General surgery

• Medicine & Surgery 2025
• General Surgery is presented by Prof. Mark Greenwood

Anatomy

• Key organs in the abdomen are the esophagus, liver, gallbladder, stomach, pancreas, appendix, large intestine, and small intestine
• Kidney issues can cause back pain

History - SOCRATES

• A way to remember how to take a patients history
• S - Site
• O - Onset
• C - Character
• R - Radiation/Relieving factors
• A - Associated symptoms
• T - Time/duration
• E - Exacerbating factors
• S - Severity of pain

Common Non-Traumatic Causes of Acute Abdomen

• Inflammation: Appendicitis, cholecystitis
• Ischaemia: Strangulated hernia, volvulus
• Obstruction: Intestinal, gall bladder
• Perforation: Peptic ulcer, diverticulitis
• Rupture: Abdominal aortic aneurysm, ectopic pregnancy

History - Radiation/Referred Pain

• Visceral: Originates from an abdominal organ but is felt remotely due to shared nerve pathways
• Biliary pain: Impacts the phrenic nerve and is referred to the right supra-clavicular region/shoulder

History - Site of Pain

• Regions of the Abdominal Area
• Right and left hypochondriac region
• Epigastric region
• Right and left lumbar region
• Umbilical region
• Right and left iliac region
• Hypo-gastric region

Visceral Pain

• Originates from abdominal organs
• Poorly localised
• Impacts the sympathetic nervous system
• Described as dull or colicky pain

Somatic/Parietal Pain

• Described as 'knife-like' and localised
• Mediated by somatic nerves, specifically nerves to the abdominal wall (T5 to L2), which supply the parietal peritoneum
• Irritants like escaped intestinal contents, enzyme-rich exudates, and pus mediate this pain

Visceral and Somatic Pain Combined

• Some acute abdominal conditions, like acute appendicitis, may involve both
• Acute appendicitis starts with periumbilical colic from obstruction of the appendix
• Pain becomes more localised (somatic) in the right iliac fossa as the parietal peritoneum becomes inflamed

History - Associated Symptoms

• Anorexia
• Nausea
• Vomiting
• Altered bowel habit
• Blood in stool (intestinal ischaemia, ulcerative colitis/Crohn's, dysentery)
• Melaena from upper gastrointestinal bleeding causes stool to go black

History - In Females

• Important to ask when was last period (LMP)
• Could the patient be pregnant?
• Consider gynaecological/obstetric causes like Rupture Graafian follicle/Corpus Luteum, ectopic pregnancy, or acute salpingitis

Principles of Abdominal Examination

• Inspection
• Gentle palpation
• Deep palpation
• Percussion
• Auscultation
• Patient should be flat, with the area from xiphisternum to groin exposed

Examination - Signs in the Hands

• Finger clubbing
• Palmer erythema is related to liver issues
• Spoon shaped nail/Kolinicia could indicate anaemia

Abdominal Examination: Distension

• Ascites: shifting dullness
• Intestinal obstruction: resonant on percussion
• Abnormal masses

Investigations: Laboratory Tests

• Full Blood Count tests haemoglobin, WCC, and platelets
• Biochemistry tests amylase (pancreatitis), LFTs (biliary/hepatic causes), urea & electrolytes (kidney)
• Urea, creatinine, sodium, and potassium
• Arterial Blood Gas can test for metabolic acidosis in sepsis

Erect Chest XRay

• Used to check for Perforation
• Checks for presence of free gas under the diaphragm

Laparoscopy/Laparoscopic Surgery

• Used to diagnose and treat

Brief Overview Examples

• Perforated peptic ulcer
• Intestinal obstruction
• Acute appendicitis
• Acute pancreatitis

Peptic Ulcer - Aetiology

• Helicobacter pylori infection can directly damage and impair the mucosal barrier
• NSAIDs inhibit the production of protective prostaglandins in the mucosa
• Also caused by Steroids, Smoking and Stress

Perforated Peptic Ulcer

• Common and important emergency
• Older age groups, especially on steroids or NSAIDs are prone - should not be on both types of medication
• Extreme pain, sudden onset from Perforated Peptic Ulcer, especially if worse on moving
• Sub-phrenic irritation can cause shoulder pain
• Haematemesis/melaena possible
• Cold, sweaty, shallow breaths may occur
• Silent rigid abdomen may be present
• Erect CXR indicates free gas under diaphragm in 70% of Perfereated Peptic Ulcer cases
• Can be confused with: Perforated appendix, Acute Cholecystitis, Acute Pancreatitis, Myocardial Infarction

Intestinal Obstruction - Signs/Symptoms

• Colicky Pain
• Distension
• Absolute constipation
• Vomiting

Acute Appendicitis

• Commonest acute abdominal emergency in children, adolescents, and young adults in the UK
• Uncommon before 2 years old, less than 5% is over 60 years

Acute Appendicitis Symptoms

• Pain in the periumbilical colic region then right iliac fossa which worsens when coughing or moving
• Anorexia
• Rare vomiting
• Constipation or diarrhoea
• Depends on position of appendix, may be atypical

Acute Appendicitis Treatment

• Antibiotics
• Appendicectomy

Acute Appendicitis Complications

• Perforation
• Abscess and mass

Acute Pancreatitis

• Caused by gall stones
• Alcohol
• Raised amylase

Thyroid Gland Embryology

• At the junction of the anterior 2/3 and posterior 1/3 of the tongue
• Foramen caecum starts at the apex of the tongue
• Thyroglossal duct goes down this duct

Endocrinology

• Euthyroid: Normal levels of T3 and T4
• Hypothyroid: Low levels of T3 and T4
• Hyperthyroid: High levels of T3 and T4

Goitre

• Thyroid Enlargement
• Types: Diffuse, Multinodular, Solitary Nodule

Differential Diagnosis - Lateral Neck Swelling

• Lymph node
• Thyroid
• Salivary gland
• Branchial cyst

Differential Diagnosis - Midline Neck Swelling

• Thyroglossal cyst
• Sublingual dermoid
• Plunging ranula
• Pharyngeal pouch

Thyroid Cancer (Surgery)

• Partial, subtotal, or total thyroidectomy
• +/- Neck dissection(s)
• Goal is preserving some thyroid and parathyroid function

Thyroid Cancer - Prognosis

• Papillary: Good
• Follicular: Good
• Anaplastic: Poor
• Medullary: Fair

Principles for Surgical Drans

• Surgical drains are placed to prevent haematomas
• They are removed when draining minimally

Acute Confusional State (ACS) - Potential Causes (Primary Care)

• Infection
• Hypoxia
• Trauma
• Metabolic issues e.g. hypoglycaemia
• Drugs (recreational, prescribed)
• Epilepsy
• Stroke, MI

Signs of Sepsis

• Feeling faint/dizzy
• Change in mental state (confusion or disorientation)
• Diarrhoea
• Nausea and vomiting
• Slurred speech
• Severe muscle pain
• Severe breathlessness
• Less urine production than normal, like not urinating for a day

Septicaemic Shock

• Endotoxin induced vasodilatation may be sudden and severe
• Shock and coma but no sign(s) of infection

GDP Sepsis Decision Support Tool For Primary Dental Care Considerations

• Is there a presumed infection?
• Is ONE Red Flag present?
  • New deterioration in GCS/ AVPU
  • Systolic B.P ≤90 mmHg (or ≥40 mmHg below normal)
  • Heart rate ≥130 per minute
  • Respiratory rate ≥25 per minute
  • Needs oxygen to keep SpO₂ 92% (88% in COPD)
  • Non-blanching rash or mottled/ashen/cyanotic
  • Not passed urine in last 18 hours
  • Recent chemotherapy (within last 6 weeks)
  • Dial 999 and state the patient has "Red Flag Sepsis"
    • Arrange blue light transfer
    • Administer oxygen to maintain saturations >94%
• Is ONE Amber Flag present?
  • Relatives worried about mental state/behaviour
  • Acute deterioration in functional ability
  • Immunosuppressed (without recent chemotherapy)
  • Trauma, surgery or procedure in last 6 weeks
  • Respiratory rate 21-24 OR dyspnoeic
  • Systolic B.P 91-100 mmHg
  • Heart rate 91-130 OR new dysrhythmia
  • Not passed urine in last 12-18 hours
  • Tympanic temperature ≤36°C
  • Clinical signs of wound, device or skin infection e.g. cellulitis, wound dehiscence,
  • If under 17 & immunity impaired treat as Red Flag Sepsis

S.E.P.S.I.S - Safety Netting

• An acronym for spotting sepsis
• S: slurred speech or confusion
• E: extreme shivering or muscle pain
• P: passing no urine (in a day)
• S: severe breathlessness
• I: it feels like you are going to die
• S: skin mottled or discoloured

What Happens in Secondary Care?

• Sepsis Six protocol gets used

Management - Give (3)

• Oxygen - aim for oxygen saturations >94%
• Fluids - if the patient is hypotensive or lactate is >2mmol/L then 500ml of fluid stat
• Antibiotics: IV antibiotics per hospital protocols

Management - Take (3)

• Blood cultures (consider CSF, urine, sputum cultures)
• Lactate: serial lactates, arterial blood gases
• Urine output: may need urinary catheter

Conclusions

• Basic knowledge of abdominal pain/thyroid disorders only
• Suspect the NSAID/steroid taking patient and signpost accordingly
• Be alert to the possibility of sepsis

This lesson covers conditions mimicking sepsis and the importance of vigilance in specific patient populations. It also explores abdominal pain assessment, including types of pain and referred pain patterns related to abdominal conditions. The lesson highlights key steps in initial sepsis management.