1. SURGICAL EMERGENCIES
BY DR F DERY

2. A) BLEEDING IN SURGICAL
PRACTICE
Types of Bleeding
1 Vessel Involved
• Arterial bleeding is bright red, spurts as a
jet which rises and falls in time with the
pulse.
• Venous bleeding is dark red and
escapes as a steady flow
• Capillary bleeding is bright red and often
rapid ooze
2. Commencement of bleeding
• Primary haemorrhage: occurs at time of
injury or operation.

3. Commencement of Bleeding cont,d
• Reactionary haemorrhage: follow primary
haemorrhage within 24hrs and mainly due to
slipping of ligature or dislodgement of a clot.
• Secondary haemorrhage: occurs after 7-14 days
and it is due to infection and sloughing of part of
the wall of an artery.
3. Internal (Concealed) bleeding: bleeding may
occur but not seen externally as in: ruptured
spleen, ruptured ectopic gestation.
4. External (revealed) bleeding: concealed
haemorrhage may become revealed as
haematemesis or malaena from Peptic Ulcer
Disease (PUD)

4. Examples of Bleeding in Surgical
Practice
1. PUD
2. Bleeding haemorrhoids
3. Ectopic gestation
4. Abortions
5. RTA (Road Traffic Accident) or Trauma
• Ruptured spleen
• Fractured femur

5. 1) PUD
There are 3 types-duodenal, gastric, or
oesophageal.
Causes:
• Reflux of corrosive acid pepsin and sometimes
bile through a lax oesophageal sphincter. The
tendency to the oesophageal reflux may be
compounded by increased abdominal
pressure in the obese and pregnancy and by
consumption of fatty meals, alcohol, caffeine
and tobacco, all of which relax the sphincter—
oesophageal cause
• Helicobacter pylori infection: it is a bacterium
—gastric/duodenal cause.

6. Causes cont,d
• Drugs-NSAIDS, corticosteroids—
duodenal/ gastric cause
• Alcohol-reduces local reduction of
mucosal blood flow leading to acute
erosions—duodenal/gastric cause
• Excessive secretion of gastric acid—
duodenal/gastric cause

7. Symptoms
The main symptom is pain in the
epigastrium or right hypochondrium or
behind the sternum.
• Heart burn which is worse after meals and
at night when recumbent—oesophageal
• Intermittent epigastric pain that is relieved
by food or alkalis with night waking and
heart burn--duodenal
• Vomiting may occur in both duodenal and
gastric ulcers
• Many however do not have symptoms .

8. Signs
• The only sign is tenderness in the midline
of the epigastrium or right hypochondrium
• There may be no signs
• There may be history of malaena stools

9. Investigations
• Haemoglobin level
• Stool examination to rule out intestinal
worms as cause of dyspepsia
• Oesophago-gastro-duodenoscopy plus
urease test (for H. pylori)
• Barium meal in the absence of endoscopy

10. Complications
Oesophageal
• Stricture formation which causes dysphagia
Duodenal/gastric
• Bleeding
• Perforation
• Pyloric stenosis
• Hour-glass deformity

11. Treatment
1. Advice about diet
• Losing weight if obese
• Avoid late large and fatty meals
• Avoid coffee, alcohol
• Stop smoking
• Avoid sleeping flat
• Avoid spicy foods
2 Relief of anxiety and stress

12. Treatment cont;d
3 Drugs
a) For H. pylori eradication use the triple
therapy regime
Omeprazole (PPI) 20mg bd/7days PLUS
• Amoxycillin 500mg tid + metronidazole
400mg tid for 7 days OR
• Amoxycillin 1gm daily +clarithromycin
500mg bd for 7 days OR
• Clarithromycin 500mg bd +
metronidazole 400mg bd for 7 days

13. Treatment cont,d
b) For maintenance
• Omeprazole 20mg bd for 4-6weeks OR
ranitidine (H2 receptor antagonist) 150mg
daily for 4weeks. Repeat if symptom recur
• For dyspepsia—give antacids eg
magnesium trisilicate 15mls tid in between
meals but avoid within 2hrs of intake of H2
receptor antagonist. It impedes absorption

14. 2) HAEMORRHOIDS
Haemorrhoids are dilated veins occuring in
relation to the anus originating in the
subepithelial plexus. Haemorrhoids may be
external or internal ie internal or external to
the anal orifice
Haemorrhoids may be
1. Symptomatic-ie a symptom of other condition
• Cancer of rectum-compressing rectal veins
• During pregnancy-pressure on veins by
uterus
• From straining-urethral stricture or prostate

15. Haemorrhoids cont,d
2 Not symptomatic-ie those which are not a
manifestation of some underlying disease.
They are the majority.
Classification of Haemorrhoids
• 1st
Degree- remain in the rectum
• 2nd
Degree- prolapse through the anus on
defaecation but spontaneously reduce
• 3rd
Degree- as for 2nd
degree but require
digital reduction
• 4th
Degree- remain persistently prolapsed

16. Symptoms
• Passage of bright red blood during
defaecation. It usually drops on the stool
but not mixed with the stool. If using the
bed pan or water closet blood splashes on
it.
• Discharge-mucoid discharge is a frequent
accompaniment of prolapsed
haemorrhoids.
• Pruritis-certainly follows the discharge.
• Pain-only when complications supervene.

17. Signs
• Inspection of the anus may show no
evidence of internal haemorrhoids.
• Redundant folds or skin tags can be seen in
the position of the haemorrhoids in advance
cases
• Straining may show internal haemorrhoids
transiently
• Internal haemorrhoids can not be felt unless
they are thrombosed
• Patient may present with the complications

18. Investigation
• Full blood count (FBC)
• Proctoscopy-as you withdraw the
proctoscope the haemorrhoids will bulge
into the lumen of the proctoscope

19. Complications
• Profuse bleeding
• Strangulation
• Thrombosis
• Ulceration
• Gangrene
• Fibrosis
• Suppuration
• Anaemia

20. Treatment
Non operative
• No treatment for asymptomatic. Treat
constipation with liquid paraffin 10-30mls
nocte or senna granules 1 sachet in water
after supper. Avoid prolonged straining at
defaecation
• For itch or discomfort-use ointments or
suppositories eg anusol, proctosedyl,
scheriproct 1 bd for 7 days
• For prolapsed haemorrhoids-lie patient
down and elevate the foot end of the bed .

21. Treatment cont,d
After local anaesthetic cream try gentle
digital reduction. If this fails apply cold
compresses and sedate patient with
diazepam 10mg orally.
• If infected treat with iv gentamycin
2.5mg/kg BW and metronidazole 400mg
tid orally for 2-3 days and sitz baths.
• Correct anaemia with iron preparations or
blood transfusion
Operative
Haemorrhoidectomy

22. 3) ECTOPIC GESTATION
This is the embedding of the fertilised ovum
and development in some other site other than
the uterine cavity
Causes
• Infections (eg salpingitis)—causes adhesions
in the tube or destroys the ciliated epithelium
which propel the fertilised ovum into the uterus
• Tubal abnormalities like diverticula, abnormal
length or kinking
• Incidence increase in women using
progestogen only contraceptive

23. End Result of Tubal Pregnancy
• Tubal mole—bleeding occurs around the
embryo causing its death and is surrounded
by a blood clot
• Tubal abortion—the embryo in the tube is
expelled through the ostium of the tube. Blood
may coagulate around the ostium or
accumulate in the rectovaginal pouch and
becomes encysted
• Tubal erosion with persistence of the
pregnancy-the embryo perforates the tube and
may become attached to some of the
abdominal contents and may grow to
term( abdominal pregnancy)

24. End Result of Tubal Pregnancy
cont,d
• Tubal rupture (into peritoneal cavity)—this is
also called ruptured ectopic
Ruptured Ectopic
The patient presents with:
1 Abdominal pain
2 Fainting or collapse
3 Signs of severe blood loss:
• Low BP

25. Ruptured Ectopic cont,d
• Subnormal temperature
• Cold clammy skin
• Complains of thirst
• Restless and may show air hunger
4 Distended abdomen
5 Diffusely tender abdomen
6 Dullness on percussion in the flanks
7 Referred pain to the shoulder if the blood
reaches the diaphragm
8 Amenorrhoea of short duration usually 6-8
weeks

26. Ruptured Ectopic cont,d
Investigation
• Pregnancy test positive—a negative test cannot
be taken as prove that no ectopic pregnancy
exists
• Ultrasonography (ultrasound)
• Laparoscopy
• Haemoglobin level, group and cross matching
Treatment
Laparotomy

27. 4) ABORTIONS
The expulsion of a fetus before the 28th
week of pregnancy
Causes
• Severe malformation of the zygote
• General disease of the mother– any severe
febrile illness, syphilis, diabetes mellitus,
severe hypertension, gross malnutrition
• Uterine malformations including fibroids
• Hormone insufficiency eg progesterone

28. Causes cont,d
• Trauma—coitus, accident
• Drugs—cytotoxic drugs
• Acute emotional disturbance
Varieties of Abortion
1. Threatened Abortion:-there is bleeding but
not sufficient enough to kill the embryo. No
painful uterine contraction. The cervix is
closed.
Management—Bed rest

29. Varieties of Abortion cont,d
2 Inevitable Abortion:-painful contractions and
dilatation of the cervix. Blood loss continues
and increases in amount. Products of
conception still in the uterus.
Management—pain relief and
evacuation of the uterus if not complete.
3 Complete Abortion:-all products of
conception expelled. Pain is absent and
bleeding is slight. Cervix is slightly open.
Management--observation

30. Varieties of Abortion cont,d
4 Incomplete Abortion:-parts of the products of
conception, usually the fetus is passed out.
The placenta is retained. Bleeding can be
severe.
Management—evacuate the uterus and
prevent infection.
5 Septic Abortion:-uterine cavity infected before
an abortion even begins as a result of
criminal attempt to procure abortion by
passing unsterile instrument through the
cervical canal or may follow incomplete
abortion. There is suprapubic pain and
increase in temperature and pulse rate.

31. Varieties of Abortion cont,d
• There may be little bleeding. Infection may
spread to the other structures of the pelvis.
• Management—broad spectrum antibiotics are
given. Penicillin plus gentamycin plus
metronidazole are usually combined. If
incomplete septic abortion, evacuation follows
after 24 hrs of antibiotics
• 6 Missed Abortion:-the embryo dies but is
retained in the uterus for several weeks or
months. Patient notices little blood stained
discharge between 8-12 weeks of pregnancy.

32. Varieties of Abortion cont,d
The uterus is not increasing in size.
Management—no urgency about treatment.
Sepsis rarely occurs. D and C is done if patient is
worried she is carrying a dead fetus.
7 Habitual Abortion:-if there have been 3
consecutive spontaneous abortion. Repeated mid
trimester abortions may result from incompetence
of the internal os of the cervix. They are painless
abortions
Management—general advice if no cause is
found. If an incompetent cervix is the cause a
Shrodkhar stitch is applied

33. Varieties of Abortion cont,d
Complication of Abortions
-infection
injuries to vagina, uterus, bowel

34. 5 RUPTURED SPLEEN
Causes
• Traffic or industrial accidents
• Blows on the abdomen or left lower thorax
• Falls onto a projected object
Cases of ruptured spleen may be
divided into two:-acute and delayed

35. Ruptured Spleen cont,d
Acute
There is an initial shock ; recover from
shock and then show signs of ruptured
spleen:
1 General signs of internal haemorrhage:-
increasing pallor, a rising pulse rate,
sighing respiration and restlessness.
2 Local signs
• Abdominal rigidity most pronounced in the
left upper quadrant

36. Ruptured Spleen cont,d
• Shifting dullness in the flanks
• Abdominal distension commences 3hrs
after the accident and is due to intestinal
paresis
• Pain referred to the left shoulder. This is
due to blood in contact with the under
surface of the diaphragm
• Rectal examination frequently reveals
tenderness and often soft swelling due to
blood clot in the rectovesical pouch

37. Delayed
After the initial shock have passed off the
symptoms of serious intra-abdominal injury are
postponed for a variable period of up to 15 days
or more. These cases only collapse later from
internal haemorrhage. The reasons for the
delay are:
• The greater omentum as a policeman, shuts off
that portion of the peritoneal cavity in the
immediate vicinity of the bleeding
• A subcapsular haematoma forms and later
burst
• Blood clot sealing the rent becomes digested

38. Investigation
• FBC, grouping and cross matching
• USG
• Plain abdominal x-ray
• Laparoscopy
Treatment
Laparotomy and splenectomy

39. 6) FEMUR FRACTURE (SHAFT)
The injury is usually due to severe
violence so that associated injuries are
common.
Since we are dealing with bleeding
conditions in surgical practice, we will only
deal with that aspect of the femur fracture.
There is no obvious bleeding in a
simple fracture of the shaft of the femur,
but bleeding into the thigh is often in
excess of a litre and invariably in adults.
Such blood loss must be replaced.