A 38-year-old man presents with acute onset severe lower back pain and bilateral leg weakness. He has saddle anesthesia and cannot urinate. What is the most appropriate immediate management?

Emergency surgical decompression

A 44-year-old woman presents with sudden onset severe right upper quadrant pain radiating to the right shoulder tip. She has had previous episodes of biliary colic. Ultrasound shows gallstones with gallbladder wall thickening (6 mm), pericholecystic fluid, and a positive sonographic Murphy's sign. Blood tests show WBC 15.3×10⁹/L, CRP 78 mg/L. What is the optimal timing for cholecystectomy?

Early laparoscopic cholecystectomy within 72 hours of symptom onset

Immediate emergency cholecystectomy within 6 hours

Conservative management with antibiotics followed by interval cholecystectomy at 6-8 weeks

Percutaneous cholecystostomy followed by delayed cholecystectomy after 3 months

Urgent ERCP within 24 hours followed by cholecystectomy during same admission

A 76-year-old man with known colorectal adenocarcinoma presents with a 72-hour history of absolute constipation and abdominal distension. CT shows dilated colon up to 11 cm in diameter at the caecum with an obstructing sigmoid tumour. The caecal wall appears thinned. He has multiple comorbidities including severe COPD and recent myocardial infarction 8 weeks ago. What is the most appropriate management strategy?

Hartmann's procedure with sigmoid resection and end colostomy

Emergency subtotal colectomy with end ileostomy

Endoscopic stent placement across obstructing tumour as bridge to surgery

Proximal defunctioning transverse loop colostomy without tumour resection

On-table lavage with primary resection and anastomosis

A 67-year-old man presents with a 6-hour history of sudden onset severe epigastric pain. Erect chest radiograph shows free gas under the diaphragm. At laparotomy, a 1 cm perforated anterior duodenal ulcer is identified with minimal peritoneal contamination. What is the most appropriate surgical management?

Simple closure with omental patch (Graham patch) and peritoneal lavage

Partial gastrectomy with Billroth II reconstruction

Truncal vagotomy and pyloroplasty with ulcer excision

Whipple's procedure to ensure complete resection of ulcer-bearing area

Ulcer excision with primary closure and highly selective vagotomy

A 53-year-old woman undergoes CT for suspected appendicitis. The appendix appears normal, but CT shows streaky infiltration of mesenteric fat with a hyperdense ring surrounding a central hypodense nodule in the right lower quadrant, described as a 'fat ring sign'. The patient is haemodynamically stable with localized tenderness. What is the most appropriate management?

Conservative management with analgesia and observation as this represents epiploic appendagitis

Emergency appendicectomy due to early appendicitis not yet showing on CT

Urgent laparotomy for suspected mesenteric vein thrombosis

Right hemicolectomy to exclude underlying colonic malignancy

Broad-spectrum antibiotics for presumed bacterial peritonitis

What is Boerhaave's syndrome and what is the typical clinical presentation that distinguishes it from other causes of oesophageal perforation?

Spontaneous transmural oesophageal rupture following forceful vomiting, classically presenting with Mackler's triad of vomiting, chest pain, and subcutaneous emphysema

Iatrogenic oesophageal perforation during endoscopy presenting with subcutaneous emphysema

Oesophageal perforation from ingested foreign body causing mediastinitis and dysphagia

Malignant oesophageal perforation in advanced cancer causing pneumomediastinum

Oesophageal perforation from caustic ingestion presenting with odynophagia and drooling

A 41-year-old woman presents with a 16-hour history of severe right upper quadrant pain, fever of 38.7°C, and confusion. She appears jaundiced and unwell. Blood results: WBC 18.2×10⁹/L, bilirubin 89 μmol/L, ALP 456 U/L, ALT 234 U/L. Blood pressure 95/60 mmHg, heart rate 118 bpm. Ultrasound shows dilated common bile duct (12 mm) with multiple stones in gallbladder. What is the most appropriate immediate management?

Urgent ERCP with sphincterotomy within 24 hours combined with resuscitation and antibiotics

Emergency laparoscopic cholecystectomy within 6 hours

Percutaneous transhepatic cholangiography with biliary drainage

Conservative management with antibiotics and interval cholecystectomy at 6 weeks

Open cholecystectomy with common bile duct exploration

GI perforation for UKMLA AKT: High-Yield Emergency & Acute Care Lessons

Quick Overview

GI perforation is a surgical emergency requiring immediate recognition and management. Mortality ranges from 10-40% depending on site, time to intervention, and patient factors. NICE NG158 emphasizes early imaging, broad-spectrum antibiotics within 1 hour, and urgent surgical review. Upper GI perforations (gastroduodenal) differ significantly in management from lower GI (colorectal) perforations.

Core Facts & Concepts

Clinical Presentation

Sudden-onset severe abdominal pain (may be localized initially, then generalized)
Peritonism: guarding, rigidity, rebound tenderness, absent bowel sounds
Systemic features: tachycardia >100 bpm, hypotension, fever, sepsis
Silent abdomen: rigid, board-like on palpation

Key Investigations

Erect CXR: detects 70-80% of perforations (free gas under diaphragm)
CT abdomen/pelvis with contrast: >95% sensitivity, shows site and cause
Lactate >2 mmol/L: marker of tissue hypoperfusion and sepsis severity
Bloods: FBC, U&Es, CRP, clotting, G&S/crossmatch

Figure 1: Erect chest X-ray showing crescent of free gas under right hemidiaphragm

Common Causes by Site

Site	Common Causes	Key Features
Upper GI	Peptic ulcer (60%), malignancy, iatrogenic	Anterior perforations → pneumoperitoneum
Lower GI	Diverticulitis (40%), malignancy, IBD, ischaemia	Faecal peritonitis, higher mortality
Small bowel	Obstruction, Crohn's, trauma, foreign body	Rapid clinical deterioration

Figure 2: CT scan showing extraluminal gas and fluid with bowel wall discontinuity

Critical Numbers

Golden period: Surgery within 6 hours reduces mortality by 50%
Boey score (peptic ulcer perforation): predicts mortality based on shock, comorbidity, delayed presentation

Problem-Solving Approach

1. Immediate Recognition & Resuscitation (ABCDE)

Airway/Breathing: High-flow O₂ to maintain SpO₂ >94%
Circulation: 2× large-bore IV access, fluid resuscitation (500mL crystalloid boluses)
Disability: GCS, analgesia (IV morphine titrated)
Exposure: Full abdominal examination

2. Sepsis Six Bundle (within 1 hour)

Give: Oxygen, IV fluids, IV antibiotics
Take: Blood cultures, Lactate, Urine output monitoring

3. Antibiotic Protocol (NICE NG158)

Broad-spectrum within 1 hour: Co-amoxiclav 1.2g IV TDS + Metronidazole 500mg IV TDS
Penicillin allergy: Gentamicin + Metronidazole + Teicoplanin
Adjust based on local guidelines and sepsis severity

4. Imaging Pathway

Stable patient: Erect CXR → CT abdomen/pelvis with IV contrast
Unstable patient: Consider direct to theatre if peritonitis obvious

5. Surgical Referral (urgent)

Immediate if peritonitis, free gas, or clinical deterioration
Upper GI perforation: Primary repair ± omental patch vs conservative (selected cases)
Lower GI perforation: Resection ± stoma (Hartmann's procedure common)

⚠️ Warning: Up to 30% of perforations have no free gas on CXR - CT is gold standard if clinical suspicion persists

Analysis Framework

Upper vs Lower GI Perforation Management

Feature	Upper GI	Lower GI
Conservative option	Possible if <24h, minimal contamination, sealed	Rarely appropriate
Operative approach	Laparoscopic repair + washout	Laparotomy, resection, often stoma
Mortality	10-20%	20-40%
Post-op NGT	Yes, for gastric decompression	Variable
PPI therapy	High-dose IV (omeprazole 80mg then 8mg/h)	Not routinely indicated

Red Flags for Deterioration 🚩

Lactate >4 mmol/L or rising
Systolic BP <90 mmHg despite fluids
Urine output <0.5 mL/kg/h
Worsening peritonism or new organ dysfunction

📌 Remember: PERFORATION - Pain sudden, Erect CXR, Rigid abdomen, Free gas, Operative urgency, Resuscitate first, Antibiotics <1h, Time critical, Imaging CT, Outcome depends on speed, Notify surgeons immediately

Visual Aid

Key Points Summary

✓ Mortality 10-40%: Time to surgery is the single most modifiable factor - aim for <6 hours

✓ Imaging hierarchy: Erect CXR (70-80% sensitive) → CT with contrast (>95% sensitive, shows site/cause)

✓ Sepsis Six within 1 hour: Antibiotics (co-amoxiclav + metronidazone), fluids, lactate, cultures, O₂, urine output

✓ Upper GI: May consider conservative management if <24h, minimal contamination, and sealed; otherwise laparoscopic repair + high-dose PPI

✓ Lower GI: Usually requires laparotomy with resection ± stoma (Hartmann's procedure); higher mortality than upper GI

✓ 30% have no free gas on CXR - don't exclude perforation without CT if clinical suspicion remains

✓ Boey score predicts mortality in peptic ulcer perforation: shock + comorbidity + delay >24h

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GI perforation