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. Common bile duct stones Stones within the common bile duct can cause several problems: \200 Acute pancreatitis ( b p.508). \200 Obstructive jaundice. \200 Ascending infectio n. Obstructive jaundice Biliary obstruction results in i jaundice with pale stools and dark urine ( pain). Acute hepatitis and cholangio-/pancreatic carcinoma may present in a sim ilar fashion. A palpable gallbladder implicates pancreatic carcinoma as the more likely dia gnosis (Courvoisier \200\231s law: \200\230In the presence of jaun- dice, if the gallbladd er is palpable, the cause is unlikely to be a stone \200\231). Ascending cholangitis Biliary stasis predisposes to infection, characterized by Charcot \200\231s triad (abdominal pain, jaundice, and fever). The patient may be very ill and requ ire resuscitation for septic shock ( b p.59). 511 PEPTIC ULCER DISEASE Peptic ulcer disease Perforated peptic ulcer History Perforation of a gastric or duodenal u lcer is usually a severely painful sudden event. It may occur in those without known peptic ulcer disease, as well as those with previously diagnosed problems. However, close questio ning may reveal recent symptoms attributed to \200\230indigestion \200\231. Sudden localiz ed epigastric pain spreads to the remainder of the abdomen \200\224 the pain is worse on c oughing or moving and may radiate to the shoulder tip. Examination Although distressed, the patient often prefers to lie still, rather than roll a bout. However, some patients in extreme pain writhe or roll in agony and are unable to keep still for examination or X-rays until analgesia is given. Absent bowel sounds, shock, gene ralized peritonitis and fever develop as time passes. Investigations An erect CXR will demonstrate free gas under the diaphragm in \211\210 75 % of patients with perforated peptic ulceration (if the patient is not \201 t enough for a n erect CXR, obtain a left lateral decubitus X-ray). In those cases where the diagnosis is suspected, but not proven by X-ray, a contrast CT scan may help. Other relevant investigati ons are: U&E, glucose, amylase (may be slightly i ), FBC (WCC typically i ), SpO 2 , ABG, E CG/troponin (ensure symptoms do not re \202 ect MI rather than peptic ulcer disease). Trea tment \200 Give O 2. \200 Provide IV analgesia (eg morphine titrated according to respo nse). \200 Give an antiemetic (eg slow IV metoclopramide 10mg). \200 Resuscitate with I V 0.9 % saline. \200 Refer to the surgeon and give IV antibiotics (eg cefotaxime 1g and i n late presentations, metronidazole 500mg as well). Other GI perforations Perforations may affect any part of the GI tract, but the chief cause s are peptic ulceration, trauma, diverticular disease, and colonic carcinoma. The emergency treatment principles are similar to those of perforated peptic ulcer (described above). Bo wel perforation usually results in gas under the diaphragm on an erect CXR, but remember th at there are other possible causes, including: recent surgery, peritoneal dialysis, gas-for ming infections, and occasionally, vaginal gas insuf \202 ation during waterskiing, or ora l sex. Other presentations of peptic ulcer disease In addition to perforation, peptic ulcer diseas e may also present with upper or lower GI hemorrhage ( b p.122), or pain from oesophagitis, gastritis or duodenitis. If the patient \200\231s presentation suggests in \202 ammation of the upper GI tract, consider discharging the patient with a supply of antacid and GP fol low-up. This course of action is not appropriate if there is any possibility of serious com plication. Similarly, it is not usually appro- priate to initiate therapy with H 2 blockers or proton pump inhibitors in the ED without an accurate diagnosis. 512 CHAPTER 10 Surgery Intestinal obstruction Intestinal obstruction may be mechanical or paralytic in nature. Paralytic intestinal obstruction is relatively rare in the ED. Causes include postoperative ileus, electrolyte disturbance (eg hypokalaemia) and pseudo-obstruction (see opposite). Causes of mechanical intestinal obstruction \200 Adhesions after previous surgery. \200 Obstructed hernia (commonly: inguinal, femoral, para-umbilical, incisional; rarely: obturator, Spigelian, lumbar). Tumors (gastric, pancreatic or large bowel carcinoma). \200 Volvulus (gastric, caecal or most commonly, sigmoid) \200\224 see b p.516. \200 In \202 ammatory mass (eg diverticul ar, Crohn \200\231s). \200 Peptic ulcer disease. \200 Gallstone ileus. \200 Intussusc eption. History Classic symptoms of intestinal obstruction are: abdominal pain, distension, vomiting, and constipation. The exact presentation depends upon the site of obstruction an d the underlying cause. Ask about previous surgery. A history of severe pain suggests stran gulation and developing ischaemia in a closed loop. The nature of the vomit (eg faeculent) may give a clue to the site of obstruction. Examination Check T . Look for evidence of dehydration or shock. Carefully examine the h ernial ori \201 ces (an obstructed femoral hernia is otherwise easily missed). Inspect for scars from old surgery. Note any distension and areas of tenderness (peritonism implies th e surgical problem is advanced). Bowel sounds may be tinkling or absent. PR examination may reveal an \200\230empty \200\231 rectum. Investigations Blood tests Check U&E, glucose, amylase, FBC, LFTs, clotting, group, and save. X-rays Request CXR and supine abdominal X-rays. If there is no con- vincing evidence of obs truction on the supine view, but still a high index of clinical suspicion, consider request ing an erect abdominal \201 lm. X-rays may demonstrate distended loops of bowel (with mul tiple \202 uid levels visible on an erect abdominal view). The site and nature of the dis tended bowel loops may suggest the site of obstruction. Note that although gallstone ileus is rare, X-rays may be diagnostic \200\224 the \201 stula between the bowel and gallblad der allows gas into the biliary tree, which shows up as an abnormal Y-shaped gas shadow in the right hypochondrium). ECG Obtain this if the patient is middle-aged or elderly. ABG If the patient is shocked, check SpO 2 , ABG and lactate. Old notes Request previous ho spital case notes as soon as possible. 513 INTESTINAL OBSTRUCTION Management of mechanical obstruction \200 Insert an IV cannula and start IVI 0.9 % saline . \200 If the patient is shocked, resuscitate with O 2 and IV \202 uids and insert a ur inary catheter. Consider the need to insert a central venous line to guide resuscitation an d involve ICU specialists at an early stage. Provide analgesia (eg IV morphine titrated according to response \200\224 b Analgesics: opioids, p.276). Give an anti-emetic (eg cyclizine 50mg). \200 Insert a NG tube. \200 Refer to the surgi cal team for ongoing care. Intestinal pseudo-obstruction This condition results from chronic impairment of GI motility . Many of the patients affected are elderly and taking tricyclic antidepressants or other d rugs with anticholinergic actions. Although pseudo-obstruction may involve any part of the GI tract, it typically presents with colonic distension. On rare occasions, this may be suf \201 ciently severe to rupture the caecum or cause hypotension by compressing the inferio r vena cava and blocking venous return. There may be a diagnostic X-ray appearance showing gas in the bowel all the way to the rectum, whereas in a classical, more proximal obstructi on, gas will be absent from the rectum. Treatment of acute colonic distension from pseudo-o bstruction is by decompression using a colonoscope. 514 CHAPTER 10 Surgery Mesenteric ischaemia/infarction Acute mesenteric infarction Abrupt cessation of the blood s upply to a large portion of the gut results in irreversible gangrene of the bowel within a relatively short space of time. This is associated with a very high mortality. Unfortunatel y, however, the diagnosis can be very dif \201 cult to make \200\224 the challenge theref ore lies with making an early diagnosis. Pathophysiology One or more of the following processes may be responsible: \200 Mesenteri c arterial embolism (often associated with AF). \200 Mesenteric arterial thrombosis. \200 d Mesenteric arterial blood \202 ow (eg hypotension secondary to MI). \200 Mesent eric venous thrombosis. Most cases involve either arterial embolism or thrombosis. History Acute mesenteric infarction usually occurs in middle-aged or elderly patients. It i s often heralded by severe, sudden onset, diffuse abdominal pain. Typically, the severity o f the pain initially far exceeds the associated physical signs. The pain may radiate to the back. Some patients have a preceding history of chronic mesenteric ischaemia, with pain after mea ls and weight loss. There is often an associated history of vascular disease elsewhere (eg intermittent claudication). Examination Shock, absent bowel sounds, abdominal distension, and tenderness are late signs . Initially, there may be little more than diffuse mild abdominal tenderness. If the diagno sis is suspected, search carefully for evidence of an embolic source (eg AF, recent MI with high risk of mural thrombus, aortic valve disease or valve prosthesis, recent cardiac cath eter). Investigations \200 U&E, BMG, and laboratory blood glucose. \200 Amylase may be moderately i \200 FBC may demonstrate i WCC. \200 Coagulation screen. \200 Group and save. \200 ABG typically reveals a severe metabolic acidosis and lactate may be i . \200 X-rays may show non-speci \201 c dilatation of bowel loops and, in advanced cases, gas within the hepatic portal venous system. ECG may demonstrate AF. \200 Other specialist investigations (USS, CT, angiography) may b e helpful, but let the surgeon decide about this. Management If the diagnosis is suspected: \200 Resuscitate with O 2 and IV \202 uids. \200 Provide analgesia (eg IV morphine titrated according to response). \200 Consider br oad spectrum IV antibiotics. \200 Refer urgently to the surgeon. 515 MESENTERIC ISCHAEMIA/INFARCTION Ischaemic colitis Chronic arterial insuf \201 ciency to the bowel usually affects the muco sa and submucosa, typically in the region of the splenic \202 exure (junction of territor y supplied by the superior and inferior mesenteric arteries). The patient presents with abdominal pain, starting in the left iliac fossa. Loose stools wi th blood may be passed. The patient may have had previous similar episodes and exhibit evid ence of cardiovascular disease. Examination may reveal a low grade pyrexia, tachycardia, an d colonic tenderness with blood PR. Check FBC, U&E, group and save, ECG, CXR. Plain abdominal X-rays may show \200\230thumb pr inting \200\231 (submucosal colonic oedema), typically at the splenic \202 exure. Provide analgesia, IV \202 uids, and refer to the surgical team. 516 CHAPTER 10 Surgery Large bowel emergencies Volvulus (see bowel obstruction \200\224 b p.512) Responsible for \211\210 10 % of large bowel obstruction. Occurs at the caecum or, more commonly, the sigm oid, due to poor \201 xation in their respective iliac fossae. Sigmoid volvulus usually o ccurs in the elderly with initially intermittent cramping lower abdominal pain and progress ive abdominal distension, which may be spontaneously relieved by passage of large amounts o f \202 atus/feces. Some patient \200\231s progress to complete obstruction: marked disten sion progressing to fever and peritonitis suggests strangulation. Plain abdominal X-ray typically shows a large single dilated loop of colon (a \200\230bent inner tube \200\231) on the left side with both ends down in the pelvis. Refer to the inpatient surgical team for sigmoidoscopy (if not strangulated) or surgery if strangulated. Caecal volvulus is most common between the ages of 25 \200\22335yr. Patients have symptoms of acute onset small bowel obstruction. Plain abdominal \201 lms usually show one large dilated segment of the colon in the mid-a bdomen with distended small bowel loops and empty distal large bowel. Refer to the surgical team. Diverticular disease Diverticulosis is common in the middle-aged and elderly, particularly affecting the sigmoid colon. Without signi \201 cant complications, there may be a change in bowel habit with passage of mucus. Acute diverticulitis Results from in \202 ammation/perforation of a diverticulum and may b e con- \201 ned to colonic wall by the serosa. If this perforates, then in \202 ammation may remain localized (pericolic abscess) or spread (frank peritonitis). Symptoms and signs re \202 ect the extent of the infection \200\224 there may be lower abdom- inal dull con stant pain, low grade fever with tenderness, rigidity and occa- sionally a mass in the left lower quadrant. The elderly (the group most at risk of diverticulitis and its complication s), and those on immunosuppres- sants may not manifest the expected pyrexia and signs of pe ritonitis. Investigations Check FBC, U&E, CRP, group and save, and blood cultures. Plain ab dominal X-rays may show non-speci \201 c changes and help to exclude perforation/large bow el obstruction. An erect CXR often shows copious subdiaphragmatic gas in free perforations. Treatment Give analgesia, IV \202 uids, keep fasted, and refer to the surgeon. Start bro ad spectrum antibiotics (eg cefuroxime + metronidazole). Complications \200 Perforation: may be localized and walled off (forming an abscess), or generalized. Intestinal obstruction: both large and small (due to adherent loops). \200 Massive PR ble eding. \200 Fistulae to adjacent structures: small bowel, uterus, vagina, bladder. \200 Post-infective strictures. 517 LARGE BOWEL EMERGENCIES Ulcerative colitis Severe acute colitis is characterized by the passage of > 6 loose bloody motions per day, together with systemic signs (tachycardia, fever) and hypoalbuminaemia. T here is a risk of hemorrhage, perforation and toxic megacolon. The crucial points in manage ment are early recognition and prompt referral to the inpatient gastroenterology service, f or aggressive medical therapy (IV and PR steroids, IV \202 uids) and joint review by medi cal and surgical teams. Surgery may be required for complications, especially toxic megacol on. Suspect toxic megacolon if the colonic width is > 5.5cm on abdominal X-ray (this sign i s associated with a 75 % risk of requiring colectomy). Refer any patient who presents with suspected new onset ulcerative colitis for investigation and control of the disease. Mesenteric ischaemia/infarction See b p.514. Crohn \200\231s disease Colonic Crohn \200\231s disease may present as colitis with bloody diarrhea, urgency and frequency, similar to ulcerative colitis. Fibrosis may cause diarrhea or obstructive symptoms. Peri-anal disease with chronic anal \201 ssure may be the \201 rst presenting symptom. Emergency surgery is indicated in acute fulminating Crohn \200\231s colitis with bleeding, toxic dilatation, or perforation. Epiploic appendagitis Primary in \202 ammation of one of the hundreds of appendices epiplo icae on the antimesenteric colonic border may present in similar fashion to acute diverticu litis or appendicitis. However, T and WCC are usually normal. Although often diagnosed a t laparotomy, CT scan may be characteristic, allowing conservative treatment (including IV analgesia). Irritable bowel syndrome Patients are usually aged 20 \200\22340 years with a prolonged his tory of inter- mittent symptoms \200\224 altered bowel function (diarrhea, constipation, o r diarrhea alternating with constipation). Typically, the abdominal pain is crampy/aching a nd localized in the lower abdomen over the sigmoid colon. Pain may be eased by the passage of stool or \202 atus. Examination fails to reveal any worrying features. The diagnosis i s one of exclusion \200\224 be vigilant for clues that may point to other organic disease. 518 CHAPTER 10 Surgery Anorectal problems Any PR bleeding requires surgical follow-up to exclude malignancy. Complications of hemorrhoids ( \200\230piles \200\231) \200 Bleeding: hemorrhoids typical ly cause painless, bright red PR bleeding, associated with defaecation, but blood is not mi xed with the stools. Check the abdomen and inspect the anus \200\224 if there is no prolap sed or external haemorrhoid, perform PR and arrange surgical follow-up. Prolapsed piles are acutely painful \200\224 treat conservatively with adequate analgesia (may need admission), bed rest, and stool softeners. Thrombosed external pile is due to rupture of a tributary of the inferior haemorrhoidal vei n, producing a peri-anal haematoma . One or more dark blue nodules covered with squamous ep ithelium may be visible at the anus and a clot palpable. Refer to the surgeon to decide bet ween incision and drainage under LA or conservative management. Anal \201 ssure Typically causes severe pain on defaecation and for 1 \200\2232hr afterwa rds. There may be blood on the toilet paper, but usually bleeding is minimal. The \201 ss ure is located just inside the anal ori \201 ce and is usually associated with the passage of hard stools. Most are located posteriorly in the midline. PR examination may be impossi ble due to pain, but the \201 ssure is often visible with traction of anal skin. Treatmen t Prescribe analgesia and stool softeners. Most heal spon- taneously, but the presence of s igni \201 cant ulceration, hypertrophied tissue, or a skin tag suggests chronicity and nee d for surgical follow-up. Be suspicious of those \201 ssures not in the midline and those that are multiple (the differential diagnosis includes chronic in \202 ammatory bowel dis ease, anal cancer and adenocarcinoma of the rectum invading the anal canal). Pruritus ani Not strictly an emergency problem. There are numerous possible causes: \200 Poor hygiene. \200 Fissure, prolapsing piles, \201 stulae, rectal prolapse, anal cancer . \200 Contact dermatitis due to local applications (especially local anaes- thetics). Threadworms. \200 Part of a general condition (eg obstructive jaundice, lymphoma, severe iron de \201 cency anemia, uraemia, diabetes). Lichen sclerosis. \200 Sexually transmitted disease (herpes, anal warts, HIV). Treatment requires identi \201 cation of the underlying problem \200\223refer to the GP. In the mean time, advise avoidance of ointments and creams. Pilonidal abscess An infected pit in the natal cleft causes pain and/or offensive discharge . Treatment Refer to the surgical team. Treatment may involve initial incision and drainage , followed by healing, then elective excision of the sinus. Note: Fissures, tears or bruising around the anus of a child arouses suspicion of abuse in the \201 rst instance. Refer to a specialist and avoid rectal examination. 519 ANORECTAL PROBLEMS Anorectal abscesses Most begin with infection involving an anal crypt and its gland, from w hich it can spread between the external and internal sphincters to a variety of sites \200 \224 these determine its symptomatology and mode of presentation. Peri-anal and ischiorecta l abscesses account for \211\210 80 % of cases. In 20 % , there is a clear predisposing ca use, such as in \202 ammatory bowel disease, anorectal cancer, or anal \201 ssure (Fig. 10.1 ). D C The four types of anorectal abscess \200\224(A) Perianal. (B) Ischio-rectal. (C) Submucous. (D) Pelvi-rectal. (After W.F.W. Southwood, F.R.C.S., Bath). B A Fig. 10.1 Types of anorectal abscesses. Clinical features Pain is a prominent initial feature of peri-anal and super \201 cial isc hiorectal abscesses, followed by local signs of in \202 ammation. Patients complain of per sistent dull throbbing pain, made worse by walking and sitting, and prior to defaecation. S uch symptoms are less evident with deep infections, which tend to develop slowly with pyrex ia and systemic upset. Peri-anal abscesses produce localized \202 uctuant red tender swel lings close to the anus. With ischiorectal sepsis, the \201 ndings are more diffuse and \202 uctuance is a late \201 nding. Deeper infections are less obvious \200\224 PR exam ination may reveal a mass or tender area of induration. Treatment Provide analgesia and refer to the surgical team for incision and drainage under GA. Venereal proctitis The organisms are similar to those transmitted by vaginal intercourse: a ssume more than one type of organism is present. Patients complain of pain, irritation, dis charge, and bleeding. Consider gonococcus, chlamydia, syphilis, herpes simplex. Refer urgen tly to a genitourinary specialist. Rectal foreign bodies X-rays may demonstrate the position and shape of FBs. More especially , look for the presence of any free air \200\224 perforation of the rectum or colon is the most frequent and most serious complication, in which case give IV antibiotics (eg cephalo sporin + metronidazole). Refer the patient for removal of the FB by the surgical team. 520 CHAPTER 10 Surgery Retention of urine Causes of acute urinary retention This more commonly presents in the mal e: Common causes in males \200 Prostatic hyperplasia/cancer. \200 Urethral stricture. \200 Post-operative. Common causes in females \200 Retroverted gravid uterus. \200 Atr ophic urethritis. \200 Multiple sclerosis. Other causes include: acute urethritis, prosta titis, phimosis, urethral rupture following trauma, bladder blood clot, urethral calculus, prolapsed intervertebral disc, drugs (alcohol, antihistamines, anticholinergics, antihypert ensives, tricyclics), fecal impaction, anal pain. Presentation In most cases, the diagnosis is obvious: the patient complains of inability to pass urine combined with bladder discomfort. Remember, however, to consider the diagnosis in those patients unable to describe their symp- toms (eg those unconscious after trauma). Examination will reveal a tender enlarged bladder, with dullness to percussion well above t he symphysis pubis. Search for the causes listed above. In particular, search for evidence of prolapsed disc/cord compression by checking the lower limb power/re \202 exes and perin eal sensation. Perform PR examination to assess anal tone and the prostate. Initial management The patient requires urgent bladder decompression. Provided there is no contraindication (eg urinary retention following trauma or as a result of urethral stenosis ), achieve this by urethral catheterization. Use an aseptic technique (male catheterization is described opposite). If urethral catheterization is impossible or contraindicated, cons ider the need for a suprapubic catheter, but this should only be performed by a doctor expe rienced in the technique. Further management After bladder drainage, record the volume of urine obtained, then re-exa mine the abdomen for pathology that might have been previously masked. Test the urine for the presence of blood and send a mid-stream specimen of urine (MSU) for culture and sensitivity. Perform investigations appropriate to the likely underlying cause, and then refer to the urology team. 521 RETENTION OF URINE Chronic urinary retention Patients with chronic retention often have massive, almost painle ss bladder distension. They are at risk of pressure damage to the upper urinary tract. Foll owing drainage, they may develop haematuria or post-obstructive diuresis, with attendant pr oblems of signi \201 cant \202 uid and electrolyte derangements. Male catheterization \200 Prepare the equipment \200\224 a Foley catheter size 14G is ap propriate for an adult. Ensure that the patient does not have an allergy to latex. Check the volume required for the catheter balloon. \200 Wash hands and don sterile glove s. \200 Clean the external genitalia with antiseptic solution and surround with a sterile \201 eld. Slowly insert local anesthetic into the urethra. \200 Gently massage the local anesthetic down the urethra and wait for a few minutes for the LA to take effect. Holding the penis at right angles to the body, insert the lubricated catheter. The catheter should pass easily into the bladder with drainage of urine. If any resistance or dif \201 culty is encountered, stop and seek senior assistance. Once urine appears, advance the catheter a few centimeters further before in \202 ating the balloon. Connect the catheter to a closed drainage system and tape the tubing to the upper thigh. Ensure that the foreskin is not left retracted \200\224 this could result in paraphimosis. 522 CHAPTER 10 Surgery Testicular problems Remember that any pain of testicular origin may be initially referred t o the abdomen. Testicular torsion Testicular torsion is most frequently seen in children and young adults. Any suspicion of testicular torsion should prompt immediate referral. The condition is cov ered fully on b Inguinal and scrotal swellings, p.700. Acute epididymitis Causes For those aged <35 years, infection with chlamydia or gonococcus is com- monly responsible. Acute epididymitis in those aged > 35 years is usually secondary to UTI and associated with underlying urinary tract pathology. Clinical features There is typically a gradual onset of progressive testicular ache, with sub- sequent swelling of the epididymis and testis. There may be a history of dysuria or urethral discharge. The patien t may be pyrexial. The epididymis is acutely tender, with the testis lying low in the scrot um. Advanced, late cases may have progressed to abscess formation. Investigations Send an M SU and take a urethral swab (take lab advice regarding the correct media for chlamydia). Management The chief initial concern is to ensure that testicular torsion is not being miss ed: if there is any possibility of this ( b Inguinal and scrotal swellings, p.700), refer u rgently. Treatment of acute epididymitis comprises antibi- otics (eg cipro \202 oxacin for 2 weeks), analgesia, and rest. Some patients require admission; others may be managed on a n outpatient basis. Urology investigation and follow-up will be required, so involve the ur ologist early. Patients with suspected chlamydia or gonococcus require appropriate advice a nd contact tracing of sexual partners. Orchitis Orchitis may present as epididymo-orchitis, an extension of bacterial epididymitis (see above). Orchitis of viral origin may also occur \200\224 typically mumps, following \211\210 5days after parotitis. Mumps orchitis may be unilateral or bilateral and can occu r in the absence of overt parotitis. Rarely, orchitis is secondary to tuberculosis (TB) or syphilis. Treatment All patients with orchitis require analgesia and follow-up. If there is any possibility of bacterial infection, antibiotics are indicated (see above). Testicular lumps Patients may present to the ED with scrotal/testicular lumps. Causes are v aried and include: hydrocoele, inguinal hernia, epididymal cyst, epidi- dymitis, orchitis, and testicular tumor. Many patients will be managed appropriately by referral back to GP or to an outpatient clinic. Be particu- larly wary of an apparent epididymo-orchitis which ha s failed to respond to antibiotics \200\224 it could be an atypical presentation of a test icular tumor. Testicular trauma \200\224See b p.352. 523 PENILE PROBLEMS AND PROSTATITIS Penile problems and prostatitis Paraphimosis Paraphimosis occurs when the foreskin is left retracted, thereby causing swelling of the glans, which results in dif \201 culty replacin g the foreskin to its proper position. Untreated, tissue necrosis may develop. Paraphimosis may be iatrogenic, occurring after urethral catheterization. Treatment Initially attempt r eduction by manual decompression, which may require the use of Entonox , IV sedation, or LA (a small amount of topical 1 \200\2232 % lidocaine gel or injection of 10mL plain 1 % l idocaine around the base of the penis). Digital pressure may allow the glans to d in size, prior to the foreskin being delivered back into its usual position. If unsuccessful, refer to the surgical team for reduction under GA or dorsal slit of the prepuce followed by later circumcision. Priapism Priapism is persistent (and usually painful) penile erection. Causes \200 Iatrogenic (following intra-cavernosal injection of one or more of: papaverin e, alprostadil, vasoactive intestinal polypeptide, phentolamine for impotence). Others: leukemia, myeloma, sickle cell disease, spinal injury, drugs (eg sildena \201 l [V iagra], phenothiazines, cannabis, cocaine), renal dialysis. Management Priapism is a urolog ical emergency. Refer urgently to the urology team. Initial emergency treatment of a prolon ged ( > 6hr) arti \201 cial erection (ie following an intra-cavernosal drug injection or o ral sildena \201 l) is to aspirate 50mL of blood from each corpus cavernosum through a 19G butter \202 y needle into a 50mL syringe with a Luer lock. Urethritis This usually presents with dysuria/urinary frequency, re \202 ecting underlying STD. Refer for appropriate investigation, treatment, and follow-up. Prostatitis In \202 ammation of the prostate may be acute or chronic and present in a vari ety of ways (fever, urgency, frequency, perineal pain, urethral dis- charge). PR examinatio n reveals a tender prostate. Urinalysis demonstrates protein. Refer for further investigati on and treatment. Penile trauma Minor super \201 cial tears These are relatively common. Most involve the fr enulum. The patient complains of pain and bleeding following sexual intercourse. Bleeding u sually responds to local pressure (if this is not successful, consider tissue glue or refer to the surgical team). Once bleeding has stopped, advise a period of abstinence from sexua l activity ( \211\210 10 days) to allow healing to occur and prevent recurrence. Fracture of the penis This occurs infrequently. It involves injury to the tunica albuginea of the erect penis. The result is penile tenderness and swelling. Refer to the urolo- gist for urgent surgical exploration, evacuation of haematoma and repair. 524 CHAPTER 10 Surgery Ureteric colic New onset \202 ank/back pain in the elderly may represent a leaking aortic aneurysm (even if haematuria is present). Causes Calculi or blood clots may cause ureteric (or \200\230renal \200\231) colic. Colick y pain is produced by ureteric obstruction, i intraluminal pressure, and muscle spasm. Calc uli most commonly consist of calcium oxalate and/or calcium phosphate. Less common are magn esium ammonium phosphate (associated with UTIs and urea-splitting organisms, such as Proteu s ), urate, and cystine stones. are associated with hypercalcaemia, hyperoxaluria and Calculi hyperuricaemia. \200\230Stag horn \200\231 calculi in the collecting system predispose to infections. Calculi may form throughout the length of the renal tract. They vary in size from tiny part icles to large \200\230stones \200\231 in the bladder. They cause symptoms from local obst ruction, infection, and rarely may ulcerate through the wall of the structure in which they are present. Clinical features The most common presenting symptoms are pain from obstruction or UTI and/ or haematuria. Constant dull, severe, loin discomfort is associ- ated with excruciating col icky pain, spreading to the respective iliac fossa, testis, tip of penis or labia. The pain may cause the patient to move or walk about. Nausea, vomiting, pallor, sweating are common . There is frequently a previous history of stone disease \200\224 ask about this and whet her there is any past history of renal disease. Ask about urinary and GI symptoms.