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CATASTROPHIC ABDOMINAL EMERGENCIES

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.

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CATASTROPHIC ABDOMINAL EMERGENCIES

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  1. CATASTROPHIC ABDOMINAL EMERGENCIES O. N. M. Panton, MB, BS, FRCSC, FACS, Head, UBC Division of General Surgery, VGH/UBCH

  2. WHAT ARE ABDOMINAL CATASTROPHIES?

  3. CATASTROPHIC EMERGENCIES • HAEMORRHAGE • SEPSIS

  4. HAEMORRAHGE • Upper GI • Small Bowel • Colorectal • Solid organ

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

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

  7. Gastric Bleeding • Gastritis • Superficial • Stress ulceration • Mechanical

  8. 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

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

  10. Duodenal Bleeding • Haemobilia • Aortoduodenal fistula

  11. Duodenal Bleeding • Benign ulcer • May have all the same etiology as stomach • Major bleeding usually gastroduodenal artery

  12. SB Haemorrhage accounts for 2-3% of GI bleeds

  13. Jejunal diverticulosis

  14. Meckel’s Diverticulum

  15. 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 ++++

  16. UGI BLEED • OR STAT laparotomy • Codes shortly after laparotomy • Duodenotomy/gastrotomy • Watermelon stomach torrential haemorrhage • Blood gushing from duodenum • Died on table

  17. Angiodysplasia Diverticular disease Neoplasia: Adenocarcinoma, GIST’s Ischemia Hemmorhoids IBD Infection: Campylobacter, Shigella, Salmonella, Enteropathogenic E. coli Colon Bleeding

  18. LGI Bleed • Acute bleeding occurs in 20-30 cases/100,000 annually • 20-30% of GI bleeds

  19. Angiodysplasia

  20. Diverticulosis

  21. Barium enema - diverticulosis

  22. Lower gi bleed red cell scan

  23. 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 caneoadjuvant short course radiorx • Leak/Hartmann

  24. LGI BLEED • STAT OR • Pre-sacral ulcer communicating with rectal stump • Packed/controlled • ICU plan for IR angio/embolization • DIC ICU & died

  25. 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

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

  27. 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

  28. SEPSIS • DL RLQ abscess • Laparotomy: gangrenous appendicitis/faecolith • Appendectomy & drainage of abscess

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