Causes by site of pain
| Site | Surgical causes | Do not miss |
|---|---|---|
| Right upper quadrant | Biliary colic, cholecystitis, cholangitis, liver abscess, perforated duodenal ulcer | Right lower lobe pneumonia, hepatitis, myocardial infarction, sickle cell crisis |
| Epigastrium | Perforated or bleeding peptic ulcer, pancreatitis, gastric outlet obstruction | Myocardial infarction, aortic dissection, DKA |
| Left upper quadrant | Splenic rupture, splenic infarct (sickle cell), pancreatitis | Left lower lobe pneumonia |
| Periumbilical | Early appendicitis, small bowel obstruction, mesenteric ischaemia, ruptured abdominal aortic aneurysm | — |
| Right iliac fossa | Appendicitis, appendix mass, ileocaecal tuberculosis, typhoid perforation, Crohn's disease, ureteric colic, Meckel's diverticulitis | Ectopic pregnancy, ovarian torsion, pelvic inflammatory disease, testicular torsion |
| Left iliac fossa | Sigmoid volvulus, diverticulitis, colorectal carcinoma, ureteric colic | Ectopic pregnancy, ovarian pathology |
| Loin | Ureteric colic, pyelonephritis, renal abscess | Ruptured aneurysm |
| Suprapubic | Acute urinary retention, cystitis | Pregnancy complications |
| Generalised | Peritonitis (any perforation), obstruction, mesenteric ischaemia, pancreatitis | DKA, sickle cell crisis, porphyria, lead poisoning |
Peritonitis or colic?
| Feature | Peritonitis (inflammation) | Colic (obstruction of a hollow tube) |
|---|---|---|
| Pain | Constant, worse on movement and coughing | Comes in waves, with pain-free spells |
| Patient | Lies still | Restless, rolling about |
| Signs | Guarding, rebound or percussion tenderness, rigidity | Tenderness may be mild between spasms |
| Bowel sounds | Reduced or absent | Normal or hyperactive (obstruction) |
| Examples | Perforation, appendicitis, cholecystitis | Biliary, ureteric, intestinal colic |
Intestinal obstruction
| Feature | Small bowel | Large bowel |
|---|---|---|
| Common causes (Nigeria) | Obstructed hernia, adhesions, intussusception, tuberculosis, worm bolus in children | Sigmoid volvulus, colorectal cancer, faecal impaction |
| Common causes (world) | Adhesions, hernias, Crohn's disease, tumours | Colorectal cancer, diverticular stricture, volvulus |
| Vomiting | Early, bilious, then faeculent | Late |
| Distension | Mild to moderate, central | Marked, flanks |
| Constipation | Late | Early, absolute |
| X-ray | Central loops over 3 cm with valvulae conniventes crossing the whole width ("stack of coins") | Peripheral loops over 6 cm (caecum over 9 cm) with haustra that do not cross the full width |
Signs of strangulation
Constant pain, fever, tachycardia, localised tenderness, peritonism, a tender irreducible hernia, leucocytosis, raised lactate and acidosis. Any of these means surgery now.
Non-operative management of adhesive small bowel obstruction
- "Drip and suck": nasogastric decompression, IV fluids, correct electrolytes
- Water-soluble contrast challenge (100 mL of Gastrografin via nasogastric tube): contrast in the colon on an X-ray within 24 hours predicts resolution
- Operate if there are signs of strangulation, contrast fails to reach the colon, or no resolution in 48–72 hours
Plain X-ray signs to recognise
| Sign | Meaning |
|---|---|
| Free gas under the diaphragm on an erect chest X-ray | Perforated viscus (or recent surgery) |
| Rigler's sign — both sides of the bowel wall visible | Pneumoperitoneum on a supine film |
| Coffee-bean loop from the pelvis | Sigmoid volvulus |
| Thumbprinting | Colonic wall oedema — ischaemic colitis, severe colitis |
| Toxic megacolon — transverse colon over 6 cm | Severe colitis |
| Air in the biliary tree with small bowel obstruction | Gallstone ileus (Rigler's triad adds an ectopic gallstone) |
| Sentinel loop, colon cut-off sign | Acute pancreatitis |
| Portal venous gas, pneumatosis intestinalis | Bowel ischaemia |
Acute pancreatitis
Diagnosis — two of three: typical epigastric pain radiating to the back; lipase or amylase over 3 times the upper limit; characteristic imaging.
Causes — "I GET SMASHED": Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps and other viruses, Autoimmune, Scorpion venom, Hypertriglyceridaemia and hypercalcaemia, ERCP, Drugs (azathioprine, valproate, thiazides, HIV drugs).
Revised Atlanta severity
| Severity | Definition |
|---|---|
| Mild | No organ failure, no local or systemic complications |
| Moderately severe | Transient organ failure (resolves within 48 hours), or local complications |
| Severe | Persistent organ failure (over 48 hours) |
Modified Glasgow (Imrie) score — within 48 hours; 3 or more predicts severe disease
The mnemonic is PANCREAS — tick each criterion that is met.
Modified Glasgow (Imrie) score
Severity of acute pancreatitis, scored within 48 hours of admission.
Score 0 of 8
Predicted mild attack.
Management principles
- Moderate, goal-directed fluids with Hartmann's — for example 1.5 mL/kg/hour after a 10 mL/kg bolus only if hypovolaemic (WATERFALL trial: aggressive fluids increased fluid overload without benefit)
- Early oral or enteral feeding as tolerated; nasojejunal or nasogastric feeding if not
- No prophylactic antibiotics; treat proven infection
- CT at 72–96 hours only if not improving or diagnosis unclear — not on admission
- Gallstone pancreatitis: ERCP within 24 hours only for coexisting cholangitis; cholecystectomy during the same admission for mild disease
- Infected necrosis: antibiotics, then the step-up approach — percutaneous or endoscopic drainage first, delayed necrosectomy (ideally after 4 weeks when walled off)
Emergency laparotomy pathway
- Senior review and risk score (NELA or P-POSSUM) documented
- Antibiotics within 1 hour if sepsis is suspected
- CT reported before surgery where the patient is stable
- Theatre within the NCEPOD timeframe; consultant surgeon and anaesthetist for high-risk patients
- Post-operative critical care for predicted mortality over 5%
- Frailty assessment and geriatric input for those over 65
Examiner questions
References
- O'Connell PR, McCaskie AW, Sayers RD, eds. Bailey & Love's Short Practice of Surgery. 28th ed. Boca Raton: CRC Press; 2023.
- Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis — 2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102–11.
- Di Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery. 2020;15:27.