From the Guidelines
Diagnoses requiring immediate referral to general surgery include complicated rectal prolapse with signs of shock or gangrene/perforation of prolapsed bowel, acute severe ulcerative colitis with free perforation, life-threatening hemorrhage, or generalized peritonitis, and unstable patients presenting with hemorrhagic shock or non-responders to resuscitation. These conditions represent surgical emergencies where delay in operative management could lead to significant morbidity or mortality, as highlighted in the study by 1. The urgency stems from the potential for rapid clinical deterioration, as these conditions can quickly progress to sepsis, shock, or irreversible tissue damage. While initial stabilization with IV fluids, antibiotics, and pain management may be initiated in the emergency department, definitive treatment typically requires surgical intervention, and early surgical evaluation improves outcomes by reducing the time to definitive care.
Some key diagnoses that require immediate referral to general surgery are:
- Complicated rectal prolapse with signs of shock or gangrene/perforation of prolapsed bowel, as recommended by 1
- Acute severe ulcerative colitis with free perforation, life-threatening hemorrhage, or generalized peritonitis, as stated in 1 and 1
- Unstable patients presenting with hemorrhagic shock or non-responders to resuscitation, as recommended by 1 and 1
- Other surgical emergencies such as acute appendicitis, bowel obstruction, perforated viscus, acute cholecystitis, incarcerated or strangulated hernias, mesenteric ischemia, necrotizing soft tissue infections, and severe gastrointestinal bleeding.
Patients presenting with severe abdominal pain, peritoneal signs, hemodynamic instability, or signs of sepsis should be promptly evaluated by a surgeon, as emphasized in the studies by 1, 1, 1, 1, and 1. Certain traumatic injuries, including penetrating abdominal trauma, blunt trauma with signs of internal bleeding, and pancreatic injuries, also warrant immediate surgical consultation. The study by 1 highlights the importance of early surgical intervention in patients with complicated rectal prolapse and signs of shock or gangrene/perforation of prolapsed bowel, and recommends immediate surgical treatment in these cases. Similarly, the studies by 1, 1, 1, and 1 emphasize the need for prompt surgical evaluation and intervention in patients with acute severe ulcerative colitis and other surgical emergencies.
From the Research
Diagnoses Requiring Immediate Referral to General Surgery
The following diagnoses require immediate referral to general surgery:
- Acute appendicitis, especially in patients with high-risk CT findings such as appendicolith, mass effect, or a dilated appendix greater than 13 mm 2
- Acute cholecystitis, as comprehensive guidelines are available for its management 3
- Acute diverticulitis, particularly in cases involving perforated small and large bowel, where broader spectrum antimicrobial therapy should be considered 4
- Traumatic appendicitis, which can occur after blunt abdominal trauma and requires a high index of suspicion for timely diagnosis 5
- Complicated intra-abdominal infections, such as those secondary to appendicitis and cholecystitis, where empirical therapy with ceftriaxone and metronidazole may be appropriate 4
Key Considerations
When referring patients to general surgery, it is essential to consider the following:
- The patient's overall health and fitness for surgery 2
- The presence of high-risk CT findings, which may indicate a higher risk of treatment failure with antibiotics-first approach 2
- The need for broader spectrum antimicrobial therapy in cases involving perforated bowel or complicated sigmoid diverticulitis 4
- The importance of timely diagnosis and treatment to reduce complications and improve outcomes 6