 \231. Constitutional symptoms are not a feature. X-rays may show asymmetrical joint space n arrowing, osteophytes and subchondral cyst formation. Advise NSAID and/or paracetamol, plus graduated exercises. 496 CHAPTER 9 Wounds, fractures, orthopedics Acute arthritis 2 Acute gout Most often affects 1st MTPJ or knee. Precipitated by trauma, d iet, diuretics, renal failure, myeloproliferative disease and cytotoxics. Ask about previou s renal stones. Look for tophi. Joint aspiration reveals negatively birefringent crystals. Septic arthritis can occur with gout \200\224 ensure aspirates are Gram stained and cultur ed. X-rays initially show soft tissue swelling, later punched out lesions in peri-articular bone. Serum uric acid may be i , but can be normal in an attack. Treat with rest and NSAID (eg diclofenac 75mg bd) or if NSAID is contra-indicated, consider colchicine (500mcg bd in itially, slowly i to qds as needed to control symptoms, preferably with GP review). Do not alter treatment of patients already on long-term gout therapy. Note: oral steroids (eg pred nisolone 30mg od for 5 days) may help patients who are unable to tolerate NSAIDs or who are resistant to other treatments. Acute pseudogout Typically affects the knees, wrists, or hips of an elderly person with his tory of arthritic attacks precipitated by illness, surgery, or trauma. Associated with: hyp erparathyroidism, haemochromatosis, Wilson \200\231s disease, hypothy- roidism, diabetes, h ypophosphatemia. X-ray shows calci \201 cation in joint, menisci, tendon insertions, ligam ents, bursae. Aspiration reveals weakly + ve birefringent crystals on polarizing microscopy . Treat symptomatically (with NSAID) and refer. Rheumatoid arthritis Presentation Persistent symmetrical deforming peripheral arthropathy t ypically starts with swollen, painful, stiff hands and feet, which gradually get worse, wit h larger joints becoming involved. Other modes of presen- tation are: persistent or relapsi ng monoarthritis of different large joints, systemic illness with minimal joint problems, s udden onset widespread arthritis, vague limb girdle aches. Hand signs include MCPJ and PIPJ swelling, ulnar deviation and volar subluxation at MCPJs, boutonni re, and \200\230swan- neck \200\231 \201 nger deformities. Extensor tendon rupture may occur. Neck problems Deg eneration of the transverse ligament of the dens carries the risk of subluxation and cord d amage. Extra-articular features SC nodules, vasculitis, pulmonary \201 brosis, splenomega ly, anemia, pleurisy, pericarditis, scleritis, kerato-conjunctivitis. Rhematoid factor is + ve in 70 % of cases. X-rays show soft tissue swelling, peri-articular osteoporosis, joint space narrowing, bony erosions/subluxation. Treatment Refer patients who are systemically u nwell. Others may bene \201 t from NSAID, splintage, and rheumatology clinic referral. Viral arthritis Rubella, hepatitis B, mumps, Epstein \200\223Barr virus, and enteroviruses may cause arthritis. In hepatitis B, arthritis usually affects PIPJ, MCPJ or knee and prece des the onset of jaundice. Rubella is associated with an acute symmetrical arthritis and te nosynovitis. 497 ACUTE ARTHRITIS 2 Rheumatic fever (see b p.672) This is a non-infectious immune disease which follows infecti on with Group A -haemolytic streptococci. Typically, a migratory or additive symmetrical polyarthritis affects the knees, ankles, elbows, and wrists. Diagnosis is based on revised Jones criteria: evidence of previous streptococcal infection (ie recent scarlet fever, + v e throat swab, or anti- streptolysin titre > 200U/mL) plus 2 major or 1 major plus 2 minor criteria. Major criteria: carditis (pericarditis, myocarditis or endocarditis), migratory p olyarthritis, chorea, SC nodules, rash (erythema marginatum). Minor criteria: i ESR/CRP, ar thralgia, fever, history of previous rheumatic fever (or rheumatic heart disease), i PR int erval on ECG. Investigations: Throat swab, ESR, CRP, and anti-streptolysin titre. Treatment Refer for admission, rest, aspirin, benzyl penicillin, and splintage. Sero-negative spondyloarthropathies These have the following common features: involvement o f the spine and sacroiliac joints, in \202 ammation then calci \201 cation of bony tendon insertions, peripheral in \202 ammatory arthropathy, and extra-articular manifestations s uch as uveitis, aortic regurgitation, and pulmonary \201 brosis. Ankylosing spondylitis Usually presents with chronic low back pain in men aged 15 \200\2233 0 years. Progressive spinal fusion ultimately results in a \201 xed kyphotic spine (which is particularly prone to fracture after injury), hyper \202 exed neck, and restricted res piration. Hips, shoulders, and knees may be involved. Other features are: iritis, apical lu ng \201 brosis, plantar fasciitis, and Achilles tendonitis. There may be normochromic ane mia and i ESR. X-rays show \200\230bamboo spine \200\231 (squared vertebrae), eroded apoph yseal joints and obliterated sacro-iliac joints. Reiter \200\231s syndrome Triad of urethritis, conjunctivitis and sero-negative arthritis m ay follow infection (urethritis, cervicitis, or dysentery). May cause large joint monoarthr itis of a WB leg joint. Other features: iritis, keratoderma blenorrhagicum, circinate balan itis, plantar fasciitis, Achilles tendonitis, aortic incompetence. Joint aspirate yields in \202 ammatory cells, with \200\223ve culture. WCC and ESR are i . Psoriatic arthritis Arthritis rarely precedes skin involvement. Enteropathic arthropathies In \202 ammatory bowel disease is associated with spondyloarthr itis and large joint mono-arthropathy. There may also be a migratory polyarthritis. Gonococcal arthritis May present with fever, migratory tenosynovitis and polyarthralgia, ar thritis (knee, ankle or wrist) and skin rash. Genital infection may be silent, especially i n women. Take swabs with special culture media and refer for investigation. 498 CHAPTER 9 Wounds, fractures, orthopedics Eponymous fractures Correctly applied, the one or two words that comprise an eponymous inju ry convey succinctly an otherwise involved description of a complex fracture. Aviator \200\231s astragalus Fractures of the neck of the talus, previously commonly observ ed amongst World War II pilots who crash-landed their damaged planes on returning from bomb ing raids. The injuries resulted from the upward thrust of the rudder bar, causing dorsi \202 exion forcing the talus against the anterior tibia. Bankart lesion Avulsion of the joint capsule and glenoid labrum resulting from anterior dis location of the shoulder joint. It is implicated as a causative factor for recurrent disloc ations. Barton \200\231s fracture First described by Barton in 1839, this complex distal radial fra cture is intra-articular. Displacement of the distal radial fragment allows subluxa- tion o f the carpal bones. A rare variety is called a Lentenneur \200\231s fracture. Bennett \200\231s fracture dislocation These intra-articular fractures of the base of the \201 rst MC are notorious for allowing the main MC fragment to slip into a poor position. If conserv- ative treatment (POP) is preferred to internal \201 xation, careful follow-up will be needed to ensure a satisfactory outcome. Boutonni re deformity Rupture of the central slip of the extensor tendon at the PIPJ allow s the base of the middle phalanx to \200\230button-hole \200\231 through. The remaining tw o parts of the extensor expansion slip along the side of the \201 nger and act as \202 exors at the PIPJ, whilst still extending the DIPJ. This produces the characteristic deform ity. Boxer \200\231s fracture Fracture of the neck of the little \201 nger MC rarely occurs du ring formal boxing when gloves are worn. It is much more commonly seen following impromptu street or bar-room brawls: innocuous-looking overlying wounds are often compound human ( \200\230reverse \201 ght \200\231) bites ( b Speci \201 c bites and stings, p.416). Bumper fracture The height of the average car bumper renders the adult pedestrian (who is u nfortunate enough to be knocked down) particularly vulnerable to a fracture through the lat eral tibial condyle into the tibial plateau. There is often an associated tear to the media l collateral knee ligament. Chance fracture A horizontal fracture through a vertebral body, associated arch, and spinou s process may result from an injury involving distraction and \202 exion. It typically in volves the lumbar spine of car passengers restrained only by a lap belt in a road traf \201 c collision. 499 EPONYMOUS FRACTURES Clay-shoveller \200\231s fracture Resistance against neck \202 exion may produce an avuls ion of the tip of a spinous process of the lower cervical or upper thoracic spine. The lesi on typically affects C7. Colles \200\231 fracture Abraham Colles, Professor of Surgery in Dublin, described this com mon distal radial fracture in 1814. The classic dinner fork deformity results from posterio r displacement and angulation of the distal fragment ( b p.444). Dashboard dislocation A high speed head-on road traf \201 c collision causing the dashboar d to impact upon the \202 exed knee often results in posterior dislocation of the hip. Dupuytren \200\231s fracture-dislocation A highly unstable ankle injury in which there is a fracture of the distal \201 bula shaft, disruption of the medial ankle ligament and post erior tibio- \201 bular ligament. The result is gross diastasis and dislocation of the ta lus laterally. Essex \200\223Lopresti fracture-dislocation A heavy fall on the outstretched hand may cause a comminuted fracture of the radial head. It is associated with tearing of the interosseou s membrane (diastasis), allowing subluxation of the distal ulna. Galeazzi fracture-dislocation Describes the combination of a fracture of the distal radial shaft with dis- location of the distal radio-ulnar joint ( b Forearm fractures and related injury, p.448). A Moore \200\231s fracture dislocation is a similar injury, except that the radial fracture involves the distal radius, not the shaft. Gamekeeper \200\231s thumb Rupture of the ulnar collateral ligament of the 1st MCPJ was ori ginally described as an occupational injury amongst gamekeepers, sustained whilst breaking the necks of wounded rabbits. It is now most commonly seen as a result of skiing injuries, particularly on arti \201 cial slopes, when the thumb is caught in the diamond latticework matting. The injury requires prompt diagnosis and treatment in order to avoid the long-ter m complication of a weak pinch-grip. Hangman \200\231s fracture Although no longer a part of modern life in the UK, executions w ere pre- viously achieved by hanging. The victim was allowed to fall several feet before be ing arrested by a noose. This produced rapid death from sever- ance of the cervical spinal cord. The mechanism of injury is a combina- tion of distraction and extension, causing an u nstable (hangman \200\231s) fracture of the pedicles of the axis (C2), and disrupting the i ntervertebral disc between C2 and C3. The fracture may also result from extension and axial compression and may occur without neurological damage. 500 CHAPTER 9 Wounds, fractures, orthopedics Hill \200\223Sachs lesion This is an impacted compression fracture of the humeral head, whi ch occurs during anterior shoulder dislocation. It is produced by the recoil impaction of t he humeral head against the rim of the glenoid as the former dislocates. It is believed by some to be an important causative factor for recurrent dislocation. Horse rider \200\231s knee Frontal impact at the level of the proximal tibio- \201 bular j oint may result in pos- terior dislocation of the \201 bular head. Reduction usually requ ires an MUA. Hume fracture-dislocation This refers to the combination of an olecranon fracture with disl ocation of the radial head. Hutchinson fracture Also referred to as a \200\230chauffeur \200\231 fracture, this is the name sometimes given to a fracture of the radial styloid. It is classically caused by forc ed radial deviation of the wrist when the starting handle of an old-fashioned motor car \200\230kicks back \200\231. Ice skater \200\231s fracture Children aged 2 \200\2238years are susceptible to stress frac tures of the distal \201 bula. Jefferson fracture An unstable \200\230blowout \200\231 fracture of C1 follows an axial lo ad. One third are associated with a C2 fracture. Jones fracture This is a transverse fracture of the base of the 5th MT just distal to the i ntermetatarsal joint. It is a more signi \201 cant injury than an avulsion fracture at the insertion of peroneus brevis, as it is prone to non-union ( b Foot fractures and dislocati ons, p.489). Le Fort facial fractures Experiments by Le Fort in 1901 were followed by descriptions of fa cial fractures and classi \201 cation into three anatomical types ( b Middle third facial fractures, p.372), including the Gu rin fracture (Le Fort I). Lisfranc fracture-dislocation Fracture dislocation at the tarso-metatarsal joint is a signi \201 cant injury. It is named after the surgeon who described the surgical operation of p artial amputation of the foot at the level of the tarso-metatarsal joint. Luxatio erecta First described in 1859, this is an uncommon shoulder dislocation (inferior glenohumeral dislocation). The term is derived from Latin and describes the erect hyperabdu cted position of the arm after dislocation. The injury follows a hyperabduction force, most often after a fall. Axillary nerve damage occurs in 60 % . Reduction of the dislocation ma y follow overhead traction or conversion to an anterior dislocation to which conventional t echniques can be applied. 501 EPONYMOUS FRACTURES Maisonneuve injury An unstable injury in which rupture of the medial ankle ligament is asso ci- ated with a diastasis and proximal \201 bula fracture. Malgaigne \200\231s fracture An unstable injury in which the pelvic ring is disrupted in tw o places: anteriorly (through both pubic rami) and posteriorly (sacroiliac joint disruption , or fracture of ilium or sacrum). Mallet injury Stubbing a \201 nger may rupture the extensor tendon (or avulse its phalan- geal attachment) at the DIPJ, causing a \200\230mallet deformity \200\231, in which the D IPJ is held \202 exed. The mechanism of injury is forced \202 exion of the extended DIP J. March fracture This refers to a stress fracture of the (usually 2nd) MT shaft after stren- uous and unaccustomed exercise. Traditionally, it was observed after heavy marching in new army recruits. Monteggia fracture-dislocation Fracture of the proximal ulna shaft is associated with dislo cation of the radial head. The latter is relatively easy to miss. Never accept an ulna frac ture as an isolated injury without obtaining complete views of both forearm bones, includin g the elbow and wrist joints. Nursemaid \200\231s elbow Alternative name for a \200\230pulled elbow \200\231 in a pre-sc hool child ( b p.724). Nutcracker fracture Lateral force applied to the forefoot may cause the cuboid to be fractu red as it is compressed between the calcaneum and the base of the 4th and 5th MTs. O \200\231Donahue \200\231s triad A torn medial meniscus, ruptured anterior cruciate ligame nt and ruptured medial collateral ligament combine to produce a signi \201 cant knee injur y. Pelligrini \200\223Stieda \200\231s disease Ossi \201 cation of the medial collateral knee ligament may follow avulsion of the super \201 cial part from its attachment to the media l femoral condyle. Pilon fracture These intra-articular fractures of the distal tibia are uncommon, but may al so be subdivided into three types. Pipkin fracture-dislocation This refers to a posterior hip dislocation in which part of the femoral head is avulsed by the ligamentum teres and remains attached to it within the acet abulum. The avulsed fragment is rarely large enough to be reattached. 502 CHAPTER 9 Wounds, fractures, orthopedics Pott \200\231s fracture This term has come to be applied indiscriminately to any ankle frac ture, which may be simply subdivided into \200\230uni- \200\231, \200\230bi- \200\231, or \200\230tri-malleolar \200\231. Rolando fracture Essentially a comminuted Bennett \200\231s fracture, the classic descripti on is of Y shaped intra-articular fractures at the base of the 1st MC. Treatment is dif \201 cult. Runner \200\231s fracture Stress fractures of the tibia are particularly common amongst run ners who chalk up many miles of running on roads each week. Smith \200\231s fracture The so-called \200\230reversed Colles \200\231 fracture \200\231 was \201 rst described by Smith in 1847. Straddle fracture Falls astride classically produce bilateral vertical pubic rami fractures . Tillaux fracture An avulsion fracture of the distal lateral tibia may occur due to the pull of the anterior tibio- \201 bular ligament. Toddler \200\231s fracture Undisplaced spiral fractures of the tibial shaft in children <7 years often follow minimal trauma and not be visible on initial X-ray. Subperiosteal bone f ormation is usually apparent radiologically by 2 weeks (see b Pediatric lower limb injuries , p.727). 503 Chapter 10 Surgery Approach to abdominal pain Causes of acute abdominal pain Acute appendicitis Acute pancreat itis Biliary tract problems Peptic ulcer disease Intestinal obstruction Mesenteric ischaemi a/infarction Large bowel emergencies Anorectal problems Retention of urine Testicular probl ems Penile problems and prostatitis Ureteric colic Abscesses Cellulitis and erysipelas Comp lications of varicose veins Ruptured abdominal aortic aneurysm Acute limb ischaemia 504 506 507 508 510 511 512 514 516 518 520 522 523 524 526 528 529 530 531 504 CHAPTER 10 Surgery Approach to abdominal pain First aim to identify patients requiring resuscitation or urgent treatment. The need for resuscitation is apparent in emergencies with associated hypovolae mic and/or septic shock. Less obvious, but equally important, is recognition of patients re quiring urgent treatment with no clinical evidence of shock (especially ruptured abdominal aortic aneurysm). History The pain Determine details of site, radiation, shift, character, timing, precipitat ing, and relieving factors. Vomiting Record anorexia, nausea, and vomiting. Ask about the nature of vomit (blood, bile, etc.). Vomiting that follows the onset of abdominal pain tends to imply a surgical cause, whereas vomiting preceding pain is often non-surgical. Bowel disturbance Enquire about recent change of bowel habit, particularly any rectal bleed ing. Other symptoms Do not forget that abdominal pain may be due to urological, respiratory, car diovascular or gynecological disorders. Past history Determine the nature of previous surgery, preferably by obtaining old notes. Examination Vital signs Pulse, BP, respiratory rate, GCS, and T may indicate the need fo r immediate intervention. Abdomen Note distension and scars from previous surgery. Check the hernial ori \201 ces. P alpate gently for areas of tenderness. It is unnecessary and unkind to attempt to elicit re bound tenderness \200\224 tenderness on percussion is ample evidence of peritonitis. Perfo rm PR/PV examination. General Look for evidence of dehydration and jaundice. Examine the respiratory and cardiova scular systems. Investigations Assessment of patients with abdominal pain in the ED usually depends upon hi story and examination rather than sophisticated tests. However, the following investigation s may prove useful: \200 BMG: DKA may present with abdominal pain ( b Hyperglycaemic crises, p.152). Urinalysis : abdominal pain may result from urinary stones or infection. Perform a urine pregnancy test on all women of childbearing age. Blood tests : consider the need for FBC, U&E, amylase, coagulation screen, and cross-matchi ng. If clearly unwell, check ABG, and lactate. Although FBC is frequently requested in pati ents with abdominal pain, the awaited WCC rarely alters initial patient management. ECG : especially in patients aged > 55 years, who may be suffering from an atypical present ation of an acute medical problem, most notably acute myocardial infarction (MI). 505 APPROACH TO ABDOMINAL PAIN Chest X-ray : a CXR is useful to exclude conditions above the diaphragm, which may mimic ab dominal conditions (eg congestive heart failure, basal pneumonia). Abdominal X-ray : Speci \201 c indications for abdominal X-ray include suspicion of intest inal obstruction, toxic megacolon, sigmoid volvulus, GI perforation and urinary calculi ( b Ureteric colic, p.524). X-rays are not indicated in patients with suspected uncomplicated appendicitis, UTI, \200\230simple \200\231 constipation, gastroenteritis, GI bleeding, acu te pancreatitis. They are not \200\230routinely indicated \200\231 in the investigation of abdominal pain. In severely ill patients requiring imaging, CT or USS is usually more appr opriate than plain abdominal X-rays. USS : reveals gallstones, free peritoneal \202 uid, urinary stones and aortic aneurysms. It is increasingly used in the ED, but needs speci \201 c training. \200 CT scan may hav e a role in assisting with the diagnosis of certain conditions (eg acute appendicitis). Treatment Prompt resuscitation and provision of analgesia are integral components of the ma nagement of serious abdominal conditions. Ensure that patients who are very sick and/or hyp otensive receive early IV \202 uids and full monitoring (this includes measuring urinary output via a urinary catheter). Follow the guidelines outlined in b Severe sepsis and shock for patients with suspected sepsis, p.59. The traditional belief that analgesia should not be given because it might mask a serious d iagnosis is incorrect and cruel. Diagnosis is often easier when pain is relieved and the pa tient can give a better history and co-operate with examination. The most appropriate form of analgesia is usually IV opioid (eg morphine). It can be dif \201 cult to decide if admission is needed for a patient with abdominal pain . Adopt a low threshold for seeking senior help. In general, if doubt exists, refer to the surgeon, who may decide that it is prudent to admit the patient for observation and investi gation. Pitfalls \200 Steroids, NSAIDs, or obesity may render physical signs less obvious. \200 B -blockade may mask signs of shock. \200 Absence of fever does not exclude infection, e specially in the very old, the very ill, and the immunosuppressed. When severe abdominal pain is out of all proportion to the physical \201 ndings, consider mesenteric infarction, aortic rupture/dissection, acute pancreatitis, torsion of ovarian c yst. Splenic rupture may occur after relatively trivial trauma in patients with glandular fever or hematological disorders. Consider gynecological causes of abdominal pain in any woman of child-bearing age \200\224 always perform a pregnancy test. \200 WCC may be normal in es tablished peritonitis/sepsis. \200 Amylase may be normal in acute pancreatitis. Conversel y, moderate amylase i may occur in acute cholecystitis, perforated peptic ulcer, and mesent eric infarction. 506 CHAPTER 10 Surgery Causes of acute abdominal pain The cause of abdominal pain is often unclear initially. Inde ed, many patients get better without any de \201 nite cause being identi \201 ed ( \200 \230non-speci \201 c \200\231 abdominal pain). Remember also that a patient is much more l ikely to have a common condition (perhaps with an atypical presentation), rather than a ver y rare condition. Thus, a patient presenting with atypical abdom- inal pain is more likely to have acute appendicitis than tabes dorsalis, lead poisoning, or acute intermittent porph yria. The following conditions are seen relatively frequently: Surgical \200 Non-speci \201 c abdominal pain. \200 Acute appendicitis. \200 Cholecystitis and biliary colic. \200 Pancreatitis. \200 Peptic ulcer disease (including perforation). \200 Ruptured ab dominal aortic aneurysm. \200 Mesenteric infarction. \200 Diverticulitis. \200 Large bowel perforation. \200 Intestinal obstruction from various causes. \200 Ureteric calcu li. \200 Urinary retention. \200 Testicular torsion. \200 Intussusception. \200 Can cer (especially of the colon: see below). Gynecological \200 Ectopic pregnancy. \200 Pe lvic in \202 ammatory disease (PID). \200 Rupture/torsion of ovarian cyst. \200 Endome triosis. \200 Mittelschmertz. Medical \200 MI. \200 Pneumonia. \200 Pulmonary embol us (PE). \200 Aortic dissection. \200 Acute hepatitis. \200 DKA. \200 Urinary tract infection (UTI). \200 Herpes zoster. \200 Irritable bowel syndrome. \200 Gastroenter itis. Cancer causing abdominal pain Unexplained abdominal pain in patients > 50 years may b e caused by cancer, especially of the large bowel. The pain may result from transient or pa rtial bowel obstruction. Ask about previous episodes of pain, weight loss and change of bow el habit. If there is no indication for admission, consider referral to a surgical clinic f or investigation. 507 ACUTE APPENDICITIS Acute appendicitis This common cause of abdominal pain in all ages is particularly dif \201 cult to diagnose in the extremes of age and in pregnancy. However, the diagnosis of ac ute appendicitis is often missed initially at all ages. History The classic presentation is of central colicky abdominal pain, followed by vomiting , then shift of the pain to the right iliac fossa. Many presentations are atypical, with a variety of other symptoms (eg altered bowel habit, urinary frequency) partly depending upon the position of the tip of the in \202 amed appendix (retrocaecal 74 % ; pelvic 21 % ; pa racaecal 2 % ; other 3 % ). Examination (see also Table 10.1 ) In the early stages, there may be little abnormal; in th e late stages the patient may be moribund with septic shock and generalized peritonitis. Be tween these extremes, there may be a variety of \201 ndings, including i T , tachy- ca rdia, distress, foetor oris. There is usually a degree of tenderness in the right iliac fos sa ( peritonitis). Rovsing \200\231s sign (pain felt in the right iliac fossa on pressin g over the left iliac fossa) may be present. PR examination may reveal tenderness high up o n the right with in \202 ammation of a pelvic appendix. Investigations The diagnosis of acute appendicitis is essentially clinical. CT and X-rays a re not routinely indicated, but perform urinalysis pregnancy test. Although FBC may reve al an i WCC, this is not invariable. Differential diagnosis Depending upon the presentation, the potential differential diagnosi s is very wide \200\224 remember to consider urinary, chest, and gynecological causes. Treatment \200 Obtain IV access and resuscitate if necessary. Commence IV \202 uids if there is evidence of dehydration. Give IV opioid and antiemetic (eg slow IV metoclopramide 10mg). \200 If acute appendiciti s is likely, or even possible, keep \200\230nil by mouth \200\231 and refer to the surgeon . If appendicectomy is required, pre-operative antibi- otics (eg cefuroxime + metronidazole ) d risk of infective complications. Appendix mass Untreated, acute appendicitis may proceed to perforation with general- ized p eritonitis, or may become \200\230walled off \200\231 to produce a localized right iliac f ossa in \202 ammatory mass. There are many causes of such a mass. Refer to the surgeon for further investigation and management. Table 10.1 Causes of a right iliac fossa mass Iliac lymphadenitis \200 Psoas abscess \200 Retroperitoneal tumor \200 Actinomycosis \200 Common iliac artery aneurysm \200 Spigelian hernia Appendix mass \200 Caecal carcinoma \200 Crohn \200\231s disease \200 Ovarian mass \200 Pelvic kidney \200 Enlarged gall bladder \200 Iliocaecal TB 508 CHAPTER 10 Surgery Acute pancreatitis This is a relatively common serious cause of abdominal pain in the middl e aged and elderly, with an incidence of \211\210 5 per 100,000/year. Causes Often due to gallstones and alcohol. Many are idiopathic. Other causes: hypothermia, trauma, infection (glandular fever, mumps, Coxsackie, and infectious hepatitis), hyperlipi daemia, hyperparathyroidism, drugs (steroids, azathioprine, thiazides, and statins), polyar teritis nodosa, pancreatic cancer. Symptoms Typically, the complaint is of severe constant epigastric pain radiating to the ce nter of the back, with associated nausea and vomiting. Signs The patient may be distressed, sweating and mildly pyrexial. Look for evi- dence of s hock \200\224 there may be a need for urgent resuscitation. Abdominal tenderness is likely to be maximal in the epigastrium guarding. The oft- quoted, but uncommon bluish discolo uration in the loins (Gray Turner \200\231s sign) only develops after several days. Investigations \200 Check BMG and SpO 2. \200 Serum amylase is likely to be grossly i t o > 5 \227 upper limit of normal range (but if not diagnostically i , consider urinary amylase level). FBC may reveal i WCC. \200 U&E, Ca 2 + , LFTs, glucose \200\224 hypocalcaemia is relativ ely common. \200 Coagulation screen. \200 CXR, ECG, ABG; consider lactate if unwell. Treatment \200 Provide oxygen (O 2). \200 Obtain IV access and resuscitate with IV \202 uids as necessary. \200 Give IV analgesia (eg morphine titrated according to respons e \200\224 b Approach to abdominal pain, p.504). Give an anti-emetic (eg cyclizine 50mg or metoclopramide 10mg slow IV). Insert an nasogastric (NG) tube. \200 Insert a urinary catheter and monitor urine output. \200 Consider early insertion of a central venous line to monitor the central venous pre ssure (CVP) and guide IV \202 uid therapy in the seriously ill, particularly the elderly. Contact the appropriate specialist(s) and transfer to HDU/ICU. 509 ACUTE PANCREATITIS Complications of acute pancreatitis Acute pancreatitis has a signi \201 cant mortality. Ea rly complications include acute renal failure, disseminated intravascular coagulation (DIC) , hypocalcaemia, adult respiratory distress syndrome (ARDS). Later, pancreatic abscess or p seudo-cyst may occur. The risk of death may be predicted according to the number of prognos tic indicators present (Glasgow scoring system). 3 or more of the following on admission and subsequent repeat tests over 48hr constitutes s evere disease: Age > 55yrs; WCC > 15 \227 10 9 /L; fasting glucose > 10mmol/L; urea > 16mm ol/L; arterial partial pressure of oxygen ( p O 2 ) <7.9kPa; Ca 2 + <2mmol/L; albumin <32g/ L; serum LDH > 600U/L; AST > 100U/L. Chronic pancreatitis The term chronic pancreatitis implies permanent pancreatic damage. The condition often results from alcohol excess. Some patients with chronic pancreatitis prese nt frequently to the ED requesting opioid analgesia. This can pose a dif \201 cult problem for the doctor who has not treated them previously. Follow the approach shown opposite and request previous hospital case notes early. 510 CHAPTER 10 Surgery Biliary tract problems The majority of emergency biliary tract problems relate to gallstone s. Both solitary cholesterol and multiple mixed gallstones are common amongst the middle ag ed and elderly. Pigment stones comprise a small proportion \200\224 they occur in heredita ry spherocytosis, malaria, and haemolytic anemia. Complications of gallstones Acute and chr onic cholecystitis, biliary colic, obstructive jaundice, ascending cholangitis, mucocoele, empyema, acute pancreatitis, gallstone ileus, carcinoma of the gallbladder. Acute cholecystitis History Impaction of gallstones with acute in \202 ammation of the gal lbladder usually manifests itself by right hypochondrial pain radiating to the right side o f the back vomiting. Examination Look for features of an acute in \202 ammatory process . Fever is frequently present, combined with right hypochondrial tenderness (particularly f elt on inspiration \200\224 Murphy \200\231s sign). There may be a palpable mass \200\224 this is also a feature of mucocoele and empyema (the latter causing high fever, extreme te nderness and septic shock). Management \200 Provide IV analgesia and anti-emetic (see b Analgesics: opioids, p.276). \200 Check FBC (WCC often i ), U&E, glucose, amylase, LFTs. \200 CXR, ECG (in case pain is due to atypical presentation of MI). \200 USS will con \201 rm the diagnosis (tender ness on pressing the USS transducer over the area where the thickened gallbladder containin g stones is located is called the ultrasonic Murphy \200\231s sign). Commence antibiotics (eg cefotaxime 1g IV) and refer to the surgeon. Biliary colic/chronic cholecystitis Patients (sometimes with known gallstones) may present with short-lived recurrent episodes of epigastric/right hypochondrial pain radiation to the back. This pain of biliary colic/chronic cholecystitis may be dif \201 cult to disting uish from other causes, including peptic ulcer disease. If the pain has subsided and there are no residual abnormal physical signs, discharge the patient with arrangements for GP or surgical outpatient follow-up.