Surgical Emergencies Project - Storage
Created | Updated Jan 13, 2012
<ARTICLE>
<SUBJECT>Surgical Emergencies: Introduction</SUBJECT>
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<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B>
Surgical Emergencies</B><BR/>
<LINK H2G2="A46290323">Acute Appendicitis</LINK> |
<LINK H2G2="A14173742">Acute Pancreatitis</LINK> |
<LINK H2G2="A13756854">Acute Diverticulitis</LINK> |
<LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK> |
<LINK H2G2="A46289794">Testicular Torsion </LINK><BR/>
<LINK H2G2="A13738539">Extradural Haematoma</LINK> |
<LINK H2G2="A14088477">Acute Limb Ischaemia</LINK> |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>There are many medical emergencies that require the urgent attention of medical staff. The way these are treated varies greatly depending upon the problem; however, some are usually only treatable by surgery, and require the individual to be looked after by a surgical team. This project looks at some of the common surgical emergencies in detail:</P>
<UL>
<LI><LINK H2G2="A46290323">Acute Appendicitis</LINK></LI>
<LI><LINK H2G2="A14173742">Acute Pancreatitis</LINK></LI>
<LI><LINK H2G2="A13756854">Acute Diverticulitis</LINK></LI>
<LI><LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK></LI>
<LI><LINK H2G2="A46289794">Testicular Torsion </LINK></LI>
<LI><LINK H2G2="A13738539">Extradural Haematoma</LINK></LI>
<LI><LINK H2G2="A14088477">Acute Limb Ischaemia</LINK></LI>
<LI><LINK H2G2="A45561080">Intussusception</LINK></LI>
<LI><LINK H2G2="A52005773">Ectopic Pregnancy</LINK></LI>
<LI><LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK></LI>
</UL>
<P>Those not covered above are in themselves numerous, and this entry will not attempt to talk about broken bones or traumatic blood loss.</P>
<HEADER>Dealing with Emergencies</HEADER>
<P>Various concerning symptoms can hint at the presence of an emergent surgical condition but many of these, such as nausea, vomiting, and abdominal pain, are found in a wide range of conditions. Diagnosis of a disease often combines the precise nature or site of a symptom, the pattern of associated symptoms, the timing of onset and any changes since, examination of the affected part, and relevant blood tests and scans. Thus any individual who has a concerns about their wellbeing probably ought to get in touch with a medical professional.</P>
<P>If a General Practitioner or out-of-hours doctor suspects a surgical emergency they will refer them to the surgical team at the nearest hospital, who will see them in <LINK H2G2="A58060631">A+E</LINK> or on a surgical admissions unit. Patients brought in by ambulance or who self-present to A+E are either seen by the emergency medics and referred to the surgeons, or may be seen by the surgeons straight off.</P>
<P>As well as taking a <LINK H2G2="A37235577">history</LINK> and examining the patient, the doctors will often tell the patient not to eat or drink anything, insert a cannula (bendy piece of plastic), send off blood for testing, start intravenous fluids and medications, and send the patient for x-rays or a scan. This represents a combination of securing a diagnosis and making sure the patient is treated appropriately pending any potential need for surgery. A catheter may be inserted into the bladder to measure urine output, and a tube may need to be inserted through the nose into the stomach (a nasogastric tube) if the bowel is thought to be obstructed or otherwise affected by the underlying problem. The use of anti-clotting drugs to prevent clots in the legs is commonplace in surgical patients, provided there is no underlying bleeding or clotting problem.</P>
<P>Patients requiring theatre should ideally be kept Nil By Mouth for six hours before an anaesthetic, although rapid induction of the anaesthetic and airway tube can be used if there are concerns about reflux of stomach contents up through the gullet. Hospitals will have an emergency theatre, for which emergency operations are listed and performed according to priority – some emergencies have to be operated upon immediately, and will pull rank over cases that can wait for a few hours. Such emergency surgery will take place at day or night, weekday or weekend, though if time allows the patient's resilience to surgery will be maximised with intravenous fluids and drugs before taking them to theatre.</P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
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</GUIDE><EXTRAINFO><TYPE ID="1" /></EXTRAINFO></ARTICLE>
<ARTICLE>
<SUBJECT>Surgical Emergencies: Acute Appendicitis</SUBJECT>
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<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B><LINK H2G2="A13746477">
Surgical Emergencies</LINK></B><BR/>
Acute Appendicitis |
<LINK H2G2="A14173742">Acute Pancreatitis</LINK> |
<LINK H2G2="A13756854">Acute Diverticulitis</LINK> |
<LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK> |
<LINK H2G2="A46289794">Testicular Torsion </LINK><BR/>
<LINK H2G2="A13738539">Extradural Haematoma</LINK> |
<LINK H2G2="A14088477">Acute Limb Ischaemia</LINK> |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>The appendix is a blind-ending pouch that lies at the very start of the colon (large intestine), quite close to the point where the small bowel opens into the colon. Though it has no apparent use in humans, it is quite capable of becoming blocked by <LINK H2G2="A4113811">faeces</LINK>, allowing it to become inflamed and infected. The result, appendicitis, produces perhaps as many as one in ten surgical admissions to hospital. As surgery is not always performed (and it is not always appendicitis), it is quite possible to suffer with the condition more than once.</P>
<HEADER>Symptoms</HEADER>
<P>The pain of appendicitis initially begins near the belly button, as the nerves supplying the appendix are related to this part of the abdomen. Once the inflammation reaches the surrounding tissues, the pain will localise in the right lower part of the abdomen over the site of the appendix. The exact site of the appendix varies and therefore so does the pain, although the typical hotspot will be two-thirds of the way from the belly button to the hip – this is known as McBurney's point. Appendicitis can also cause fever, nausea, vomiting, loss of appetite and fetid breath.</P>
<HEADER>Diagnosis and Treatment</HEADER>
<P>Diagnosis is based upon the above symptoms, plus examination of the abdomen. A rigid abdomen with tenderness over McBurney's point is typical. It is important to rule out other diseases with similar appearances – for instance <LINK H2G2="A52005773">ectopic pregnancy</LINK> must be ruled out with a pregnancy test, and <LINK H2G2="A14173742">acute pancreatitis</LINK> should be checked for with a blood test. A wide range of diseases may be to blame, including <LINK H2G2="A13756854">diverticulitis</LINK>, kidney stones, urinary infections, gallbladder infection, and diseases of the ovaries and uterus.</P>
<P>If the symptoms are mild and blood tests are reassuring, the individual may be observed closely for a while. Children in particular may start to recover, showing that the diagnosis may instead be mesenteric adenitis – inflammation of the <LINK H2G2="A948819">immune</LINK> nodes that line the gut. However, in cases where the diagnosis and severity of disease are unclear, the individual is often taken to theatre for exploration of the abdomen. This can usually be done using a camera inserted through a small cut in the abdominal wall.</P>
<P>Treatment consists of removal of the appendix, which will be confirmed as abnormal by the laboratory in 80% of cases. This too can sometimes be done using keyhole surgery. In some cases, the surgeons will find a collection of pus (abscess) associated with the appendicitis, or even a ruptured appendix with infective contents leaked out into the abdomen. These can necessitate a larger wound, and are also treated with removal of the appendix plus copious washout of the abdomen with sterile fluid.</P>
<HEADER>Conclusion</HEADER>
<P>Appendicitis is a common surgical emergency, which is diagnosed through clinical examination and may only be confirmed at operation. A number of other conditions can produce the same appearance and some, such as ectopic pregnancy, represent equally important emergencies that must be ruled out.</P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
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</GUIDE><EXTRAINFO><TYPE ID="1" /></EXTRAINFO></ARTICLE>
<ARTICLE>
<SUBJECT>Surgical Emergencies: Acute Pancreatitis</SUBJECT>
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<BODY>
<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B><LINK H2G2="A13746477">
Surgical Emergencies</LINK></B><BR/>
<LINK H2G2="A46290323">Acute Appendicitis</LINK> |
Acute Pancreatitis |
<LINK H2G2="A13756854">Acute Diverticulitis</LINK> |
<LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK> |
<LINK H2G2="A46289794">Testicular Torsion </LINK><BR/>
<LINK H2G2="A13738539">Extradural Haematoma</LINK> |
<LINK H2G2="A14088477">Acute Limb Ischaemia</LINK> |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>The pancreas sits at the back of the abdomen, and is responsible for producing both the hormones that control blood sugar, such as insulin, and small gut <LINK H2G2="A3328355">enzymes</LINK> that digest food. The enzymes normally drain though a little duct which opens into the small gut a little downstream from the stomach – here the pancreatic duct joins with the duct system that drains the gallbladder<FOOTNOTE>The gallbladder concentrates bile, which is required for fat digestion. This bile can form into lumps known as gallstones.</FOOTNOTE> and <LINK H2G2="A134920">liver</LINK>. Acute pancreatitis is the inflammation of the pancreas, and most commonly occurs in <LINK H2G2="A13785014">overweight</LINK> middle-aged ladies and <LINK H2G2="A46288399">alcoholics</LINK>. It should not be confused with chronic pancreatitis, which is the long-standing damage that may sometimes follows, causing chronic pain.</P>
<HEADER>What Causes It?</HEADER>
<P>While common triggers include gallstones, <LINK H2G2="A29443179">excessive alcohol</LINK> and traumatic injury of the pancreas, the exact cause is not always found. Acute pancreatitis occurs when damage to pancreatic tissue causes the release of gut enzymes into the space between cells – the pancreas effectively tries to digest itself, which is understandably rather unpleasant. <LINK H2G2="A948819">Inflammatory cells</LINK> then arrive and produce various chemicals that only add to the problem.</P>
<HEADER>How Is It Diagnosed?</HEADER>
<P>The main symptom is upper abdominal <LINK H2G2="A653302">pain</LINK> that spreads to the back, and which may be relieved a little by sitting forward. The pain can come on suddenly or gradually, and is often accompanied by nausea and vomiting. The individual may be very unwell with a fever, rapid heart rate, falling blood pressure and a rigid tummy. Bruising around the flanks or belly button can occur (Grey Turner's and Cullen's signs, respectively), but these are unusual signs that turn up quite late on.</P>
<P>The amount of the gut enzyme amylase in the bloodstream can be measured, and is found to be massively raised in acute pancreatitis. Other blood tests will also indicate whether the cause is likely to be something as important as pancreatitis.</P>
<HEADER>Mild versus Severe</HEADER>
<P><I>Mild pancreatitis</I> tends to be self-limiting, affecting only the pancreas with no complications. It is still, however, quite unpleasant and may recur if the underlying cause is not removed.</P>
<P><I>Severe pancreatitis</I> occurs when the degree of inflammation produces complications, affecting either the pancreas itself or other organs:</P>
<UL>
<LI>Death of the pancreatic tissue (necrosis) may occur.</LI>
<LI>A collection of pus, or abscess, may develop within the pancreas, or the inflammation may damage nearby sections of gut or blood vessels.</LI>
<LI>High blood sugar, and potentially <LINK H2G2="A314920">diabetes mellitus</LINK>, will occur if the pancreas is unable to produce enough insulin.</LI>
<LI>Low blood calcium levels may occur, leading to muscle spasm and reduced conscious level if untreated.</LI>
<LI>Inflammation of the <LINK H2G2="A27019505">lungs</LINK> leads to poor exchange of oxygen between inhaled air and the bloodstream. This is referred to as Acute Respiratory Distress Syndome (ARDS) and can require artificial ventilation to support the lungs.</LI>
<LI>Inflammatory chemicals in the blood stream can cause rapid clotting, using up all the blood's clotting materials in a reaction known as Disseminated Intravascular Coagulation (DIC).</LI>
<LI>Other organs may be affected, leading to Multiple Organ Dysfunction Syndrome.</LI>
</UL>
<P>Severe pancreatitis is potentially life-threatening, and patients with severe disease should ideally be cared for on a high-dependency or intensive care unit. Scores such as the Glasgow Criteria or Ranson's Criteria can be used to determine the likely severity of the disease based on various markers. To demonstrate, here's the Glasgow Criteria:</P>
<UL>
<LI><B>P</B>aO2 < 60mmHg – a low blood oxygen level may occur due to degrees of lung inflammation.</LI>
<LI><B>A</B>ge > 55 – older patients are more likely to suffer from severe pancreatitis.</LI>
<LI><B>N</B>eutrophils (WBC > 15x10^9) – a higher level of inflammatory cells in the bloodstream can indicate severe disease.</LI>
<LI><B>C</B>alcium < 2 mmols/L – as mentioned, pancreatitis can cause low blood calcium, particularly in severe cases.</LI>
<LI><B>R</B>enal (urea > 16 mmols/L)– the kidneys remove urea from the blood, and a rising urea indicates problems.</LI>
<LI><B>E</B>nzymes (LDH >600) – raised liver enzymes indicate underlying gallstone disease or liver involvement.</LI>
<LI><B>A</B>lbumin – severe pancreatitis can cause leaking of albumin (the most common protein in the blood) out of the bloodstream.</LI>
<LI><B>S</B>ugar – as mentioned, failure of the pancreas to produce insulin will cause a rise in blood sugar.</LI>
</UL>
<P>Score 0-2: Likely mild pancreatitis.<BR/>Score >2: Likely severe pancreatitis.</P>
<HEADER>Treatment</HEADER>
<P>As the inflammation of the pancreas will cause leakage of fluid out of the bloodstream into the tissues, fluid management is very important. Early on in the treatment of pancreatitis, it is normal to have a cannula (bendy piece of plastic) inserted into a large vein and plenty of intravenous fluids given. The doctor will send off blood for the above tests, and ask the nurses to keep a close eye on input and output of fluids – this often necessitates a catheter (a tube inserted up into the bladder to drain urine). As if this were not enough, a tube should also be inserted into the stomach, via the nose (hence a 'nasogastric' tube), to drain the contents – this relieves any pressure on the gut and pancreas below. It is normal to restrict the individual to clear fluids only by mouth, at least until things start to improve. Antibiotics are given mostly in severe cases, whereas pain relief is important in every case of pancreatitis.</P>
<P>Once the initial treatment has been started, the individual can be sent for scans of the gallbladder, drainage ducts and pancreas, to look for gallstones and for complications of pancreatitis.</P>
<P>In severe pancreatitis where the pancreatic tissue has died, it can become necessary to remove the dead tissue. This is known as a necrosectomy. If a collection of pus (abscess) forms, this should ideally be drained. If enough of the pancreas is damaged, it may be necessary to given replacement insulin and gut enzymes.</P>
<P>If the underlying cause is gallstones, these need sorting out as soon as possible. This can often be done using a telescope passed down into the stomach to reach the biliary duct – this is known as endoscopic retrograde cholangiopancreatography (ERCP), and can be used to treat gallstone disease and widen the entrance of the drainage ducts. Surgery to remove the gallbladder should be performed as soon as practical, although sometimes this must be delayed to allow inflammation to settle.</P>
<HEADER>Summary</HEADER>
<P>Acute pancreatitis is due to inflammation of an important gland, usually due to gallstones, alcoholism or trauma. It requires prompt treatment with intravenous fluids, and is investigated and closely monitored by the surgical team as it can produce dangerous complications if severe.</P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
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<ARTICLE>
<SUBJECT>Surgical Emergencies: Acute Diverticulitis</SUBJECT>
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<BODY>
<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B><LINK H2G2="A13746477">
Surgical Emergencies</LINK></B><BR/>
<LINK H2G2="A46290323">Acute Appendicitis</LINK> |
<LINK H2G2="A14173742">Acute Pancreatitis</LINK> |
Acute Diverticulitis |
<LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK> |
<LINK H2G2="A46289794">Testicular Torsion </LINK><BR/>
<LINK H2G2="A13738539">Extradural Haematoma</LINK> |
<LINK H2G2="A14088477">Acute Limb Ischaemia</LINK> |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>The large bowel, or colon, is responsible for reasborbing water from the faeces, which go from being liquid to solid as they pass clockwise through the colon to reach the rectum. With a Western diet, the stools are less fibre-filled and take more pushing to get them round to the rectum – as with squeezing a toothpaste tube, the colon has to push harder when it is almost empty. At many points in the colon, little blood vessels pass through the outer wall, creating weak points. With the excess pressure demanded by the Western diet, little outpouchings form at these points. These are known as diverticuli, and having them is referred to as diverticular disease. This is present in maybe as many as half of all Westerners over 50, and in most cases causes no symptoms. However, if these diverticuli become inflamed or infected – diverticulitis – then, much in the manner of the <LINK H2G2="A46290323">appendix</LINK>, they can cause problems.</P>
<HEADER>Diagnosis and Initial Treatment</HEADER>
<P>Diverticulitis most commonly occurs in the sigmoid colon – the part on the lower left side of the abdomen shortly before the rectum. It often causes pain and tenderness here, along with fever, nausea, vomiting, bloating, diarrhoea or constipation, and may result in <LINK H2G2="A23499039">rectal bleeding</LINK>.</P>
<P>All cases of diverticulitis are treated with antibiotics and put on a fluids-only diet in order to rest the colon. An abdominal x-ray and a CT scan of the colon may be sought early on to aid diagnosis and determine the severity of the disease. Individuals with mild disease will recover after 24-48 hours and can move to a 'low residue' diet, building up to a full fibre-containing diet once fully recovered. Given the age group affected, it is common to examine the colon using a special telescope (<LINK H2G2="A19645220">colonoscopy</LINK>) once symptoms have settled down, in order to rule out any sinister problems.</P>
<HEADER>An Emergency?</HEADER>
<P>Diverticulitis represents in the cases where the infection does not settle, as a collection of pus (abscess) may form, and the diverticuli may even rupture, allowing infected pus or faecal material into the abdomen. In these cases emergency surgery is warranted, to remove the offending section of bowel. The common approach is a Hartmann's operation, where the upstream bowel is then brought out to the skin to form a stoma, while the downstream bowel is closed up. This may be reversed around six months later. The alternative, removing the offending bowel and then joining up the ends, is liable to fail as the joined ends will be infected with pus or faecal material.</P>
<HEADER>Summary</HEADER>
<P>Diverticulitis is the inflammation and infection of outpouchings of the large bowel, causing pain, bleeding and bowel symptoms. It is sometimes treatable with antibiotics and bowel rest, but severe cases require urgent surgery.</P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
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<ARTICLE>
<SUBJECT>Surgical Emergencies: Bowel Obstruction, Perforation and Ischaemia</SUBJECT>
<GUIDE>
<BODY>
<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B><LINK H2G2="A13746477">
Surgical Emergencies</LINK></B><BR/>
<LINK H2G2="A46290323">Acute Appendicitis</LINK> |
<LINK H2G2="A14173742">Acute Pancreatitis</LINK> |
<LINK H2G2="A13756854">Acute Diverticulitis</LINK> |
Bowel Obstruction and Perforation |
<LINK H2G2="A46289794">Testicular Torsion</LINK><BR/>
<LINK H2G2="A13738539">Extradural Haematoma</LINK> |
<LINK H2G2="A14088477">Acute Limb Ischaemia</LINK> |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>Appendicitis, diverticulitis and pancreatitis represent just a few problems that may involve the bowel. The main intestinal tract can suffer from obstruction, perforation, strangulation of herniated bowel, or other lack of blood supply (mesenteric ischaemia) – all surgical emergencies and thus worth covering here. It is worth noting that various severe infections within the abdomen cause similar symptoms and signs, adding to the challenge of correctly diagnosing the cause of the problem. As a result, individuals with severe abdominal symptoms are treated as detailed in the <LINK H2G2="A13746477">introduction</LINK>.</P>
<HEADER>General Presentation</HEADER>
<P>Most bowel-related emergencies will produce some combination of abdominal pain, nausea, vomiting, loss of appetite, constipation, abdominal tenderness, rigid abdominal wall and, in the cases such as hernias, a mass. The combination is usually enough to cause the individual to present to hospital, and will give away the fact that they are unwell. The causes of abdominal pain are many, though, and the story alone may not allow the surgeon to identify the exact diagnosis. Specific clues in the history and examination may help, as can blood tests and scans, but in some cases it is necessary to take the individual to theatre to look inside the abdomen. This may be done by passing a camera into the abdomen through a small cut, but in severely unwell individuals it is common to open the abdomen using a large midline incision.</P>
<HEADER>Obstruction</HEADER>
<P>Obstruction of the intestine accounts for perhaps one in five surgical admissions, and although the problem is usually mechanical, the cause and site of the blockage both vary. The most common causes of small bowel obstruction are strangulated hernias and adhesions between bowel loops, whereas large bowel obstruction is often a sign of bowel cancer in the older individual but can also be due to diverticular disease, volvulus of the sigmoid colon (just before the rectum), or a number of other causes. As well as simply blocking the bowel, obstruction causes leakage of vast quantities of fluid into the bowel, which in turn worsens the pressure head above the obstruction. It is possible for the bowel to perforate (see below), or to strangulate its blood supply.</P>
<P>Symptoms include central abdominal pain, which comes and goes as the gut contracts, abdominal distension and vomiting. Strangulation will produce constant pain with a tender abdomen, and perforation will produce a rigid 'washing board' abdomen. The initial treatment is for the individual to be Nil By Mouth, given intravenous fluids, and have a nasogastric tube inserted via the nose to allow free drainage of the stomach, which takes the pressure head off the bowel. Antibiotics are used if strangulation or perforation is suspected. A CT scan of the abdomen will help determine the cause, and guide as to what form of surgery is required to fix the underlying problem.</P>
<HEADER>Volvulus</HEADER>
<P>The intestine hangs reasonably free in the abdomen, attached to the back of the abdomen by a plane of tissue known as the mesentery. The mesentery contains the blood vessels that supply the bowel wall and muscles. It is possible for the bowel to twist on its mesentery, cutting off its blood supply while also obstructing itself – this is known as volvulus. This occurs most commonly in those with a high fibre diet and those who are prone to constipation, in particular institutionalised elderly individuals. A volvulus effectively produces the symptoms of bowel obstruction, and is usually detectable on a plain abdominal x-ray. Provided there is no suggestion that the twisted section of gut has begun to die, it is possible to treat a sigmoid volvulus (one just above the rectum) by passing a scope up into the large bowel and using a tube to decompress the bowel contents. However, in sigmoid volvulus complicated by dead bowel, and in cases of caecal volvulus (those occuring where the small bowel meets the large bowel), surgery is necessary to remove the affected bowel.</P>
<HEADER>Strangulated Hernia</HEADER>
<P>A hernia is the protrusion of abdominal contents – often bowel – out through a weakness in the lining of the abdominal cavity. If the hernia is reducible (can be pushed back in), it usually does not represent an emergency. However, if the hole through which the bowel protrudes is narrow the bowel can become stuck. If the drainage of blood from the bowel is thus cut off, the herniated bowel will become swollen and, given enough time, will die. So-called strangulated hernias are life-threatening surgical emergencies, requiring surgery correct the hernia and remove any dead bowel found at operation.</P>
<HEADER>Mesenteric Ischaemia</HEADER>
<P>Mesenteric ischaemia occurs when the blood supply to the bowel's supporting mesentery is cut off. This is often due to obstruction of the blood vessels with clots from the left atrium of the heart – clot formation here occurs if the heart is beating either weakly or in the wrong rhythm, as this allows blood to sit and stagnate in the atrium. The pain of mesenteric ischaemia is usually much greater than the physical signs found on examination, and is thus difficult to diagnose except when the abdominal contents are examined in theatre, revealing a dead section of bowel.</P>
<HEADER>Perforation</HEADER>
<P>Perforation of the bowel can occur at any point from the gullet down to the rectum, though the causes differ – the gullet may rupture due to forceful vomiting, the stomach may perforate due to a deep ulcer, and the bowel may perforate due to bowel ischaemia (lack of blood supply), <LINK H2G2="A46290323">appendicitis</LINK>, <LINK H2G2="A13756854">diverticulitis</LINK>, obstruction, or a number of other diseases of the bowel. It may present as localised pain and tenderness if the perforation is walled off by structures within the abdomen, but otherwise will generally produce a rigid, painful abdomen and a particularly sick patient. Perforation usually necessitates a trip to theatre to remove the perforated bowel and washout the surrounding tissues to remove as much contamination as possible.</P>
<HEADER>Summary</HEADER>
<P>There are a number of emergencies involving the bowel, many of which present with similar symptoms. Examination and scans are often vital in making the correct diagnosis, although sometimes it is necessary to look inside the abdomen in order to find out what is really happening. </P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
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</GUIDE><EXTRAINFO><TYPE ID="1" /></EXTRAINFO></ARTICLE>
<ARTICLE>
<SUBJECT>Surgical Emergencies: Testicular Torsion</SUBJECT>
<GUIDE>
<BODY>
<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B><LINK H2G2="A13746477">
Surgical Emergencies</LINK></B><BR/>
<LINK H2G2="A46290323">Acute Appendicitis</LINK> |
<LINK H2G2="A14173742">Acute Pancreatitis</LINK> |
<LINK H2G2="A13756854">Acute Diverticulitis</LINK> |
<LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK> |
Testicular Torsion <BR/>
<LINK H2G2="A13738539">Extradural Haematoma</LINK> |
<LINK H2G2="A14088477">Acute Limb Ischaemia</LINK> |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>The testicles are each supplied with blood via a spermatic cord, which surrounds the relevant blood vessels, nerves and muscles as they pass out of the abdominal cavity and down into the scrotum. If the testicle becomes twisted on its spermatic cord, the blood vessels are compressed and the testicle loses blood supply. This causes intense testicular and/or abdominal <LINK H2G2="A653302">pain</LINK>, often followed by light-headedness, nausea and even vomiting. Urgent surgery within 4-6 hours is usually required to save the testicle. The problem is most common towards the beginning of puberty, and so any young boy with testicular pain ought to see a doctor as a matter of some urgency.</P>
<HEADER>What Causes it?</HEADER>
<P>Testicular torsion sometimes occurs following injury to the testes or as a result of strenuous activity. <LINK H2G2="A20218709">Cold weather</LINK> is also blamed, as the movement from warm to cold environs causes the scrotum to contract around the testicle, potentially trapping a slightly-twisted testicle. In most cases, it is an abnormality in the development of the testes that allows them sufficient mobility to become twisted. During normal development, the back of the testicle becomes stuck to inner lining of the scrotum; however, in the so-called '<LINK H2G2="A1304786">bell</LINK>-clapper deformity', the testicle hangs free inside the scrotum, making it more likely to twist on its cord.</P>
<HEADER>Diagnosis and Treatment</HEADER>
<P>Suspecting torsion is important, as the diagnosis is based mainly on the sudden onset of testicular pain. The presence of an 'exquisitely' painful, high-riding testicle would be typical in testiculat torsion, but there are large enough grey areas that doubt as to the diagnosis cannot be entertained. Swelling of the testes is more common in mumps<FOOTNOTE>Viral infection and swelling of the testes and salivary glands.</FOOTNOTE> or epididymitis<FOOTNOTE>Inflammation of the epididymis, which sits next to the testicle and stores maturing sperm.</FOOTNOTE>, and adults are less likely to have the condition, but if there is reason to suspect torsion then surgery becomes mandatory. Scanning of the testicular blood vessels using an ultrasound probe to look at blood flow is sometimes used to rule out an unlikely case of torsion, but surgery remains the only way to be absolutely sure, and is generally regarded as best practice.</P>
<P>Surgery involves examination of the scrotal contents under anaesthetic, with the torsion being corrected if the testicle is still alive. (If the testicle is dead, it must be removed to prevent infection.) Once the torsion has been corrected, the testicle is secured by sewing it to the scrotal inner wall behind it. This is known as orchidopexy, and is often done for the normal testicle as well as the torted one, so as to prevent future problems.</P>
<HEADER>Summary</HEADER>
<P>Testicular torsion is due to sudden twisting of the testicle, resulting in a lack of blood supply, severe pain, and the need for urgent surgery to save the testicle.</P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
</BODY>
</GUIDE><EXTRAINFO><TYPE ID="1" /></EXTRAINFO></ARTICLE>
<ARTICLE>
<SUBJECT>Surgical Emergencies: Extradural Haematoma</SUBJECT>
<GUIDE>
<BODY>
<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B><LINK H2G2="A13746477">
Surgical Emergencies</LINK></B><BR/>
<LINK H2G2="A46290323">Acute Appendicitis</LINK> |
<LINK H2G2="A14173742">Acute Pancreatitis</LINK> |
<LINK H2G2="A13756854">Acute Diverticulitis</LINK> |
<LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK> |
<LINK H2G2="A46289794">Testicular Torsion </LINK><BR/>
Extradural Haematoma |
<LINK H2G2="A14088477">Acute Limb Ischaemia</LINK> |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>Several blood vessels supply the lining of the brain, and this includes the three meningeal arteries on each side of the skull. The middle meningeal artery is particularly important as it runs through the skull near the temple at a weak point called the pterion. This makes it particularly prone to damage following a serious head injury. A torn meningeal artery will bleed into the potential space between the skull and the outer lining of the brain<FOOTNOTE>The layers covering the brain are known as the dura, arachnoid and pia mater. Bleeding outside of the dura mater is thus said to be 'extradural' or 'epidural'.</FOOTNOTE>. The pooling blood (haematoma) creates and enlarges a gap between the skull and the dura, putting pressure on the brain and forcing it to shift towards the opposite side of the skull.</P>
<P>Extradural haematomas are just one type of bleed within the skull. Subdural haematomas occur, often in the elderly, following a bump to the head, but develop slowly and do no present as emergencies. Subarachnoid haemorrhages also occur, whereby a blood vessel more closely related to the brain bursts due to an aneurysm. These produce a severe sudden onset 'thunderclap' headache and do present as emergencies; however, they are often treated from the inside via the blood vessels, and are covered in the entry on <LINK H2G2="A2315990">aneurysms</LINK>.</P>
<HEADER>Symptoms and Signs</HEADER>
<P>The individual unfortunate enough to suffer an extradural haematoma will initially recover from the head injury, but may then become drowsy or vomit. The pupil on the injured side will become dilated ('blown') as the third <LINK H2G2="A646139">cranial nerve</LINK> on that side is compressed by the shifting brain. A low heart rate, fixed dilated pupils on both sides, reduced consciousness and abnormal movements will follow. If the bleeding continues it will eventually push the brain down against the base of the skull and into the spinal column – this is known as 'coning' and is fatal.</P>
<HEADER>Diagnosis and Treatment</HEADER>
<P>The diagnosis can be suspected based upon the above, and is confirmed with a CT scan of the head. This shows the collection of blood clearly pooling between the skull and the brain. Drugs and careful intensive care management can be used to improve blood supply to the brain and reduce swelling. However, definitive treatment must be surgical, namely the drilling of a burr hole in the skull to allow the haematoma to be evacuated. If this is done quickly enough, most patients can make a full recovery, though this is dependent on them being fit for surgery.</P>
<HEADER>Summary</HEADER>
<P>An extradural haematoma forms following trauma to one of the blood vessels running through the skull. Though it is potentially life-threatening, in many cases emergency surgery will completely restore the patient.</P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
</BODY>
</GUIDE><EXTRAINFO><TYPE ID="1" /></EXTRAINFO></ARTICLE>
<ARTICLE>
<SUBJECT>Surgical Emergencies: Acute Limb Ischaemia</SUBJECT>
<GUIDE>
<BODY>
<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B><LINK H2G2="A13746477">
Surgical Emergencies</LINK></B><BR/>
<LINK H2G2="A46290323">Acute Appendicitis</LINK> |
<LINK H2G2="A14173742">Acute Pancreatitis</LINK> |
<LINK H2G2="A13756854">Acute Diverticulitis</LINK> |
<LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK> |
<LINK H2G2="A46289794">Testicular Torsion </LINK><BR/>
<LINK H2G2="A13738539">Extradural Haematoma</LINK> |
Acute Limb Ischaemia |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>The arms and legs rely on a good blood supply in order to function – in particular, the leg muscles have a high requirement for oxygen and do not tolerate a reduction in blood supply. If the blood supply to a limb is slowly blocked off over a matter of months or years, so-called 'collateral' blood vessels may be able to take on the work, thus allowing the muscles some degree of blood supply. This manifests as intermittent claudication, where muscle pain is experienced above a certain level of exercise. However, if the blood supply is suddenly cut off due to complete blockage of the main vessel, there is no time for collateral vessels to develop. The result is acute limb ischaemia: a sudden onset of a pale, painful, cold limb that requires urgent treatment. </P>
<HEADER>What Causes It?</HEADER>
<P>Atherosclerosis is a disease of the inner lining of blood vessels whereby a plaque of fatty material accumulates and harden on the artery wall. This is the cause of most heart attacks, as the coronary arteries are gradually blocked off by plaques, and is also the cause of some strokes due to disease of the blood vessels supplying the brain. The aorta can be affected, causing weakening of its wall and thus the fomration of an <LINK H2G2="A2315990">atherosclerotic aneurysm</LINK>. Unsurprisingly, this disease actually affects all arteries, including those in the arms and legs. As atherosclerosis is accelerated by an unhealthy diet and smoking, it provides a good advertisement for a healthy diet.</P>
<P>Thus, the majority of cases of intermittent claudication and acute limb ischaemia are due to narrowing of the limb arteries due to fatty plaque formation. As with the heart and brain, acute ischaemia of the limb occurs if the plaque suddenly ruptures, blocking the vessel.</P>
<P>It is also possible for a free-floating clot (embolus) to drift along an artery and become stuck in the narrowing. These clots are usually from the left atrium of the heart – clot formation here occurs if the heart is beating either weakly or in the wrong rhythm, as this allows blood to sit and stagnate in the atrium.</P>
<HEADER>Treatment</HEADER>
<P>An acutely ischaemic limb requires urgent treatment, else it will eventually become all of the six 'P's: pale, painful, pulseless, paraesthetic (pin and needles), paralysed and perishingly cold. A dose of anti-clotting medication should be given provided there is no underlying bleeding risk. When a limb has lost both feeling and movement, surgery is required urgently to restore blood supply. If this does not occur, surgery will instead be required to amputate the affected part. Sometimes restoration of blood supply causes the limb to swell up, requiring further surgery to relieve the pressure inside the muscle compartments.</P>
<P>In the case of atherosclerotic arteries, it is necessary to create a bypass around the obstruction using either veins borrowed from elsewhere, or synthetic graft material. In severe intermittent claudication, such surgery is preceded by a scan using a contrast material to show where artery is obstructed. However, in acute limb ischaemia there is little time, and the contrast will only show the start of the blockage as there are no collateral vessels leading to the other end.</P>
<P>An embolus blocking the artery is sometimes so inaccessible as to require treatment with a clot-busting drug (which comes with a risk of bleeding and bruising), but can usually be removed from the artery surgically. Originally this was done by opening the artery at the site of the obstruction and pulling out the embolus by hand. However, an American surgeon by the name of Thomas J Fogarty became distressed by the poor survival rate following such procedures. The result was the Fogarty catheter consists of a tube with an inflatable balloon at the end. The catheter can enter the artery through a small cut at the groin and be fed down past the clot; once the balloon has passed through the blockage, it is inflated and then pulled back out, bringing the embolus with it. It is estimated that this apparently simple idea has saved millions of lifes and limbs.</P>
<HEADER>Summary</HEADER>
<P>Fatty plaques will cause the arteries to narrow slowly over time and cause intermittent pain on exercise, but a plaque rupture or embolus of a clot from the heart can fully obstruct an artery suddenly, leading a a limb that is cold, pale, painful and liable to be lost unless the blood supply can be restored quickly.</P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
</BODY>
</GUIDE><EXTRAINFO><TYPE ID="1" /></EXTRAINFO></ARTICLE>
<SUBJECT>Surgical Emergencies: Introduction</SUBJECT>
<GUIDE>
<BODY>
<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B>
Surgical Emergencies</B><BR/>
<LINK H2G2="A46290323">Acute Appendicitis</LINK> |
<LINK H2G2="A14173742">Acute Pancreatitis</LINK> |
<LINK H2G2="A13756854">Acute Diverticulitis</LINK> |
<LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK> |
<LINK H2G2="A46289794">Testicular Torsion </LINK><BR/>
<LINK H2G2="A13738539">Extradural Haematoma</LINK> |
<LINK H2G2="A14088477">Acute Limb Ischaemia</LINK> |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>There are many medical emergencies that require the urgent attention of medical staff. The way these are treated varies greatly depending upon the problem; however, some are usually only treatable by surgery, and require the individual to be looked after by a surgical team. This project looks at some of the common surgical emergencies in detail:</P>
<UL>
<LI><LINK H2G2="A46290323">Acute Appendicitis</LINK></LI>
<LI><LINK H2G2="A14173742">Acute Pancreatitis</LINK></LI>
<LI><LINK H2G2="A13756854">Acute Diverticulitis</LINK></LI>
<LI><LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK></LI>
<LI><LINK H2G2="A46289794">Testicular Torsion </LINK></LI>
<LI><LINK H2G2="A13738539">Extradural Haematoma</LINK></LI>
<LI><LINK H2G2="A14088477">Acute Limb Ischaemia</LINK></LI>
<LI><LINK H2G2="A45561080">Intussusception</LINK></LI>
<LI><LINK H2G2="A52005773">Ectopic Pregnancy</LINK></LI>
<LI><LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK></LI>
</UL>
<P>Those not covered above are in themselves numerous, and this entry will not attempt to talk about broken bones or traumatic blood loss.</P>
<HEADER>Dealing with Emergencies</HEADER>
<P>Various concerning symptoms can hint at the presence of an emergent surgical condition but many of these, such as nausea, vomiting, and abdominal pain, are found in a wide range of conditions. Diagnosis of a disease often combines the precise nature or site of a symptom, the pattern of associated symptoms, the timing of onset and any changes since, examination of the affected part, and relevant blood tests and scans. Thus any individual who has a concerns about their wellbeing probably ought to get in touch with a medical professional.</P>
<P>If a General Practitioner or out-of-hours doctor suspects a surgical emergency they will refer them to the surgical team at the nearest hospital, who will see them in <LINK H2G2="A58060631">A+E</LINK> or on a surgical admissions unit. Patients brought in by ambulance or who self-present to A+E are either seen by the emergency medics and referred to the surgeons, or may be seen by the surgeons straight off.</P>
<P>As well as taking a <LINK H2G2="A37235577">history</LINK> and examining the patient, the doctors will often tell the patient not to eat or drink anything, insert a cannula (bendy piece of plastic), send off blood for testing, start intravenous fluids and medications, and send the patient for x-rays or a scan. This represents a combination of securing a diagnosis and making sure the patient is treated appropriately pending any potential need for surgery. A catheter may be inserted into the bladder to measure urine output, and a tube may need to be inserted through the nose into the stomach (a nasogastric tube) if the bowel is thought to be obstructed or otherwise affected by the underlying problem. The use of anti-clotting drugs to prevent clots in the legs is commonplace in surgical patients, provided there is no underlying bleeding or clotting problem.</P>
<P>Patients requiring theatre should ideally be kept Nil By Mouth for six hours before an anaesthetic, although rapid induction of the anaesthetic and airway tube can be used if there are concerns about reflux of stomach contents up through the gullet. Hospitals will have an emergency theatre, for which emergency operations are listed and performed according to priority – some emergencies have to be operated upon immediately, and will pull rank over cases that can wait for a few hours. Such emergency surgery will take place at day or night, weekday or weekend, though if time allows the patient's resilience to surgery will be maximised with intravenous fluids and drugs before taking them to theatre.</P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
</BODY>
</GUIDE><EXTRAINFO><TYPE ID="1" /></EXTRAINFO></ARTICLE>
<ARTICLE>
<SUBJECT>Surgical Emergencies: Acute Appendicitis</SUBJECT>
<GUIDE>
<BODY>
<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B><LINK H2G2="A13746477">
Surgical Emergencies</LINK></B><BR/>
Acute Appendicitis |
<LINK H2G2="A14173742">Acute Pancreatitis</LINK> |
<LINK H2G2="A13756854">Acute Diverticulitis</LINK> |
<LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK> |
<LINK H2G2="A46289794">Testicular Torsion </LINK><BR/>
<LINK H2G2="A13738539">Extradural Haematoma</LINK> |
<LINK H2G2="A14088477">Acute Limb Ischaemia</LINK> |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>The appendix is a blind-ending pouch that lies at the very start of the colon (large intestine), quite close to the point where the small bowel opens into the colon. Though it has no apparent use in humans, it is quite capable of becoming blocked by <LINK H2G2="A4113811">faeces</LINK>, allowing it to become inflamed and infected. The result, appendicitis, produces perhaps as many as one in ten surgical admissions to hospital. As surgery is not always performed (and it is not always appendicitis), it is quite possible to suffer with the condition more than once.</P>
<HEADER>Symptoms</HEADER>
<P>The pain of appendicitis initially begins near the belly button, as the nerves supplying the appendix are related to this part of the abdomen. Once the inflammation reaches the surrounding tissues, the pain will localise in the right lower part of the abdomen over the site of the appendix. The exact site of the appendix varies and therefore so does the pain, although the typical hotspot will be two-thirds of the way from the belly button to the hip – this is known as McBurney's point. Appendicitis can also cause fever, nausea, vomiting, loss of appetite and fetid breath.</P>
<HEADER>Diagnosis and Treatment</HEADER>
<P>Diagnosis is based upon the above symptoms, plus examination of the abdomen. A rigid abdomen with tenderness over McBurney's point is typical. It is important to rule out other diseases with similar appearances – for instance <LINK H2G2="A52005773">ectopic pregnancy</LINK> must be ruled out with a pregnancy test, and <LINK H2G2="A14173742">acute pancreatitis</LINK> should be checked for with a blood test. A wide range of diseases may be to blame, including <LINK H2G2="A13756854">diverticulitis</LINK>, kidney stones, urinary infections, gallbladder infection, and diseases of the ovaries and uterus.</P>
<P>If the symptoms are mild and blood tests are reassuring, the individual may be observed closely for a while. Children in particular may start to recover, showing that the diagnosis may instead be mesenteric adenitis – inflammation of the <LINK H2G2="A948819">immune</LINK> nodes that line the gut. However, in cases where the diagnosis and severity of disease are unclear, the individual is often taken to theatre for exploration of the abdomen. This can usually be done using a camera inserted through a small cut in the abdominal wall.</P>
<P>Treatment consists of removal of the appendix, which will be confirmed as abnormal by the laboratory in 80% of cases. This too can sometimes be done using keyhole surgery. In some cases, the surgeons will find a collection of pus (abscess) associated with the appendicitis, or even a ruptured appendix with infective contents leaked out into the abdomen. These can necessitate a larger wound, and are also treated with removal of the appendix plus copious washout of the abdomen with sterile fluid.</P>
<HEADER>Conclusion</HEADER>
<P>Appendicitis is a common surgical emergency, which is diagnosed through clinical examination and may only be confirmed at operation. A number of other conditions can produce the same appearance and some, such as ectopic pregnancy, represent equally important emergencies that must be ruled out.</P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
</BODY>
</GUIDE><EXTRAINFO><TYPE ID="1" /></EXTRAINFO></ARTICLE>
<ARTICLE>
<SUBJECT>Surgical Emergencies: Acute Pancreatitis</SUBJECT>
<GUIDE>
<BODY>
<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B><LINK H2G2="A13746477">
Surgical Emergencies</LINK></B><BR/>
<LINK H2G2="A46290323">Acute Appendicitis</LINK> |
Acute Pancreatitis |
<LINK H2G2="A13756854">Acute Diverticulitis</LINK> |
<LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK> |
<LINK H2G2="A46289794">Testicular Torsion </LINK><BR/>
<LINK H2G2="A13738539">Extradural Haematoma</LINK> |
<LINK H2G2="A14088477">Acute Limb Ischaemia</LINK> |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>The pancreas sits at the back of the abdomen, and is responsible for producing both the hormones that control blood sugar, such as insulin, and small gut <LINK H2G2="A3328355">enzymes</LINK> that digest food. The enzymes normally drain though a little duct which opens into the small gut a little downstream from the stomach – here the pancreatic duct joins with the duct system that drains the gallbladder<FOOTNOTE>The gallbladder concentrates bile, which is required for fat digestion. This bile can form into lumps known as gallstones.</FOOTNOTE> and <LINK H2G2="A134920">liver</LINK>. Acute pancreatitis is the inflammation of the pancreas, and most commonly occurs in <LINK H2G2="A13785014">overweight</LINK> middle-aged ladies and <LINK H2G2="A46288399">alcoholics</LINK>. It should not be confused with chronic pancreatitis, which is the long-standing damage that may sometimes follows, causing chronic pain.</P>
<HEADER>What Causes It?</HEADER>
<P>While common triggers include gallstones, <LINK H2G2="A29443179">excessive alcohol</LINK> and traumatic injury of the pancreas, the exact cause is not always found. Acute pancreatitis occurs when damage to pancreatic tissue causes the release of gut enzymes into the space between cells – the pancreas effectively tries to digest itself, which is understandably rather unpleasant. <LINK H2G2="A948819">Inflammatory cells</LINK> then arrive and produce various chemicals that only add to the problem.</P>
<HEADER>How Is It Diagnosed?</HEADER>
<P>The main symptom is upper abdominal <LINK H2G2="A653302">pain</LINK> that spreads to the back, and which may be relieved a little by sitting forward. The pain can come on suddenly or gradually, and is often accompanied by nausea and vomiting. The individual may be very unwell with a fever, rapid heart rate, falling blood pressure and a rigid tummy. Bruising around the flanks or belly button can occur (Grey Turner's and Cullen's signs, respectively), but these are unusual signs that turn up quite late on.</P>
<P>The amount of the gut enzyme amylase in the bloodstream can be measured, and is found to be massively raised in acute pancreatitis. Other blood tests will also indicate whether the cause is likely to be something as important as pancreatitis.</P>
<HEADER>Mild versus Severe</HEADER>
<P><I>Mild pancreatitis</I> tends to be self-limiting, affecting only the pancreas with no complications. It is still, however, quite unpleasant and may recur if the underlying cause is not removed.</P>
<P><I>Severe pancreatitis</I> occurs when the degree of inflammation produces complications, affecting either the pancreas itself or other organs:</P>
<UL>
<LI>Death of the pancreatic tissue (necrosis) may occur.</LI>
<LI>A collection of pus, or abscess, may develop within the pancreas, or the inflammation may damage nearby sections of gut or blood vessels.</LI>
<LI>High blood sugar, and potentially <LINK H2G2="A314920">diabetes mellitus</LINK>, will occur if the pancreas is unable to produce enough insulin.</LI>
<LI>Low blood calcium levels may occur, leading to muscle spasm and reduced conscious level if untreated.</LI>
<LI>Inflammation of the <LINK H2G2="A27019505">lungs</LINK> leads to poor exchange of oxygen between inhaled air and the bloodstream. This is referred to as Acute Respiratory Distress Syndome (ARDS) and can require artificial ventilation to support the lungs.</LI>
<LI>Inflammatory chemicals in the blood stream can cause rapid clotting, using up all the blood's clotting materials in a reaction known as Disseminated Intravascular Coagulation (DIC).</LI>
<LI>Other organs may be affected, leading to Multiple Organ Dysfunction Syndrome.</LI>
</UL>
<P>Severe pancreatitis is potentially life-threatening, and patients with severe disease should ideally be cared for on a high-dependency or intensive care unit. Scores such as the Glasgow Criteria or Ranson's Criteria can be used to determine the likely severity of the disease based on various markers. To demonstrate, here's the Glasgow Criteria:</P>
<UL>
<LI><B>P</B>aO2 < 60mmHg – a low blood oxygen level may occur due to degrees of lung inflammation.</LI>
<LI><B>A</B>ge > 55 – older patients are more likely to suffer from severe pancreatitis.</LI>
<LI><B>N</B>eutrophils (WBC > 15x10^9) – a higher level of inflammatory cells in the bloodstream can indicate severe disease.</LI>
<LI><B>C</B>alcium < 2 mmols/L – as mentioned, pancreatitis can cause low blood calcium, particularly in severe cases.</LI>
<LI><B>R</B>enal (urea > 16 mmols/L)– the kidneys remove urea from the blood, and a rising urea indicates problems.</LI>
<LI><B>E</B>nzymes (LDH >600) – raised liver enzymes indicate underlying gallstone disease or liver involvement.</LI>
<LI><B>A</B>lbumin – severe pancreatitis can cause leaking of albumin (the most common protein in the blood) out of the bloodstream.</LI>
<LI><B>S</B>ugar – as mentioned, failure of the pancreas to produce insulin will cause a rise in blood sugar.</LI>
</UL>
<P>Score 0-2: Likely mild pancreatitis.<BR/>Score >2: Likely severe pancreatitis.</P>
<HEADER>Treatment</HEADER>
<P>As the inflammation of the pancreas will cause leakage of fluid out of the bloodstream into the tissues, fluid management is very important. Early on in the treatment of pancreatitis, it is normal to have a cannula (bendy piece of plastic) inserted into a large vein and plenty of intravenous fluids given. The doctor will send off blood for the above tests, and ask the nurses to keep a close eye on input and output of fluids – this often necessitates a catheter (a tube inserted up into the bladder to drain urine). As if this were not enough, a tube should also be inserted into the stomach, via the nose (hence a 'nasogastric' tube), to drain the contents – this relieves any pressure on the gut and pancreas below. It is normal to restrict the individual to clear fluids only by mouth, at least until things start to improve. Antibiotics are given mostly in severe cases, whereas pain relief is important in every case of pancreatitis.</P>
<P>Once the initial treatment has been started, the individual can be sent for scans of the gallbladder, drainage ducts and pancreas, to look for gallstones and for complications of pancreatitis.</P>
<P>In severe pancreatitis where the pancreatic tissue has died, it can become necessary to remove the dead tissue. This is known as a necrosectomy. If a collection of pus (abscess) forms, this should ideally be drained. If enough of the pancreas is damaged, it may be necessary to given replacement insulin and gut enzymes.</P>
<P>If the underlying cause is gallstones, these need sorting out as soon as possible. This can often be done using a telescope passed down into the stomach to reach the biliary duct – this is known as endoscopic retrograde cholangiopancreatography (ERCP), and can be used to treat gallstone disease and widen the entrance of the drainage ducts. Surgery to remove the gallbladder should be performed as soon as practical, although sometimes this must be delayed to allow inflammation to settle.</P>
<HEADER>Summary</HEADER>
<P>Acute pancreatitis is due to inflammation of an important gland, usually due to gallstones, alcoholism or trauma. It requires prompt treatment with intravenous fluids, and is investigated and closely monitored by the surgical team as it can produce dangerous complications if severe.</P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
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</GUIDE><EXTRAINFO><TYPE ID="1" /></EXTRAINFO></ARTICLE>
<ARTICLE>
<SUBJECT>Surgical Emergencies: Acute Diverticulitis</SUBJECT>
<GUIDE>
<BODY>
<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B><LINK H2G2="A13746477">
Surgical Emergencies</LINK></B><BR/>
<LINK H2G2="A46290323">Acute Appendicitis</LINK> |
<LINK H2G2="A14173742">Acute Pancreatitis</LINK> |
Acute Diverticulitis |
<LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK> |
<LINK H2G2="A46289794">Testicular Torsion </LINK><BR/>
<LINK H2G2="A13738539">Extradural Haematoma</LINK> |
<LINK H2G2="A14088477">Acute Limb Ischaemia</LINK> |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>The large bowel, or colon, is responsible for reasborbing water from the faeces, which go from being liquid to solid as they pass clockwise through the colon to reach the rectum. With a Western diet, the stools are less fibre-filled and take more pushing to get them round to the rectum – as with squeezing a toothpaste tube, the colon has to push harder when it is almost empty. At many points in the colon, little blood vessels pass through the outer wall, creating weak points. With the excess pressure demanded by the Western diet, little outpouchings form at these points. These are known as diverticuli, and having them is referred to as diverticular disease. This is present in maybe as many as half of all Westerners over 50, and in most cases causes no symptoms. However, if these diverticuli become inflamed or infected – diverticulitis – then, much in the manner of the <LINK H2G2="A46290323">appendix</LINK>, they can cause problems.</P>
<HEADER>Diagnosis and Initial Treatment</HEADER>
<P>Diverticulitis most commonly occurs in the sigmoid colon – the part on the lower left side of the abdomen shortly before the rectum. It often causes pain and tenderness here, along with fever, nausea, vomiting, bloating, diarrhoea or constipation, and may result in <LINK H2G2="A23499039">rectal bleeding</LINK>.</P>
<P>All cases of diverticulitis are treated with antibiotics and put on a fluids-only diet in order to rest the colon. An abdominal x-ray and a CT scan of the colon may be sought early on to aid diagnosis and determine the severity of the disease. Individuals with mild disease will recover after 24-48 hours and can move to a 'low residue' diet, building up to a full fibre-containing diet once fully recovered. Given the age group affected, it is common to examine the colon using a special telescope (<LINK H2G2="A19645220">colonoscopy</LINK>) once symptoms have settled down, in order to rule out any sinister problems.</P>
<HEADER>An Emergency?</HEADER>
<P>Diverticulitis represents in the cases where the infection does not settle, as a collection of pus (abscess) may form, and the diverticuli may even rupture, allowing infected pus or faecal material into the abdomen. In these cases emergency surgery is warranted, to remove the offending section of bowel. The common approach is a Hartmann's operation, where the upstream bowel is then brought out to the skin to form a stoma, while the downstream bowel is closed up. This may be reversed around six months later. The alternative, removing the offending bowel and then joining up the ends, is liable to fail as the joined ends will be infected with pus or faecal material.</P>
<HEADER>Summary</HEADER>
<P>Diverticulitis is the inflammation and infection of outpouchings of the large bowel, causing pain, bleeding and bowel symptoms. It is sometimes treatable with antibiotics and bowel rest, but severe cases require urgent surgery.</P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
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</GUIDE><EXTRAINFO><TYPE ID="1" /></EXTRAINFO></ARTICLE>
<ARTICLE>
<SUBJECT>Surgical Emergencies: Bowel Obstruction, Perforation and Ischaemia</SUBJECT>
<GUIDE>
<BODY>
<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B><LINK H2G2="A13746477">
Surgical Emergencies</LINK></B><BR/>
<LINK H2G2="A46290323">Acute Appendicitis</LINK> |
<LINK H2G2="A14173742">Acute Pancreatitis</LINK> |
<LINK H2G2="A13756854">Acute Diverticulitis</LINK> |
Bowel Obstruction and Perforation |
<LINK H2G2="A46289794">Testicular Torsion</LINK><BR/>
<LINK H2G2="A13738539">Extradural Haematoma</LINK> |
<LINK H2G2="A14088477">Acute Limb Ischaemia</LINK> |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>Appendicitis, diverticulitis and pancreatitis represent just a few problems that may involve the bowel. The main intestinal tract can suffer from obstruction, perforation, strangulation of herniated bowel, or other lack of blood supply (mesenteric ischaemia) – all surgical emergencies and thus worth covering here. It is worth noting that various severe infections within the abdomen cause similar symptoms and signs, adding to the challenge of correctly diagnosing the cause of the problem. As a result, individuals with severe abdominal symptoms are treated as detailed in the <LINK H2G2="A13746477">introduction</LINK>.</P>
<HEADER>General Presentation</HEADER>
<P>Most bowel-related emergencies will produce some combination of abdominal pain, nausea, vomiting, loss of appetite, constipation, abdominal tenderness, rigid abdominal wall and, in the cases such as hernias, a mass. The combination is usually enough to cause the individual to present to hospital, and will give away the fact that they are unwell. The causes of abdominal pain are many, though, and the story alone may not allow the surgeon to identify the exact diagnosis. Specific clues in the history and examination may help, as can blood tests and scans, but in some cases it is necessary to take the individual to theatre to look inside the abdomen. This may be done by passing a camera into the abdomen through a small cut, but in severely unwell individuals it is common to open the abdomen using a large midline incision.</P>
<HEADER>Obstruction</HEADER>
<P>Obstruction of the intestine accounts for perhaps one in five surgical admissions, and although the problem is usually mechanical, the cause and site of the blockage both vary. The most common causes of small bowel obstruction are strangulated hernias and adhesions between bowel loops, whereas large bowel obstruction is often a sign of bowel cancer in the older individual but can also be due to diverticular disease, volvulus of the sigmoid colon (just before the rectum), or a number of other causes. As well as simply blocking the bowel, obstruction causes leakage of vast quantities of fluid into the bowel, which in turn worsens the pressure head above the obstruction. It is possible for the bowel to perforate (see below), or to strangulate its blood supply.</P>
<P>Symptoms include central abdominal pain, which comes and goes as the gut contracts, abdominal distension and vomiting. Strangulation will produce constant pain with a tender abdomen, and perforation will produce a rigid 'washing board' abdomen. The initial treatment is for the individual to be Nil By Mouth, given intravenous fluids, and have a nasogastric tube inserted via the nose to allow free drainage of the stomach, which takes the pressure head off the bowel. Antibiotics are used if strangulation or perforation is suspected. A CT scan of the abdomen will help determine the cause, and guide as to what form of surgery is required to fix the underlying problem.</P>
<HEADER>Volvulus</HEADER>
<P>The intestine hangs reasonably free in the abdomen, attached to the back of the abdomen by a plane of tissue known as the mesentery. The mesentery contains the blood vessels that supply the bowel wall and muscles. It is possible for the bowel to twist on its mesentery, cutting off its blood supply while also obstructing itself – this is known as volvulus. This occurs most commonly in those with a high fibre diet and those who are prone to constipation, in particular institutionalised elderly individuals. A volvulus effectively produces the symptoms of bowel obstruction, and is usually detectable on a plain abdominal x-ray. Provided there is no suggestion that the twisted section of gut has begun to die, it is possible to treat a sigmoid volvulus (one just above the rectum) by passing a scope up into the large bowel and using a tube to decompress the bowel contents. However, in sigmoid volvulus complicated by dead bowel, and in cases of caecal volvulus (those occuring where the small bowel meets the large bowel), surgery is necessary to remove the affected bowel.</P>
<HEADER>Strangulated Hernia</HEADER>
<P>A hernia is the protrusion of abdominal contents – often bowel – out through a weakness in the lining of the abdominal cavity. If the hernia is reducible (can be pushed back in), it usually does not represent an emergency. However, if the hole through which the bowel protrudes is narrow the bowel can become stuck. If the drainage of blood from the bowel is thus cut off, the herniated bowel will become swollen and, given enough time, will die. So-called strangulated hernias are life-threatening surgical emergencies, requiring surgery correct the hernia and remove any dead bowel found at operation.</P>
<HEADER>Mesenteric Ischaemia</HEADER>
<P>Mesenteric ischaemia occurs when the blood supply to the bowel's supporting mesentery is cut off. This is often due to obstruction of the blood vessels with clots from the left atrium of the heart – clot formation here occurs if the heart is beating either weakly or in the wrong rhythm, as this allows blood to sit and stagnate in the atrium. The pain of mesenteric ischaemia is usually much greater than the physical signs found on examination, and is thus difficult to diagnose except when the abdominal contents are examined in theatre, revealing a dead section of bowel.</P>
<HEADER>Perforation</HEADER>
<P>Perforation of the bowel can occur at any point from the gullet down to the rectum, though the causes differ – the gullet may rupture due to forceful vomiting, the stomach may perforate due to a deep ulcer, and the bowel may perforate due to bowel ischaemia (lack of blood supply), <LINK H2G2="A46290323">appendicitis</LINK>, <LINK H2G2="A13756854">diverticulitis</LINK>, obstruction, or a number of other diseases of the bowel. It may present as localised pain and tenderness if the perforation is walled off by structures within the abdomen, but otherwise will generally produce a rigid, painful abdomen and a particularly sick patient. Perforation usually necessitates a trip to theatre to remove the perforated bowel and washout the surrounding tissues to remove as much contamination as possible.</P>
<HEADER>Summary</HEADER>
<P>There are a number of emergencies involving the bowel, many of which present with similar symptoms. Examination and scans are often vital in making the correct diagnosis, although sometimes it is necessary to look inside the abdomen in order to find out what is really happening. </P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
</BODY>
</GUIDE><EXTRAINFO><TYPE ID="1" /></EXTRAINFO></ARTICLE>
<ARTICLE>
<SUBJECT>Surgical Emergencies: Testicular Torsion</SUBJECT>
<GUIDE>
<BODY>
<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B><LINK H2G2="A13746477">
Surgical Emergencies</LINK></B><BR/>
<LINK H2G2="A46290323">Acute Appendicitis</LINK> |
<LINK H2G2="A14173742">Acute Pancreatitis</LINK> |
<LINK H2G2="A13756854">Acute Diverticulitis</LINK> |
<LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK> |
Testicular Torsion <BR/>
<LINK H2G2="A13738539">Extradural Haematoma</LINK> |
<LINK H2G2="A14088477">Acute Limb Ischaemia</LINK> |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>The testicles are each supplied with blood via a spermatic cord, which surrounds the relevant blood vessels, nerves and muscles as they pass out of the abdominal cavity and down into the scrotum. If the testicle becomes twisted on its spermatic cord, the blood vessels are compressed and the testicle loses blood supply. This causes intense testicular and/or abdominal <LINK H2G2="A653302">pain</LINK>, often followed by light-headedness, nausea and even vomiting. Urgent surgery within 4-6 hours is usually required to save the testicle. The problem is most common towards the beginning of puberty, and so any young boy with testicular pain ought to see a doctor as a matter of some urgency.</P>
<HEADER>What Causes it?</HEADER>
<P>Testicular torsion sometimes occurs following injury to the testes or as a result of strenuous activity. <LINK H2G2="A20218709">Cold weather</LINK> is also blamed, as the movement from warm to cold environs causes the scrotum to contract around the testicle, potentially trapping a slightly-twisted testicle. In most cases, it is an abnormality in the development of the testes that allows them sufficient mobility to become twisted. During normal development, the back of the testicle becomes stuck to inner lining of the scrotum; however, in the so-called '<LINK H2G2="A1304786">bell</LINK>-clapper deformity', the testicle hangs free inside the scrotum, making it more likely to twist on its cord.</P>
<HEADER>Diagnosis and Treatment</HEADER>
<P>Suspecting torsion is important, as the diagnosis is based mainly on the sudden onset of testicular pain. The presence of an 'exquisitely' painful, high-riding testicle would be typical in testiculat torsion, but there are large enough grey areas that doubt as to the diagnosis cannot be entertained. Swelling of the testes is more common in mumps<FOOTNOTE>Viral infection and swelling of the testes and salivary glands.</FOOTNOTE> or epididymitis<FOOTNOTE>Inflammation of the epididymis, which sits next to the testicle and stores maturing sperm.</FOOTNOTE>, and adults are less likely to have the condition, but if there is reason to suspect torsion then surgery becomes mandatory. Scanning of the testicular blood vessels using an ultrasound probe to look at blood flow is sometimes used to rule out an unlikely case of torsion, but surgery remains the only way to be absolutely sure, and is generally regarded as best practice.</P>
<P>Surgery involves examination of the scrotal contents under anaesthetic, with the torsion being corrected if the testicle is still alive. (If the testicle is dead, it must be removed to prevent infection.) Once the torsion has been corrected, the testicle is secured by sewing it to the scrotal inner wall behind it. This is known as orchidopexy, and is often done for the normal testicle as well as the torted one, so as to prevent future problems.</P>
<HEADER>Summary</HEADER>
<P>Testicular torsion is due to sudden twisting of the testicle, resulting in a lack of blood supply, severe pain, and the need for urgent surgery to save the testicle.</P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
</BODY>
</GUIDE><EXTRAINFO><TYPE ID="1" /></EXTRAINFO></ARTICLE>
<ARTICLE>
<SUBJECT>Surgical Emergencies: Extradural Haematoma</SUBJECT>
<GUIDE>
<BODY>
<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B><LINK H2G2="A13746477">
Surgical Emergencies</LINK></B><BR/>
<LINK H2G2="A46290323">Acute Appendicitis</LINK> |
<LINK H2G2="A14173742">Acute Pancreatitis</LINK> |
<LINK H2G2="A13756854">Acute Diverticulitis</LINK> |
<LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK> |
<LINK H2G2="A46289794">Testicular Torsion </LINK><BR/>
Extradural Haematoma |
<LINK H2G2="A14088477">Acute Limb Ischaemia</LINK> |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>Several blood vessels supply the lining of the brain, and this includes the three meningeal arteries on each side of the skull. The middle meningeal artery is particularly important as it runs through the skull near the temple at a weak point called the pterion. This makes it particularly prone to damage following a serious head injury. A torn meningeal artery will bleed into the potential space between the skull and the outer lining of the brain<FOOTNOTE>The layers covering the brain are known as the dura, arachnoid and pia mater. Bleeding outside of the dura mater is thus said to be 'extradural' or 'epidural'.</FOOTNOTE>. The pooling blood (haematoma) creates and enlarges a gap between the skull and the dura, putting pressure on the brain and forcing it to shift towards the opposite side of the skull.</P>
<P>Extradural haematomas are just one type of bleed within the skull. Subdural haematomas occur, often in the elderly, following a bump to the head, but develop slowly and do no present as emergencies. Subarachnoid haemorrhages also occur, whereby a blood vessel more closely related to the brain bursts due to an aneurysm. These produce a severe sudden onset 'thunderclap' headache and do present as emergencies; however, they are often treated from the inside via the blood vessels, and are covered in the entry on <LINK H2G2="A2315990">aneurysms</LINK>.</P>
<HEADER>Symptoms and Signs</HEADER>
<P>The individual unfortunate enough to suffer an extradural haematoma will initially recover from the head injury, but may then become drowsy or vomit. The pupil on the injured side will become dilated ('blown') as the third <LINK H2G2="A646139">cranial nerve</LINK> on that side is compressed by the shifting brain. A low heart rate, fixed dilated pupils on both sides, reduced consciousness and abnormal movements will follow. If the bleeding continues it will eventually push the brain down against the base of the skull and into the spinal column – this is known as 'coning' and is fatal.</P>
<HEADER>Diagnosis and Treatment</HEADER>
<P>The diagnosis can be suspected based upon the above, and is confirmed with a CT scan of the head. This shows the collection of blood clearly pooling between the skull and the brain. Drugs and careful intensive care management can be used to improve blood supply to the brain and reduce swelling. However, definitive treatment must be surgical, namely the drilling of a burr hole in the skull to allow the haematoma to be evacuated. If this is done quickly enough, most patients can make a full recovery, though this is dependent on them being fit for surgery.</P>
<HEADER>Summary</HEADER>
<P>An extradural haematoma forms following trauma to one of the blood vessels running through the skull. Though it is potentially life-threatening, in many cases emergency surgery will completely restore the patient.</P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
</BODY>
</GUIDE><EXTRAINFO><TYPE ID="1" /></EXTRAINFO></ARTICLE>
<ARTICLE>
<SUBJECT>Surgical Emergencies: Acute Limb Ischaemia</SUBJECT>
<GUIDE>
<BODY>
<PICTURE EMBED="LEFT" SHADOW="None" H2G2IMG="uni_science_sm.jpg" ALT="Faculty of Science, Mathematics and Engineering" />
<CENTER><SMALL><B><LINK H2G2="A13746477">
Surgical Emergencies</LINK></B><BR/>
<LINK H2G2="A46290323">Acute Appendicitis</LINK> |
<LINK H2G2="A14173742">Acute Pancreatitis</LINK> |
<LINK H2G2="A13756854">Acute Diverticulitis</LINK> |
<LINK H2G2="A46290242">Bowel Obstruction and Perforation </LINK> |
<LINK H2G2="A46289794">Testicular Torsion </LINK><BR/>
<LINK H2G2="A13738539">Extradural Haematoma</LINK> |
Acute Limb Ischaemia |
<LINK H2G2="A45561080">Intussusception</LINK> |
<LINK H2G2="A52005773">Ectopic Pregnancy</LINK> |
<LINK H2G2="A57226250">Pre-eclampsia and Eclampsia</LINK>
</SMALL></CENTER><BR/><BR/>
<P>The arms and legs rely on a good blood supply in order to function – in particular, the leg muscles have a high requirement for oxygen and do not tolerate a reduction in blood supply. If the blood supply to a limb is slowly blocked off over a matter of months or years, so-called 'collateral' blood vessels may be able to take on the work, thus allowing the muscles some degree of blood supply. This manifests as intermittent claudication, where muscle pain is experienced above a certain level of exercise. However, if the blood supply is suddenly cut off due to complete blockage of the main vessel, there is no time for collateral vessels to develop. The result is acute limb ischaemia: a sudden onset of a pale, painful, cold limb that requires urgent treatment. </P>
<HEADER>What Causes It?</HEADER>
<P>Atherosclerosis is a disease of the inner lining of blood vessels whereby a plaque of fatty material accumulates and harden on the artery wall. This is the cause of most heart attacks, as the coronary arteries are gradually blocked off by plaques, and is also the cause of some strokes due to disease of the blood vessels supplying the brain. The aorta can be affected, causing weakening of its wall and thus the fomration of an <LINK H2G2="A2315990">atherosclerotic aneurysm</LINK>. Unsurprisingly, this disease actually affects all arteries, including those in the arms and legs. As atherosclerosis is accelerated by an unhealthy diet and smoking, it provides a good advertisement for a healthy diet.</P>
<P>Thus, the majority of cases of intermittent claudication and acute limb ischaemia are due to narrowing of the limb arteries due to fatty plaque formation. As with the heart and brain, acute ischaemia of the limb occurs if the plaque suddenly ruptures, blocking the vessel.</P>
<P>It is also possible for a free-floating clot (embolus) to drift along an artery and become stuck in the narrowing. These clots are usually from the left atrium of the heart – clot formation here occurs if the heart is beating either weakly or in the wrong rhythm, as this allows blood to sit and stagnate in the atrium.</P>
<HEADER>Treatment</HEADER>
<P>An acutely ischaemic limb requires urgent treatment, else it will eventually become all of the six 'P's: pale, painful, pulseless, paraesthetic (pin and needles), paralysed and perishingly cold. A dose of anti-clotting medication should be given provided there is no underlying bleeding risk. When a limb has lost both feeling and movement, surgery is required urgently to restore blood supply. If this does not occur, surgery will instead be required to amputate the affected part. Sometimes restoration of blood supply causes the limb to swell up, requiring further surgery to relieve the pressure inside the muscle compartments.</P>
<P>In the case of atherosclerotic arteries, it is necessary to create a bypass around the obstruction using either veins borrowed from elsewhere, or synthetic graft material. In severe intermittent claudication, such surgery is preceded by a scan using a contrast material to show where artery is obstructed. However, in acute limb ischaemia there is little time, and the contrast will only show the start of the blockage as there are no collateral vessels leading to the other end.</P>
<P>An embolus blocking the artery is sometimes so inaccessible as to require treatment with a clot-busting drug (which comes with a risk of bleeding and bruising), but can usually be removed from the artery surgically. Originally this was done by opening the artery at the site of the obstruction and pulling out the embolus by hand. However, an American surgeon by the name of Thomas J Fogarty became distressed by the poor survival rate following such procedures. The result was the Fogarty catheter consists of a tube with an inflatable balloon at the end. The catheter can enter the artery through a small cut at the groin and be fed down past the clot; once the balloon has passed through the blockage, it is inflated and then pulled back out, bringing the embolus with it. It is estimated that this apparently simple idea has saved millions of lifes and limbs.</P>
<HEADER>Summary</HEADER>
<P>Fatty plaques will cause the arteries to narrow slowly over time and cause intermittent pain on exercise, but a plaque rupture or embolus of a clot from the heart can fully obstruct an artery suddenly, leading a a limb that is cold, pale, painful and liable to be lost unless the blood supply can be restored quickly.</P>
<P><B>Please Note: h2g2 is <B>not</B> a definitive medical resource. If you have any health concerns you must always seek advice from your local GP. You can also visit <LINK HREF="http://www.nhsdirect.nhs.uk/" TITLE="NHS Direct">NHS Direct</LINK>.</B></P>
</BODY>
</GUIDE><EXTRAINFO><TYPE ID="1" /></EXTRAINFO></ARTICLE>
