Surgical emergencies in the time of Covid

Article written by :drRudra
Dr Rudra Krishna Maitra
MRCS (Edin), FRCS (Edin), MD (Univ of Nottingham)
Consultant General & Gastro Surgeon
Peerless Hospital

Surgical emergencies are usually not caused by Covid and exist independently of the current pandemic. However, with the current climate of increasing Corona virus case loads, people are often reluctant to come to hospital for consultation in order to reduce their exposure to the virus. Therefore, it is important to realize the potential surgical presentations that can safely be managed at home with a delayed consultation versus the surgical emergencies which require immediate intervention.

The most common abdominal symptom is one of generalized abdominal discomfort, bloating with or without a change in bowel habit. Most of these will be due to either a minor infection or hyper-acidity and will respond well to a short course of an antibiotic like metronidazole or an antacid like omeprazole. Unless they persist despite treatment, they do not require surgical intervention.

Most general surgical emergencies present either with significant abdominal pain or vomiting. As a general rule,  abdominal pain which is short-lived and relieved by simple pain-killers such as paracetamol and ibuprofen, do not require immediate surgical consultation. Intractable abdominal pain, not relieved by simple analgesia is the commonest presentation of surgical emergencies. Particularly, when abdominal pain worsens with movement, that can be a herald of peritonitis – where infection or inflammation in an abdominal organ starts causing infection within the abdominal cavity – and this usually requires urgent surgery. Intractable vomiting, where the patient is unable to keep fluids down, can also be an emergency requiring urgent surgical intervention, especially when this is accompanied by either abdominal pain or significant abdominal distension. One further surgical emergency that need not present with pain or vomiting (although is often accompanied by these) is jaundice – again, this requires immediate surgical consultation.

Surgical emergencies can usually be subdivided into upper and lower GI pathologies:

Upper GI

Gastritis
Pain in the upper abdomen in the centre, often following meals which lasts for a few hours can be due to gastritis or
gastric/duodenal ulcers. This does not need emergency consultation and can be managed safely with acid suppressing medication initially. If this persists, it requires an endoscopy to ensure there is no worrying cause (like a non-healing ulcer or a cancer), but this does not need to be done immediately

Reflux
Reflux or heartburn (acid taste in the mouth or burning sensation in the chest following meals or first thing in the
morning), also does not require emergency management. Treatment again is with acid suppression. If symptoms persist, an endoscopy is recommended but not urgently

Gallstone problems
Gallstones are common and are often not symptomatic. Sometimes, we recommend surgery for gallstones even if they are not causing symptoms, in order to prevent symptoms in future. However, for asymptomatic gallstones, immediate surgery is not required. Gallstones can cause pain following meals – this can sometimes be very similar to the pain in gastritis, occurring in the upper abdomen either in the centre or on the right side. Pain in this region that occurs occasionally and subsides after a few hours can be from gallstones – in these instances, we would recommend surgery to prevent symptoms, but again this does not have to be done as an emergency. Pain in the upper abdomen which is more on the right side, is constant and does not resolve, is associated with vomiting or is worse on movement – this can signal cholecystitis, or an infection in the gallbladder. This does require urgent consultation. Sometimes this can be managed with antibiotics with delayed surgery in a few months but more often we recommend an early operation to prevent complications.

Gallstones can cause jaundice (a yellowing of the skin and eyes, the urine turning very dark and the stools turning pale). This happens when gallstones block the outlet of the liver and is one of the commonest causes of jaundice in adults. If jaundice is accompanied by pain or fevers or vomiting, this can indicate an infection in the blocked liver which can be life-threatening. In general, jaundice requires urgent surgical consultation and treatment.

Sometimes, gallstones can irritate the pancreas gland causing pancreatitis. This presents with pain in the upper abdomen which does not go away and multiple episodes of vomiting. This can be a life-threatening condition and requires urgent surgical consultation.

Lower GI
Appendicitis
This presents with pain in the abdomen which settles in the right lower abdomen, does not go away and gets worse with movement over time. This requires an urgent operation to prevent complications.

Diverticulitis
With time, the colon can develop some ‘pockets’ due to wear and tear. Sometimes, these can get infected and cause either diarrhoea and pain. If there is pain in the lower left abdomen which is constant and worse with movement, this indicates that there may be a severe infection in this region. Sometimes this can be managed with antibiotics but sometimes it requires an emergency operation. Surgical consultation should be sought without delay.

Bowel obstruction
Both the small bowel (small intestine) or the large bowel (large intestine) can develop blockages. Causes range from
simple scar tissue within the abdomen to tumours causing blockage. There is usually significant distension of the abdomen along with vomiting, sometimes with pain that comes and goes in waves. Often, the patient will not have passed wind for some time. This require immediate surgical consultation and often an emergency operation to relieve the blockage.

Perianal abscess
Constant pain in the region of the anus with or without a lump can be a sign of an infection with pus in the region of the anus. This often requires a small but urgent operation for relief and to prevent further complications.

Hernia
Hernias present as lumps in the abdomen either in the site of previous surgical incisions or commonly in the groin. Often they require an operation if they are causing symptoms but unless a hernia is painful or is causing abdominal pain and vomiting, they can safely be observed prior to considering surgery.

Conclusion
The list above is not exhaustive or comprehensive but presents an overview of the commonest surgical emergencies. In the main, if abdominal pain is constant and not relieved by simple pain killers, especially if the pain is worse on movement, an urgent surgical consult should be sought and Covid should not deter people from seeking necessary help. Similarly with intractable vomiting or with jaundice, surgical consultation should not be delayed. Pain that comes and goes, lasts for only a few hours, or is relieved with simple pain killers, is likely not something that requires emergency management and can safely be dealt with once the Corona virus epidemic subsides.

 

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