Case selected by the ANZASM Committee 

General Surgery

Case summary
A 73-year-old woman presented to a metropolitan emergency department at 08:10 with sudden-onset sharp lower abdominal pain that had become generalised the day before. She had one episode of vomiting. This is on the background of a Whipple procedure performed 10 years prior. 

A non-contrast CT scan of the abdomen performed at 10:25 demonstrated free gas, a moderate volume of free fluid, thickened small bowel loops, and a possible transition point at splenic flexure with collapse of the distal large bowel. By 12:30, an emergency department note reported urinary retention, a tense distended abdomen, and upper abdominal tenderness, prompting referral to the surgeons. 

The patient was reviewed by a general surgical registrar at 14:30. Examination revealed generalised abdominal tenderness with percussion tenderness in the lower abdomen. A provisional diagnosis of a perforated large bowel obstruction was made, and transfer was arranged to a quaternary hospital 15 km away. 

While awaiting transfer, the patient deteriorated. At 19:30, she developed hypotension requiring a fluid bolus and increasing abdominal pain requiring intravenous morphine. She arrived at the quaternary hospital at 20:56 and was seen by another surgical registrar at 21:35—approximately 13 hours after presentation and 11 hours after identification of a free perforation. At that stage, she remained hypotensive with worsening pain. The examination documented a soft abdomen with generalised tenderness.

Following discussions with the consultant, a decision was made to manage the patient with intravenous antibiotics, proton pump inhibitors, and insertion of a nasogastric tube, with surgery scheduled for the next day. The nasogastric tube was not inserted until at least 17 hours after her initial presentation. 

At laparotomy the following day, a perforation was identified at the gastrojejunostomy site from the previous Whipple procedure. This was repaired with an omental patch in consultation with the surgeon who had performed the original operation. No bowel obstruction or other significant intra-abdominal pathology was identified. 

The patient initially appeared to recover well postoperatively. On postoperative day 4, she was documented as passing flatus and opening her bowels. 

Approximately one hour later, she became unresponsive and was transferred to the intensive care unit. Investigations revealed acute liver failure despite previously normal liver function tests. CT imaging demonstrated no vascular abnormality. N-acetyl cysteine was administered following consultation with a transplant hepatologist; however, the patient rapidly deteriorated and was not considered a candidate for liver transplantation. She subsequently died from acute liver failure of uncertain aetiology.

Discussion
Several aspects of the management of this patient raise important concerns. 

Most notably, there was a delay between radiological identification of free perforation and surgical treatment. The patient remained at the referring hospital for 11 hours after the diagnosis despite the receiving hospital being located mere 15 km away. Given the time-critical nature of gastrointestinal perforation, this represents a significant systems issue.

The reason definitive treatment could not be provided at the referring hospital is unclear, particularly as surgical services were available on site. Delays due to interhospital transfer resulted in the patient arriving at the receiving hospital late in the evening, undoubtedly contributing to further delay in surgery. 

The relatively benign abdominal findings documented on arrival at the treating hospital may also have influenced decision-making. However, as often happens with free perforation, slight improvement in the abdominal sign can occur in patients with gastrointestinal perforation and should be interpreted cautiously. 

It is also quite telling that a nasogastric tube was not placed for at least 17 hours after presentation. It may be appropriate to conservatively manage some perforations with a nasogastric tube and acid suppression, with frequent monitoring, when the suspected diagnosis is a peptic ulcer perforation. However, conservative management of a suspected large bowel perforation (the working diagnosis here) would be, at best, a controversial decision.

This case has clearly identified some opportunities for improvement and demonstrates prompt transfer is of paramount importance after this decision has been made. It also demonstrates that perhaps surgeons in peripheral hospitals need to be empowered to actively treat patients by ensuring adequate supporting services are in place, which would prevent treatment delays in the first place.

Clinical lessons
-- Delays in transfer and treatment can adversely affect outcomes, highlighting the importance of clear escalation pathways and timely access to appropriate surgical services.
-- Clinical findings should be interpreted in conjunction with imaging and the patient’s overall clinical course; temporary improvement in abdominal signs does not exclude ongoing intra-abdominal pathology.
-- Supportive measures, such as nasogastric decompression when indicated, should be implemented promptly while arrangements for definitive management are being made.

Disclaimer
Please note that these cases are edited from ANZASM first- or second-line assessments that have been generated by expert surgeons in the field. Any recommendations relate to these cases as they were presented.