What are the most critical diagnoses to consider in general surgery?

From the Guidelines

The most critical diagnoses to consider in general surgery include acute appendicitis, bowel obstruction, perforated viscus, acute cholecystitis, mesenteric ischemia, necrotizing soft tissue infections, and abdominal aortic aneurysm, as these conditions require prompt recognition and intervention to prevent significant morbidity and mortality. According to the World Journal of Emergency Surgery, acute appendicitis is the most common general surgery emergency presentation and the most common cause of intra-abdominal sepsis worldwide 1. The management of these conditions involves prompt recognition, intervention, and treatment to prevent complications such as sepsis, shock, multiorgan failure, and death.

Some key points to consider in the management of these conditions include:

• Acute appendicitis presents with right lower quadrant pain, nausea, and fever, and the "gold standard" treatment is laparoscopic appendectomy in all patients, although non-operative management with antibiotic therapy has proven to be successful in uncomplicated appendicitis 1.
• Bowel obstruction manifests with abdominal distention, vomiting, and constipation, and requires prompt recognition and intervention to prevent complications such as strangulation and perforation.
• Perforated viscus is characterized by sudden severe pain and peritoneal signs, and requires immediate surgical intervention to prevent further complications.
• Acute cholecystitis typically causes right upper quadrant pain, fever, and Murphy's sign, and the treatment of choice is laparoscopic cholecystectomy, although percutaneous cholecystostomy with IV antibiotics has been advocated as an alternative to surgery in critically ill patients 1.
• Mesenteric ischemia presents with pain disproportionate to physical findings and is particularly concerning in elderly patients with cardiovascular risk factors, and requires prompt recognition and intervention to prevent complications such as bowel infarction and perforation.
• Necrotizing soft tissue infections require immediate surgical debridement, with patients often appearing toxic with rapidly spreading erythema and crepitus, and the management involves a multidisciplinary approach with surgical, medical, and supportive care 1.
• Abdominal aortic aneurysm rupture presents as severe back or abdominal pain with hypotension and requires immediate surgical intervention to prevent further complications such as shock and death.

Early diagnosis through careful history, physical examination, appropriate laboratory tests, and imaging studies like CT scans is essential in the management of these conditions, as prompt recognition and intervention can significantly improve outcomes and prevent complications 1. The urgency of these conditions stems from their potential for rapid deterioration, with complications including sepsis, shock, multiorgan failure, and death if not addressed promptly.

In terms of postoperative pain management, the World Journal of Emergency Surgery recommends that postoperative pain must be recognized and treated as soon as possible and as best as possible in all patients, and that oral administration of analgesic drugs should be preferred over intravenous route whenever feasible 1. The use of epidural and regional anesthesia is also recommended in emergency general surgery, whenever feasible and if not delaying the emergency procedures, as it has been associated with a lower incidence of paralytic ileus, attenuation of the surgical stress response, improved intestinal blood flow, improved analgesia, and reduction of opioid use 1.

From the Research

General Surgery Diagnoses

• Acute appendicitis is a critical diagnosis to consider in general surgery, with a lifetime risk of 8.6% in males and 6.7% in females 2
• The clinical diagnosis of acute appendicitis is based on history, physical examination, laboratory evaluation, and imaging, with classic symptoms including vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever 3
• Acute cholecystitis is another common surgical emergency, and the concurrent presentation of acute appendicitis and cholecystitis, although rare, should be considered to avoid complications such as perforation and septicemia 4

Common Emergency General Surgery Conditions

• Acute appendicitis, acute cholecystitis, acute diverticulitis, acute pancreatitis, and small bowel obstruction are among the most common emergency general surgery conditions 5
• Comprehensive guidelines are available for these conditions, but further research is needed to address gaps in the evidence base, particularly in areas lacking solid evidence 5

Diagnosis and Management

• The Alvarado score, Pediatric Appendicitis Score, and Appendicitis Inflammatory Response score can help stratify patients as low, moderate, or high risk for acute appendicitis 2
• Point-of-care or formal ultrasonography is recommended as first-line imaging for acute appendicitis, and appendectomy via open laparotomy or laparoscopy is the standard treatment 2
• Intravenous antibiotics may be considered first-line therapy in selected patients with acute appendicitis, and pain control with opioids, nonsteroidal anti-inflammatory drugs, and acetaminophen should be a priority 3, 2