Urgent vs non-urgent gastrointestinal cases

It can be difficult to decide the appropriate intervention and when to perform surgery on gastrointestinal cases. The guidelines below are only guidelines and a decision must be made on each case individually.

I Regurgitation

A Many cases of chronic regurgitation are treated medically without sur­gical treatment. These include:

1 oesophagitis

2 megaoesophagus, which can be idiopathic or due to an underlying cause

3 oesophageal dysmotility

B The regurgitation case needing the most urgent intervention is oeso­phageal obstruction with a foreign body. These may often be removed with endoscopic guidance, but may require urgent surgery in some cases.

C Oesophageal strictures also require intervention, but again endoscopic guided balloon dilation is the preferred method.

D Cases of regurgitation which will likely require surgery after stabiliza­tion include:

1 hiatal hernia

2 vascular ring anomalies

3 some oesophageal diverticula

II Vomiting

(may also have diarrhoea)

A Many causes of vomiting can be treated without surgery and may po­tentially be worsened by anaesthesia and surgery. These include:

1 acute and chronic pancreatitis (without abscess or biliary obstruc­tion)

2 acute or chronic gastroenteritis

3 parvovirus infection

4 parasites

5 acute liver disease

6 gastrointestinal ulceration (without perforation)

7 toxin ingestion or dietary indiscretion

8 adverse reactions to food

9 colitis

10 diabetic ketoacidosis

11 uraemia

12 hypoadrenocorticism

13 vestibular disorders

B Emergency surgery - critical cases that require immediate surgery in­clude:

1 gastric-dilatation volvulus

2 intestinal volvulus

3 acute peritonitis

4 incarcerated bowel

5 diaphragmatic hernia with stomach or strangulated intestine

6 linear foreign bodies

7 complete high intestinal foreign body obstruction.

C Critical cases that require surgery as soon as they are stabilized:

1 gastric dilation without volvulus

2 gastric obstruction, e.g. pyloric stenosis or foreign body

3 distal or partial intestinal obstruction

4 obstructed or ruptured biliary tree

5 pyometra

6 pancreatic mass/abscess

7 intussusception

III Small intestinal diarrhoea

(see also vomiting cases above as many present with either or both clin­ical signs)

A Cases which are treated medically include:

1 enteritis

2 inflammatory bowel disease

3 food responsive disorders (adverse reactions to food)

4 parasites

5 infectious diarrhoea

6 antibiotic responsive diarrhoea

7 parvovirus infection

8 parasites

9 acute liver disease

10 gastrointestinal ulceration (without perforation)

11 toxin ingestion or dietary indiscretion

12 diabetic ketoacidosis

13 uraemia

14 hypoadrenocorticism

15 vestibular disorders

B Cases which may present with small intestinal diarrhoea that require urgent surgery include:

1 any case with a perforated intestine

2 mesenteric torsions

3 intestinal foreign bodies (although usually present with vomiting)

C Cases that require surgery as soon as they are stabilized include:

1 intussusception

2 intestinal masses/focal tumours

IV Generally not urgent, but surgery often indicated for

1 some porto-systemic shunts

V Colonic disorders

A Cases which usually are not treated surgically:

1 most cases of colitis

2 constipation

3 irritable bowel syndrome

4 colonic vascular dysplasia if generalized

5 non-resectable tumours

B May require surgery as soon as the case is stabilized include:

1 obstructive colitis (e.g. granulomatous)

C Generally not urgent, but may require surgery:

1 obstipation (may require colectomy)

2 focal colonic tumours

3 colonic vascular dysplasia if focal

VI Exploratory celiotomy for diagnostic purposes

A Exploratory surgery is necessary for biopsies for diagnosis of:

1 some intestinal mural diseases (e.g. where mucosal biopsies ob­tained with an endoscope are not deep enough)

2 small bowel lesions distal to the reach of the endoscope or if endo­scopy is not available

3 hepatopathies

4 some pancreatic masses