08 / Acute surgery
The way patients actually arrive
Nobody is referred as “anastomotic leak”. They arrive as pain, bleeding, distension, a falling pressure. Each door opens on the first moves, then the cases and operations behind them.
Presentation
Acute abdominal pain
The commonest surgical referral there is. Location, onset and peritonism sort it faster than any single test.
First moves
- Where did it start and where is it now, migration is a diagnosis in motion
- Peritonitic or colicky, a still patient guarding versus a writhing one
- The unmissables first: perforation, ischaemia, ruptured aneurysm, ectopic
Presentation
Bowel obstruction
Distension, vomiting, absolute constipation and pain: the question is simple bowel or strangulating bowel, and the clock only matters for one of them.
First moves
- Adhesions, hernia or malignancy, the causes in order, and the groins examined every time
- Strangulation signs: constant pain, tenderness, lactate, tachycardia that fluids do not fix
- Drip and suck buys time only for the bowel that is not dying
Presentation
Perforated viscus
Sudden pain, a rigid abdomen, free air under the diaphragm: the presentation where the decision is rarely whether to operate, only how fast.
First moves
- Erect chest film or CT for free air, but a rigid abdomen is already an answer
- Resuscitate on the way to theatre, not instead of it
- Source control is the treatment; antibiotics are the escort
Presentation
GI bleeding
Haematemesis, melaena or fresh blood: resuscitate first, scope second, and know when the surgeon rather than the endoscopist owns the next move.
First moves
- Two large cannulae, group and save or crossmatch, and honest shock assessment
- Upper versus lower: melaena and haematemesis point up, fresh blood usually points down
- Surgery enters when endoscopy and radiology fail or the patient cannot wait for them
Presentation
Jaundice and biliary sepsis
Charcot's triad, fever, jaundice, right upper quadrant pain, is cholangitis until proven otherwise, and pus under pressure in the biliary tree does not wait.
First moves
- Ultrasound first: stones, duct dilatation, the obstructed system
- Cholangitis needs drainage (usually ERCP), not just antibiotics
- Gallstone pancreatitis changes the order of every subsequent decision
Presentation
Post-op deterioration
The surgical patient who was fine and now is not. Day and operation narrow the differential before a single test returns.
First moves
- What was done and which post-op day it is, timing is half the diagnosis
- Tachycardia after bowel surgery is a leak until excluded
- Look at the wound, the drains and the fluid chart before the scan
Presentation
Trauma
The primary survey finds the killer first: airway, breathing, circulation, in that order because that is the order they kill in.
First moves
- ABCDE, treating as you find, not after you finish
- Where is the blood: chest, abdomen, pelvis, long bones, floor
- Damage control when physiology is failing: stop bleeding, stop contamination, leave
Presentation
Acute limb ischaemia
Pain, pallor, pulselessness, paraesthesia, paralysis, perishing cold: six Ps and roughly six hours before muscle starts dying.
First moves
- Embolus or thrombosis-on-disease, the history usually says which
- Heparin immediately while the plan forms
- Fixed mottling and rigid muscles mean salvage has passed; know that threshold
Presentation
Surgical infection
From wound erythema to necrotising fasciitis: the skill is recognising which infections antibiotics treat and which only a knife treats.
First moves
- Pain out of proportion is necrotising infection until excluded, and that exclusion is surgical
- Abscesses are drained; cellulitis is not
- Source control beats escalation of antibiotics, every time there is a source