What to do before referring

Ensure clinical stability

• Perform a full ABCDE assessment and stabilise the patient before calling.
• If the patient is acutely unwell (e.g. hypotensive, tachycardic, peritonitic), ensure resuscitation measures are underway. This included IV fluids, oxygen, antibiotics if septic, analgesia, and senior review.

Initial investigations

• Bloods: FBC, U&Es, LFTs, CRP, amylase/lipase, clotting, group & save ± crossmatch.
• ECG – always in older patients or if cardiac differential.
• Urine dipstick – to exclude UTI or pregnancy-related causes.
• β-hCG in women of childbearing age.
• Imaging:
  • CXR (for perforation or aspiration).
  • AXR (for suspected obstruction).
  • CT abdomen/pelvis (often essential for diagnosis).
  • Ultrasound (RUQ pain, gallstones, biliary sepsis).

Immediate management

• IV access ×2 large-bore.
• Fluids for dehydration or shock.
• Analgesia and antiemetics.
• Antibiotics if sepsis suspected.
• NG tube + urinary catheter if bowel obstruction suspected.
• NPO (nil by mouth) until reviewed.

Know your patient

• Name, age, sex, hospital/NHS number, and location.
• Presenting complaint and timeline.
• Relevant medical comorbidities (esp. diabetes, cardiac, renal disease).
• Past surgical history (esp. previous abdominal operations).
• Current medications (esp. anticoagulants, steroids).
• Allergies.
• Baseline function and living situation.
• DNACPR/TEP status if relevant.

Check local pathways

• Some Trusts split by subspecialty:
  • Upper GI / HPB teams for biliary, gastric, or pancreatic pathology.
  • Colorectal for lower GI problems, obstruction, perforation, diverticulitis.
  • Vascular or urology may take specific cases in larger hospitals.
• In smaller hospitals, these often fall under the on-call “general surgery” team.
• In DGH’s that lack other surgical departments like neurosurgery or cardiothoracics, patients may have to be managed locally by general surgery.
• In some trusts, gynaecology often insist on surgical pathology being ruled out first, which may require review by the general surgery team.

What to refer to general surgery

Likely surgical / potentially operative conditions

• Appendicitis
• Cholecystitis / biliary colic / gallstone pancreatitis
• Bowel obstruction (small or large)
• Perforation / peritonitis
• Diverticulitis with systemic features
• Incarcerated or strangulated hernia
• Abscess requiring drainage
• Acute abdomen of unclear cause with peritonism

Postoperative complications

• Surgical site infection, wound dehiscence.
• Anastomotic leak, intra-abdominal abscess, ileus, postoperative bleeding.

GI bleeding (may come under gastro in some settings and depending on context)

• Haematemesis or melaena with haemodynamic instability.

Abdominal trauma

• Penetrating or blunt abdominal trauma.

Some presentations might be grey areas where it is not always clear whether a referral to medicine or surgery is more suitable. If unsure, discuss with your senior first.

 What the surgical team needs to know

When you call, be structured and efficient. They will expect the following details:

Patient summary

• Name, age, sex, and location.
• Why you are calling (suspected diagnosis / acute abdomen / obstruction etc.).

Clinical picture

• Brief history of presenting complaint (onset, character, progression).
• Relevant background: comorbidities, previous surgery, current medications.
• Observations (HR, BP, RR, temp, SpO₂).
• Current clinical status — stable, septic, or peri-arrest.

Examination findings

• Abdominal signs: tenderness, guarding, rigidity, distension, bowel sounds.
• PR findings if relevant.
• Hernias or surgical scars noted.

Investigations

• Key blood results (WCC, CRP, lactate, renal function).
• Imaging findings: X-ray/CT summary.
• Any microbiology or relevant tests (urine dip, pregnancy test).

Management so far

• Resuscitation given (fluids, antibiotics, analgesia, NG tube).
• Catheterisation / output / NG aspirate volume if relevant.
• Whether patient is NBM.
• Senior input already obtained.

Your impression and request

• State your working diagnosis and what you need:
  • “I think this is likely appendicitis; could you review for admission?”
  • “This looks like a small bowel obstruction; please could you review urgently?”
  • “He is peritonitic and unstable; this is an emergency surgical case.”

Additional considerations

• Functional baseline and support at home.
• Ceiling of care or DNACPR if appropriate.
• Any communication barriers (confusion, language, hearing impairment).

 Reasons for Admission Under Surgery

• Likely surgical pathology requiring inpatient management or operative intervention.
• Unstable physiology (sepsis, bleeding, obstruction).
• Need for IV therapy (antibiotics, fluids, analgesia).
• Inability to tolerate oral intake.
• Need for further imaging or surgical decision-making.
• Frailty or social factors making discharge unsafe.

Tips for Effective Surgical Referrals

• Have all results to hand before calling.
• Be clear, concise, and assertive about the diagnosis and reason for referral.
• Always state whether you believe the patient is stable or urgent.
• Surgeons value objective data (vital signs, imaging findings, lactate) over speculation.
• Be polite, and if they decline to review and you disagree, escalate via your senior.
• Document everything: who you spoke to, grade, time, advice, and plan.

1. Suspected Appendicitis

• “Hello, it’s Dr X calling from ED. I’d like you to review a 24-year-old man with suspected appendicitis.
• He’s had about 18 hours of worsening central abdominal pain that’s now localised to the right iliac fossa, with nausea and anorexia. No vomiting or urinary symptoms.
• His obs are stable: temp 37.9, HR 98, BP 118/70. On examination he has focal RIF tenderness with some guarding and rebound.
• Bloods show a WCC of 14 and CRP of 90. Urine dip is clear. He’s otherwise fit and well, no past abdominal surgery.
• I’ve given him analgesia, IV fluids, and started IV antibiotics. He’s currently nil by mouth.
• I think this is likely appendicitis and he’ll need surgical assessment for admission and imaging if required. Could you review him please?”

2. Bowel Obstruction

• “Hi, it’s X from the acute assessment unit. I’m calling about a 68-year-old woman with suspected small bowel obstruction.
• She’s had three days of colicky abdominal pain, vomiting, and absolute constipation. No flatus for 24 hours. Her abdomen is distended and generally tender but not peritonitic.
• She’s previously had a hysterectomy and a laparotomy for bowel obstruction about 10 years ago, likely adhesional.
• Obs: HR 110, BP 100/60, afebrile, SpO₂ 96% on air. Bloods show WCC 13, lactate 2.8, U&Es slightly deranged.
• AXR shows dilated small bowel loops with multiple air–fluid levels; CXR shows no free air.
• She has an NG tube on free drainage, IV fluids running, and a catheter in place.
• I think this is a straightforward adhesional small bowel obstruction, and she’ll need admission under surgery for ongoing management and possible intervention. Could you come and review her?”

3. Perforated Viscus

• “Hello, this is Dr X on AMU I’m calling about a 72-year-old man who looks like he has a perforated viscus.
• He presented with sudden severe generalised abdominal pain about two hours ago. He’s known to have peptic ulcer disease, not on a PPI, and takes naproxen regularly for osteoarthritis.
• Obs on arrival: BP 90/60, HR 120, T 38.3, SpO₂ 94% on 4 L O₂. On exam he’s peritonitic with a rigid abdomen and rebound tenderness.
• Bloods show WCC 19, lactate 5.2, and U&Es are normal. CXR shows free air under the right hemidiaphragm.
• He’s had fluid resuscitation, IV antibiotics, an NG tube, and catheter. I’ve started high-flow oxygen and he’s on a monitor.
• I’m really concerned he’s got a perforated ulcer and will likely need urgent surgical intervention. Could you review him urgently?”

4. Diverticulitis

• “Hi, it’s Dr X from the medical take. I’m calling about a 63-year-old lady with what looks like acute diverticulitis.
• She’s had three days of worsening left lower quadrant pain and fevers, no vomiting or urinary symptoms. She’s previously had a colonoscopy showing diverticular disease.
• Obs are stable: HR 95, BP 120/70, temp 38.2. On exam she’s got LLQ tenderness without peritonism.
• Bloods show WCC 16, CRP 180. CT abdo pelvis confirms sigmoid diverticulitis with a small pericolic abscess, no free air or perforation.
• I’ve given IV fluids, analgesia, and antibiotics as per Trust policy.
• I think she needs surgical review for admission and inpatient management of this complicated diverticulitis.”

5. Gallstone Disease / Cholecystitis

• “Hello, it’s Dr X in ED. I’d like to refer a 52-year-old woman with likely acute cholecystitis.
• She’s had 24 hours of right upper quadrant pain radiating to her shoulder, with fevers and vomiting. No jaundice.
• Obs: HR 102, BP 120/70, T 38.4, SpO₂ 98% on air. On exam she has RUQ tenderness and a positive Murphy’s sign.
• Bloods: WCC 14, CRP 160, LFTs mildly raised with ALT 80. Ultrasound shows gallstones and thickened gallbladder wall.
• She’s had IV fluids, antibiotics, and analgesia, and she’s now comfortable.
• I think this is acute cholecystitis and she’ll need admission under surgery for further management and possible cholecystectomy. Could you please review her?”

6. Acute GI Bleed

• “Hi, this is Dr X from ED majors. I have a 59-year-old man with a large upper GI bleed.
• He’s vomited a large volume of fresh blood at home and again in the department. PMH includes alcoholic liver disease and known oesophageal varices.
• On arrival he was shocked: BP 85/50, HR 125, SpO₂ 93% on 10 L oxygen. He’s pale and clammy.
• Bloods: Hb 65, INR 1.9, Urea 18. Group and save done, two units crossmatched.
• He’s had IV fluids, terlipressin, antibiotics, and a PPI infusion started.
• He’s still haemodynamically unstable and continues to have haematemesis.
• We think this is a variceal bleed and he’ll need urgent endoscopic or surgical input. Could you please come urgently?”

7. Postoperative Complication – Wound Infection

• “Hello, it’s Dr X from Ward Y. I’m calling about Mrs Lewis, who had a right hemicolectomy five days ago.
• She’s now febrile at 38.5 °C with increasing pain and erythema around her wound. There’s some purulent discharge but no dehiscence.
• Her obs are stable and her abdomen is otherwise soft. WCC is 14, CRP 210. She’s already on IV co-amoxiclav.
• I’m concerned about a possible wound infection or collection and wondered if you could review her, and advise whether she needs imaging or wound drainage.”

8. Incarcerated Hernia

• “Hi, this is Dr X from ED. I’m calling about an 80-year-old man with an incarcerated inguinal hernia.
• He presented with a tender irreducible swelling in his right groin, associated with vomiting and absolute constipation.
• Obs: HR 115, BP 100/60, T 37.9, SpO₂ 95% on air. Abdomen is mildly distended and tender, hernia is firm and non-reducible.
• Bloods: lactate 3.8, WCC 16.
• He’s had fluids, antibiotics, and analgesia.

I’m worried about strangulation and obstruction — he’ll need urgent surgical assessment for possible theatre.”

With special thanks to Dr Mohamed Nunow, surgical SHO for his contribution in drafting the article