Master General Surgery
for DHA

Core Concepts

General Surgery encompasses a broad spectrum of acute and elective conditions, often involving the alimentary tract from esophagus to rectum, solid abdominal organs (liver, pancreas, spleen), endocrine glands (thyroid, parathyroid, adrenal), and abdominal wall hernias. Key principles include the diagnosis and management of acute abdominal emergencies, trauma, surgical oncology, and critical care aspects like fluid-electrolyte balance, sepsis, and wound healing. A strong emphasis is placed on immediate resuscitation (ABCs), accurate diagnosis, and timely intervention.

Clinical Presentation

• Acute Appendicitis: Periumbilical pain migrating to RLQ, anorexia, nausea/vomiting, low-grade fever, rebound tenderness (McBurney's point).
• Acute Cholecystitis: RUQ pain (often radiating to right shoulder/scapula), fever, nausea/vomiting, positive Murphy's sign.
• Bowel Obstruction: Colicky abdominal pain, distension, vomiting (bilious to feculent), absolute constipation, tinkling bowel sounds (early) or absent (late).
• Perforated Viscus (e.g., ulcer, diverticulum): Sudden onset severe, diffuse abdominal pain, guarding, rigidity ("board-like abdomen"), rebound tenderness, often signs of shock.
• Diverticulitis: LLQ pain, fever, altered bowel habits (constipation/diarrhea), leukocytosis.
• Upper GI Bleed: Hematemesis (bright red or "coffee grounds"), melena, signs of hypovolemia (tachycardia, hypotension, pallor).
• Lower GI Bleed: Hematochezia (bright red blood per rectum), maroon stools, signs of hypovolemia.
• Acute Pancreatitis: Severe epigastric pain radiating to back, nausea/vomiting, often post-prandial or alcohol-related.
• Incarcerated/Strangulated Hernia: Painful, irreducible lump in groin/umbilicus/incisional site, signs of obstruction, overlying skin changes (erythema), systemic toxicity (fever, leukocytosis).
• Surgical Sepsis: Fever/hypothermia, tachycardia, tachypnea, altered mental status, hypotension, source of infection.

Diagnosis (Gold Standard)

For most acute abdominal conditions, a combination of clinical assessment and imaging is crucial:

• Acute Appendicitis: CT Abdomen/Pelvis (adults). Ultrasound often preferred in children and pregnant women.
• Acute Cholecystitis: Abdominal Ultrasound (gallstones, gallbladder wall thickening >4mm, pericholecystic fluid, positive sonographic Murphy's sign).
• Bowel Obstruction: CT Abdomen/Pelvis with oral and IV contrast (identifies transition point, cause, and complications). Plain X-ray (dilated loops, air-fluid levels) can be initial.
• Perforated Viscus: Upright Chest X-ray (free air under diaphragm). CT Abdomen/Pelvis is more sensitive for detecting free air and source.
• Diverticulitis: CT Abdomen/Pelvis (diverticula, wall thickening, pericolic fat stranding, abscess).
• GI Bleeding: Upper Endoscopy (for UGIB), Colonoscopy (for LGIB). Angiography or tagged RBC scan for persistent obscure bleeding.
• Acute Pancreatitis: Serum Amylase/Lipase >3x upper limit of normal, supported by clinical picture. CT for severity and complications.

Management (First Line)

General surgical management prioritizes stabilization, source control, and definitive treatment:

• Initial Resuscitation: ABCs, large bore IV access, IV fluids (crystalloids), oxygen, monitor vital signs, Foley catheter, NPO, NGT (if vomiting/obstruction).
• Acute Appendicitis: Laparoscopic appendectomy. Pre-op broad-spectrum antibiotics.
• Acute Cholecystitis: NPO, IV fluids, broad-spectrum antibiotics. Early laparoscopic cholecystectomy (within 72 hours of symptom onset) is preferred if feasible.
• Bowel Obstruction: NGT decompression, IV fluids, correct electrolytes. Surgical exploration for complete or strangulated obstruction. Non-operative management for partial adhesions.
• Perforated Viscus: Emergency laparotomy (or laparoscopy) for repair/resection and peritoneal lavage. IV broad-spectrum antibiotics.
• Diverticulitis (uncomplicated): Oral antibiotics, bowel rest, clear liquids. (Complicated: IV antibiotics, NPO, percutaneous drainage for abscess >3-4cm, possible surgery).
• GI Bleeding: Resuscitation (fluids, blood products), identify source, endoscopic intervention (clips, cautery, band ligation), PPIs for UGIB.
• Acute Pancreatitis: Aggressive IV fluid resuscitation, pain control, NPO, nutritional support (enteral preferred). No routine antibiotics.
• Incarcerated/Strangulated Hernia: Emergency surgical repair with viability assessment of entrapped bowel.
• Sepsis: Early Goal-Directed Therapy (EGDT), IV broad-spectrum antibiotics, fluid resuscitation, vasopressors as needed, source control (surgery if indicated).