Surgical Emergencies

Surgical emergency is a medical emergency for which immediate surgical intervention is the only way to solve the problem successfully.

The following conditions are surgical emergencies:

Acute trauma

Acute Pancreatitis

Biliary Colic & Cholecystitis

Massive Upper GI Haemorrhage

Small Bowel Obstruction

Perforated Viscus

Appendicitis

Diverticulitis

Rectal Bleeding

Acute trauma

Trauma is a physiological wound caused by an external source. It can also be described as "a physical wound or injury, such as a fracture or blow". Unintentional and intentional injuries were the fifth and seventh leading causes, accounting for 6.23% and 2.84% of deaths worldwide, respectively in the 2002 World Health Organization estimates of causes of death by rate.

There are many causes of injury that can affect a person in different ways, both anatomically and physiologically. Depending on the severity of injury, quick management and transport to an appropriate facility may be necessary to prevent loss of life or limb. Various classification scales exist for use with trauma to determine the severity of injuries, which is used to determine the resources used and for statistical collection. The initial assessment is critical in determining the extent of injuries and what will be needed to manage an injury. The assessment involves a physical evaluation and can also include the use of imaging tools to accurately determine a type of injury and to formulate a course of treatment.

Classification

Injuries are generally classified by either severity or by the location of damage. Trauma may also be classified by demographic group, such as age or gender. It may also be classified by the type of force applied to the body, such as blunt trauma or penetrating trauma. Clinically, injury is classified using the Barell matrix, which is based on ICD-9-CM data for the purposes of research collection and analysis. The purpose of the matrix is to internationally standardize the classification of trauma. Major trauma is sometimes classified by body area; injuries affecting 40% are polytrauma, 30% head injuries, 20% chest trauma, 10%, abdominal trauma and 2%, extremity trauma

Various scales exist to provide a quantifiable metric to measure the severity of injuries. The value can be used for triaging a patient or for statistical analysis. Injury scales measure damage to anatomical parts, physiological values (blood pressure etc.), comorbidities or a combination of those. The abbreviated injury scale and the Glasgow coma scale are commonly used to quantify injuries for the purpose of triaging and allow a system to monitor or "trend" a patient's condition in a clinical setting.The data can also be used in epidemiological investigations and for research purposes.

Causes

Injuries can be caused by any combination of external forces that act physically against the body. The leading causes of traumatic death are blunt trauma, motor vehicle collisions and falls. Subsets of blunt trauma, are the number one and two causes of traumatic death.

For statistical purposes, injuries are classified as either intentional such as suicide, or unintentional, such as a motor vehicle collision. Intentional injury is a common cause of traumas. Penetrating trauma is caused when a foreign body such as a bullet or a knife enters the body tissue, creating an open wound. In the United States, most deaths caused by penetrating trauma occur in urban areas and 80% of these deaths are caused by firearms. Blast injury is a complex cause of trauma because it commonly includes both blunt and penetrating trauma, and may also be accompanied by a burn injury. Trauma may also be associated with a particular activity, such as an occupational or sports injury

Pathophysiology

The body responds to traumatic injury both systemically and at the injury site. This response attempts to protect vital organs such as the liver, to allow further cell duplication and to heal the damage. The healing time of an injury depends on various factors including sex, age, and the severity of injury.

The symptoms of injury can manifest in many different ways including:

Altered mental status

Fever

Increased heart rate

Generalized edema

Increased cardiac output

Increased rate of metabolism

Various organ systems respond to injury to restore homeostasis by maintaining perfusion to the heart and brain. Inflammation after injury occurs to protect against further damage and starts the healing process. Prolonged inflammation can cause multiple organ dysfunction syndrome or systemic inflammatory response syndrome. Immediately after injury, the body increases production of glucose through gluconeogenesis and its consumption of fat via lipolysis. Next, the body tries to replenish its energy stores of glucose and protein via anabolism. In this state the body will temporarily increase its maximum expenditure for the purpose of healing injured cells

prevention

By identifying risk factors present within a community and creating solutions to decrease the incidence of injury, trauma referral systems can help to enhance the overall health of a population. Commonly, injury prevention strategies are used to prevent injuries in children, who are a high risk population. Generally, injury prevention strategies involve educating the general public about specific risk factors and developing strategies to avoid or reduce injuries. Legislation intended to prevent injury typically involves seatbelts, child car seats, helmets, alcohol control, and increased enforcement.

The use of drugs such as alcohol or cocaine increases the risk of trauma by increasing the likelihood of traffic collisions, violence and abuse occurring. Other drugs such as benzodiazepines increase the risk of trauma in elderly people.

The care of acutely injured people in a public health system involved bystanders, community members, health care professionals, and health care systems. It encompasses pre-hospital trauma assessment and care by emergency medical services personnel, emergency department assessment, treatment, and stabilization, and in-hospital care among all age groups. An established trauma system network is also an important component of community disaster preparedness, facilitating the care of people who have been involved in disasters that cause large numbers of casualties, such as earthquakes

acute pancreatitis

The most important point in the management of pancreatitis is fluid balance and as such every effort should be made to obtain good IV access and accurate measure of fluid status. The incidence is increasing and estimated to be 150 to 420 cases per million population - so it is a common surgical emergency.

Pancreatitis can be fatal; several deaths a year occur because of it.  It is helpful inl cases of pancreatitis to have a Ransom or Glasgow score estimated to identify those most at risk. These are only useful in the fiorst 48-hrs after the onset of pain; after this the CRP level is much more useful for prognosis and severity of the disease.

Diagnosis

Suspect it in all cases of abdominal (& chest) pain

Sudden onset abdominal pain radiating to back.

Often associated with nausea and vomiting.

Grey Turner's sign (flanks) / Cullen's sign (umbilicus) - RARE & A VERY LATE SIGN (patient is most likely to already be on ITU)

O/E abdomen can be rigid (peritonitic)

Serum Amylase > 1000 i.u. / ml (this is not a marker of severity)

Serum Lipase is far more specific (but expensive and not widely available)

Predicting Severity

Severe pancreatitis can be predicted from the following:

Initial assessment

Clinical impression of severity

BMI > 30

Pleural effusion on CXR

APACHE II score >8 (details here)

24hr later

Clinical impression of severity

APACHE II score >8

Glasgow score >= 3

Persisting organ failure esp if multiple

CRP > 150mg/l

48hr later

Clinical impression of severity

Glasgow score >= 3

Ranson Score >= 3

CRP > 150mg/l

Persisting organ failure

Multiple or progressive organ failure

Initial Management consists of:

Obtain wide bore 14G venflon access in both ACF.

Start crystalloid infusion 1 litre stat - monitor response closely

Take blood for: FBC, U&E, LFT, LDH, Ca2+, Amylase, and Arterial Blood Gases.

Insert a catheter.

Ensure the nurses do strict hourly fluid balance.

Consider a CVP line in those initially predicted to have severe pancreatitis.

Nasogastric tube for all patients on free drainage & 4 hrly aspiration.

IV Cefuroxime 750mg TDS – all patients. - see below

Morphine analgesia is not contraindicated, give a decent dose 5-15mg 2-3 hrly.  May need a PCA – ask for anaesthetic help

Patients can have clear fluids PO.

Aim for a urine output of >40 mls per hr.

Monitor SaO2 if PaO2 is low

DVT prophylaxis for all patients

Obstructed biliary systems need Rx within 24-hrs!

Timing of surgery

Mild gallstone pancreatitis - early (within 2-weeks) laparoscopic cholecystectomy if fit, consider ERCP & sphincterotomy in the unfit

Severe gallstone pancreatitis - laparoscopic cholecystectomy after signs of lung injury and systemic disturbance have resolved

Acute pancreatic necrosis - the patient should be managed in a specialist hepatobiliary unit.

Feeding in Pancreatitis

There is no need to restrict food inpatients with pancreatitis

If feeding causes pain, consider using enteral supplements

The evidence is not conclusive to support enteral feeding in all patients with severe acute pancreatitis. If nutritional support is required the enteral route is best.

Nasogastric feeding should be used unless there is conclusive evidence of gastric outflow problems in which case naso-jejunal feeding should be considered. Nasogastric feeding is successful in over 80% of patients.

when to do CT scan?

Patients with persisting organ failure, signs of sepsis, or deterioration in clinical status 6–10 days after admission will require a CT

Antibiotics in Pancreatitis

The evidence about antibiotic prophylaxis to prevent infection is conflicting and difficult to interpret

Some trials show benefit, others do not

The latest guidance (GUT 2005) provide no concensus on the issue

If antibiotics are used, use in predicted severe cases only and for a maximum of 14-days

Remember there is a difference between antibiotic prophylaxis to prevent infected pancreatic necrosis and the treatment of infective complications of pancreatitis. 

There is no evidence that antibiotics in mild cases alter the course of the illness and may in fact cause more problems than they attempt to cure (eg C.diff)

Biliary Colic & Cholecystitis

In the textbooks the pain one gets with these conditions is different, the former colicky and the latter sharp.  In practise the patients description of the pain can be somewhere between the 2 fro both conditions.  Management is different between the 2 conditions. Gallstones are common  -1:8 men and 1:4 women will get them. Prevalence increases with age. 80% of stones remain asymptomatic

Distinguishing Between The 2 Conditions

Symptoms and signs go some way (in a typical presentation)

Fever, raised WCC more suggestive of cholecystitis

Don’t bother with ESR or CRP – it is raised in both and of no help

Initial Management

Pain relief is the very important.

Patients can have clear fluids only until the USS is done.  No milky drinks at all, inc milk in tea or coffee

Check FBC, U&E, LFT

Patients with suspected cholecystitis need IV Cefuroxime. Patients with biliary colic DO NOT.

If jaundice is present then add Metronidazole.

Make sure you get accurate fluid balance charts

Arrange an USS ASAP

DVT Prophylaxis for all patients

Continuing Management

Fat free diet can be introduced after the USS.  Go back to fluids if the pain is worse.

Jaundiced patients with a high Bn & ALP need urgent referral to Gastroenterologist for consideration of ERCP.  For this you will need available recent FBC, U&E, LFT, and Clotting Studies.

In fit patients consider early lap chole (preferably within same admission)

 Biliary Colic

Spasmodic Central epigastric pain, sometimes felt on the right

No fever, may have tachycardia if pain is bad

tender over gallbladder if it is distended

 Cholecystitis

 

 Constant sharp/stabbing pain in right upper quadrant

may radiate to Rt shoulder/back

Fever, tachycardia

Tenderness in right upper quadrant

Murphy's sign - guarding in right upper quadrant on deep inspiration

Massive Upper GI Bleed

Massive Upper GI Haemorrhage

Overview

Mortality of this condition is around 10% so prompt management is vital

2 distinct patient groups

older with co-morbidities - highest mortality risk

young & alcohol

x2 more common in men

Causes

Peptic ulcer (DU & Gastric = 50%) / Gastric erosions

alcohol

steroids/NSAIDs

Oesophageal or gastric varices

Mallory-Weiss tear

Angiodysplasia

Gastric cancer

Initial Management

You will usually encounter this in A&E resus where there will be plenty of people to help.  Just in case it happens to you on the ward at 3am……..

Get a nurse to call for help; you cannot resuscitate someone on your own.

Place 2 large 14G (brown) venflons in the antecubital veins and give fluid ++.  It does not matter too much which fluid you use, just give it otherwise the patient may die. Crystalloids (as per ATLS are safest)

Take blood from the venflon before you give the fluid for a crossmatch (8 units), clotting, and U&E.  FBC is useful but not essential.

Transfuse to maintain a hemoglobin level of 8-10 g.  Early aggressive fluid resus will reduce mortality.

The primary goal here is fluid resuscitation prior to definitive intervention (by endoscopy +/- surgery). The use of H2-receptor antagonists has not been shown to be effective in altering the course of UGIB.  PPIs are more effective as they probably protect the ulcer clot from fibrinolysis.

Get a nurse to get the crash trolley and have it next to the patient

Get the patients notes to the bed and try and find out some history – alcoholic, varices, ulcer etc

Put in a urinary catheter

Do not attempt to put in a central line even if you know how to do it.  You cannot resuscitate down one (remember Laplace’s law), the patient is likely to be uncooperative and you will waste valuable resuscitation time putting it in on your own.  Central lines are useful after initial resuscitation to guide further fluid replacement.

Give 10mg IV metoclopramide (makes the gastro-oesophageal sphincter contract)

If the patient is distressed give 1-2mg IV morphine.  Increase in 1-2mg aliquots every 5-10 mins

When your seniors arrive get on the phone to the lab and request:

X-match 8 units + 4 units of FFP + 4 Units cryoprecipitate

Clotting and U&E (+/- FBC)

If the patient is in extremis fast bleep the anaesthetist if he/she is not already there

If the patient is in extremis get the O-negative blood (from the lab if the haematology MLSO is on site, labour ward or A&E)

Find out from switchboard who is on-call for endoscopy

Further / Definitive Management

Joint medical / Surgical care optimises outcome

Urgent / Emergency OGD by anendoscopist experience in GI bleeding is essential

rebleeding characteristics at OGD

active bleeding (pulsatile, oozing)

visible vessel

adherent clot

Available OGD techniques:

sclerosant or epinephrine injection

heater probe coaptive coagulation

bipolar probe coaptive coagulation

haemostatic clip placement

laser therapy

The choice of treatment modality is influenced by the size of the vessel.

Surgical intervention should be considered with vessels larger than 2 mm in diameter

Angiographic embolization considered in the high risk patient.

In the patient who has an ulcer with an overlying clot, attempting to remove the clot by target washing is critical.

The findings under the clot help determine Tx needed

Rebleeding occurs in 10-30% of endoscopically treated patients.

A second attempt at endoscopic control is warranted in most cases.

Do not be fooled - surgery has a rebleed rate tooand mortality varies with the surgical intervention performed

Surgical options include:

under-run ulcer

partial gastrectomy

total gastrectomy

oesophageal transection

Vagotomy is rarely performed these days

Shunting & TIPPS - only in expert hands under specific condotions

Small Bowel Obstruction

Overview

There is no such thing as ‘subacute obstruction’ – you are either obstructed or not!

Accounts for around 10% of all acute surgical admissions

50-60% of the ‘obstructed patients we admit have adhesion related obstruction and will settle with appropriate conservative management.

There is no value in getting both a supine and erect AXR.  However, all patients should have both a CXR and plain supine AXR.

The majority of the problems experienced by patients with bowel obstruction are due to inadequate fluid management.  There are often massive fluid shifts in these patients and this must be corrected as a matter of priority.  Subsequent management then focuses on the aetiology of the obstruction.

Clinical Features

Abdominal pain - colicky, cramping

sharp & board rigid abdomen if bowel perforates

There is little relationship between the timing of pain & onset of vomiting (despite what is said in the texts).

Nausea & Vomiting

Diarrhea - early or post-obstruction after it has resolved)

Constipation - late

Fever and tachycardia - late, associated with strangulation or perforation

Previous surgery, radiotherapy

History of malignancy

Abdominal distention

Hyperactive 'tinkling' bowel sounds- early

Absent bowel sounds - late.

Initial Management

At least one decent size (green or brown) venflon in the ACF.

Take blood for U&E, FBC, Amylase

Order CXR (erect) and AXR (supine), consider CT scan

Put in a urinary catheter and ask for hourly fluid balance

Use crystalloid for resuscitation.  Do not write up bag after bag of normal saline as you can induce a hyperchloraemic metabolic acidosis.  3 litres of fluid over 24 hours will only cover maintenance fluids (30-40 mls kg-1 24hr-1), you need this plus any calculated losses .  It depends on the level of obstruction what losses the patient will have, eg high SBO lose proportionately more Na+ than lower down in the GI tract

NG tube in all patients even if not vomiting

clear fluids by mouth are allowed once NG is in place

Morphine analgesia

DVT prophylaxis - all patients

You do not need to start antibiotics unless there is clinical evidence of sepsis or in at-risk patients

Continuing Management

You need to identify those patients with strangulated obstruction - early surgical intervention is required

Get the old notes

Definite obstruction in a patient with no previous abdominal surgery needs a laparotomy

Adhesion obstruction not settling after 4-5/7 needs a laparotomy

There is no value in serial AXRs

Patients not settling with no clear indication for a laparotomy may benefit from a CT abdomen

Central lines are only required in patients with difficult fluid balance problems

Perforated Abdominal Viscus

Overview

Commonly due to either perforated peptic ulcer or colon (cancer, diverticulitis, ischamia etc).

Plain erect CXR is not always diagnostic, esp. if the abdomen is full of fluid.  The patient must be sat up at 90-degrees for at least 10 mins before you do the CXR.  If there is doubt CT is far more sensitive.

Upper GI perforations (stomach, duodenum) are usually 'sterile', but cause chemical peritonitis

Colonic perforations usually cause severe sepsis

Any penetrating injury below the nipples can cause abdominal organ perforation

Clinical Features

Careful history is essential

Penetrating injury or blunt trauma (RTA, seat belt injury etc) to the lower chest or abdomen

Aspirin, NSAIDs, or steroid intake - elderly

Alcohol & drugs - younger

known history of PUD,Crohns, UC, Cancer etc

Abdominal pain

Usually sharp & stabbing

Localised pain - may be walled off by abdominal organs &/or omentum

Generalised pain with free perforation (also board rigid abdomen, pal, sweaty etc)

Vomiting

May be shocked due to sepsis - remember this presents differently in young and old patients

Abdominal examination

board rigid

knees drawn up

brusing, injuries etc

listening to bowel sounds - probably little use

Knowledge of abdominal anatomy is essential to formulating a sensible differential diagnosis

Initial Management

Like many surgical emergencies this is mainly fluid balance in the first instance

These patients are usually in agony from the chemical / bacterial peritonitis and require sensible doses of morphine.  Use 10mg of Morphine in 10mls H2O and give in 3-4ml doses every 10-15 mins until comfortable if required.

Large bore 14G (brown) venflon, 2 litres of crystalloid to be run in relatively quickly

NG tube to empty stomach, catheter

Blood for G+S, FBC, U&E, ABG, and blood cultures

Erect CXR,

Consider CT. USS can be very useful in experienced hands

Peritoneal lavage in blunt trauma has a role, CT first though

If fluid balance is a problem make arrangements to insert a central line to guide replacement

Antibiotics are indicated - use local policies

Continuing Management

Laparotomy is usually indicated – inform theatre and anaesthetist

Initial laparoscopy if experienced enough may prevent the need for laparotomy at al or at least target the incision

If space is available and in appropriate circumstances the patient can be transferred pre-operatively to the HDU for optimisation.

Don’t forget DVT prophylaxis

Potential Post-operative Complications

Wound infection

more common in colonic perforation than upper GI perforation.

prophylactic antibiotics will reduce wound infections.

Wound dehiscence

Partial - skin opens

Total - full abdominal dehiscence

Late - Incisional hernia

Malnutrition, Sepsis, Uremia & renal failure, DM, Steroids & immunosuppresants, Obesity & poor surgical technique all contribute to wound dehiscence.

Chest & other infections

Abdominal abscess

Multiorgan failure / septic shock

Renal failure

Acute Appendicitis

Introduction

Accounts for 2-10% surgical admissions

Almost twice as common in men

Any age affected, commonest in 20s & 30s

You can have it more than once - getting it does not always mean an operation or admission to hospital is required

A normal appendix is removed in 1:5 cases

There are no diagnostic tests, scoring systems or algorithms that give a conclusive diagnosis – Appendicitis is a clinical diagnosis based on experience.

As for diagnosing the type of inguinal hernia - you will be wrong 50% of the time

In general, 50% of the RIF pain you see in A&E goes home, 25% have mesenteric adenitis and the rest genuine appendicitis.

Please remember to do an Amylase!

Please remember to do a pregnancy test in ALL women who are in their childbearing years.

Don’t waste money on CRP, or ESR, but do dipstick the urine!

Don’t start antibiotics before surgery, unless the patient is septic and you have done blood cultures first.

Clinical Features

Classically - central colicky abdominal pain moving becoming sharp right iliac fossa pain

Nausea, vomiting, anorexia, foetor oris

Pyrexia - degree depends on level of sepsis

Rovsing's sign = pain in right iliac fossa on palpation of the left iliac fossa - NOT diagnostic or always present

Investigations

Are for narrowing the differential (below), not for making the diagnosis

Pregnacy test - see above

Amylase - see above

Plain AXR - waste of time

USS - useful in experienced hands, but only if the appendix can be visualised

CT - only really indicated if a mass is palpable (but do USS first in younger patients)

Differential Diagnosis

Mesenteric Adenitis

UTI

Non-specific abdominal pain (NSAP)

Pelvic inflammatory disease (PID)

Renal colic

Ectopic pregnancy

Constipation (this is not a diagnosis, but a symptom)

Crohn's disease

Caecal carcinoma

Mucocele of the gallbladder

Psoas abscess

Pelvic kidney

Ovarian cyst

diverticulitis

Treatment

Adequate analgesia

Antibiotics only with evidence of sepsis

Period of active observation if there is clinical doubt (esp in children) - this means free fluids can be taken

Never be afraid to ask for a second opinion (esp in children)

Diagnostic laparoscopy is very useful esp in women. If a 'firm' clinical diagnosis is made in men, there is little benefit in laparoscopy except in overweight patients.

5mm laparoscope in children is useful

Try to avoid muscle cutting incisions - they are painful

Acute Diverticulitis

Overview

Implies inflammation +/- infection and is distinct from diverticulosis

Rough incidence of diverticular disease is 50% at age 50yrs

Although very common - the vast majory 80-90% remain relatively asymptomatic

Commoner in countries with westernised diets

Classically presents with LIF pain +/- PR bleeding +/- Pyrexia

DDx is cancer of the colon – remember!

On examination you must be thorough - obviously particularly the abdomen - are there any masses? DO NOT FORGET TO DO A PR

Clinical Features

See perforated abdominal viscus

LIF pain common, but site depends on where the disease is presenting in the colon (rare on right)

Pain may be crampy +/- change in bowel habit

Nausea and vomiting, constipation, diarrhea, flatulence, and bloating etc etc.....

If perforation has occurred - seee perforated abdominal viscus

Commonly tenderness in the area of the affected area (often LIF)

In complicated with abscess formation, a tender palpable mass

If a fistula forms, the Sx & Si depend on the site of fistula.

Staging

Several staging schemes available - the most useful is clinical staging by Hinchey's classification (as it can help dictate surgical intervention):

Stage I - Small or confined pericolic or mesenteric abscess

Stage II - Large abscess, often confined to the pelvis

Stage III - Perforated diverticulitis causing generalized purulent peritonitis

Stage IV - Rupture of diverticula into the peritoneal cavity with fecal contamination causing generalized fecal peritonitis

Initial Management

Check the WCC, HB & Amylase, other blood tests are only needed if medically indicated

Dipstick the urine and send some for culture

Place the patient on free fluids, no solid food, but enteral supplements can be used

Start IV Cefuroxime 750mg TDS + IV Metronidazole 500mg TDS

Get a plain AXR

Consider an early CT

Continuing Management

Patient can start ‘low residue’ diet as pain starts to settle and then goes onto ‘high residue’  (i.e. high fibre) when completely settled

Consider USS pelvis in women

Patients not settling after 48hrs need a CT abdo & Pelvis

Bowel needs to be imaged preferably by colonoscopy once the pain has settled.

The timing and need for surgical intervention is complicated and shouldbe discussed with the patients and a consultant colorectal surgeon:

Hinchey stage I may be treated medically without surgical intervention

Hinchey stage II may be treated by radiological drainage and medical treatment

Hinchey stage III/IV disease almost always requires surgical intervention

Elective surgery previously recommended in those who had 2 or more episodes of diverticulitis successfully treated medically; however, recent data call this practice into question when the patient is otherwise healthy - this very much depends on the patient and requires in-depth discussion and should be made on a case-by-case basis.

A 2-stage surgical approach is the most common & safest surgical procedure:

Hartmann's procedure with reversal 3-6 months later. This is the preferred & recomended approach in patients with faecal peritonitisand sepsis.

The alternative is resection of the diseased colon, primary anastomosis and proximal diverting stoma - this is for experienced surgeons only who can make the correct decision to perform this based on intr-operative findings - it is not recomended in faecal peritonitis

There is no role for lavage and drainage as morbidity and mortality are significantly higher

Rectal Bleeding

Overview

Very common surgical referral

Seen mainly in the elderly

Underlying cause is influenced by age

rarely requires surgical intervention (at least in the acute phase)

Essential to establish a good history from the patient and/or relative as to the amount and colour, clots, duration, mixed with stool or separate, in the pan or on the toilet tissue, any other symptoms e.g. pain, melaena/haematemesis, pruritis ani, tenesmus, urgency, weight/appetite loss, family history of cancer, change in bowel habit from normal for them, urinary symptoms etc.

Possible Causes

Diverticular Disease

Angiodysplasia  

Ischemic colitis  

Radiation-induced colitis/proctits (esp in men with Rx for prostate cancer) 

Rectal or colonic cancer

Ischaemic colitis

Infectious colitis 

Inflammatory Bowel Disease

Idiopathic colitis  

Anorectal causes

hemorrhoids

fistula

fissures

polyps

Drug-induced bleeding is caused mainly by NSAIDs

Other vascular causes

polyarteritis nodosa

Wegener granulomatosis

Aortocolonic fistula (post AAA surgery)

Investigations

As most patients tend to be stable they can be investigated once bleeding has stopped as an outpatient

In the actively bleeding patient consider:

Colonoscopy - experienced endoscopist required

Upper GI endoscopy for brisk bleeds

Selective mesenteric angiography - experienced radilogist required andthe above need to be done first

Initial Management

May need rapid resuscitation if bleeding heavily (see massive upper GI bleed)

If bleeding ++ and bright red there is a good chance it is from an upper GI source – get hold of the on-call endoscopist ASAP

Large venflons & Crystalloid infusion

Check HB, U&E, Clotting

Check for PMH of Crohn’s / Colitis, recent foreign travel etc

Do a PR

If bleeding ++ call a senior

Catheterise

Continuing Management

If bleeding ++ and once an upper GI source has been excluded then a mesenteric angiogram is required. 

Blind colectomy has no place as there is a good chance the wrong piece of bowel will be removed, and access to localising investigations is much easier now than in years gone by.

There is a potential role for on-table lavage and pan-endoscopy