In an audit of 1190 emergency admissions with abdominal pain (1166 patients) in a general surgical unit, the diagnosis was non-specific abdominal pain (NSAP) in 415 (35 per cent), acute appendicitis in 200 (17 per cent) and intestinal obstruction in 176 (15 per cent). The largest number of admissions occurred in the age groups 10-29 years (31 per cent) and 60-79 years (29 per cent). Surgical operations were performed in 551 patients (47 per cent) and there was a 16 per cent incidence of unnecessary appendicectomy (22 per cent in the age group 20-29 years). Fifty-one deaths resulted in a 30-day hospital mortality rate of 4.4 per cent and a perioperative mortality rate of 8 per cent. The mortality rate increased significantly in patients aged greater than or equal to 60 years, and patients aged 80-89 years had a perioperative mortality rate of 20 per cent. The causes of perioperative death included laparotomy for inoperable disease (28 per cent), ruptured abdominal aortic aneurysm (23 per cent), perforated peptic ulcer (16 per cent) and colonic resections (14 per cent). The perioperative mortality rates for ruptured aneurysm and perforated ulcer were 71 and 23 per cent respectively. The duration of inpatient stay increased significantly with the age of the patients, including those with NSAP. The results of the study indicate a need to review the methods of management of ruptured aortic aneurysm and perforated peptic ulcer, the methods of diagnosis of appendicitis, particularly in young females, and the factors that determine the duration of stay of patients suffering from NSAP.

The mortality rate after surgery for acute diverticular disease remains excessive and a high-risk group can be identified before operation. A policy of resection and anastomosis appears justified for selected patients. Adopting a practice of interval elective sigmoid colectomy after admission with acute diverticulitis might prevent readmission with further complications.

In a consecutive series of 284 patients with a perforated peptic ulcer (229 pyloroduodenal, 55 gastric) there was a 26 per cent hospital mortality rate, and patients aged greater than or equal to 70 years (n = 176) had a significantly higher mortality rate (34 per cent) than patients aged less than 70 years (14 per cent, P less than 0.001). Multiple clinical variables were significantly more common in the elderly group of patients (65 per cent), in those having non-steroidal anti-inflammatory drugs or steroid therapy (56 per cent), in patients where there is an absence of a previous dyspeptic history (69 per cent), and when risk factors such as delayed presentation (33 per cent) and the presence of shock on admission to hospital (27 per cent) are present. Definitive operations (vagotomy or gastrectomy) had an increased mortality rate in the elderly (P = 0.018). Risk scores based upon the presence of shock, delayed presentation or concurrent medical illness could have predicted 87 per cent of postoperative deaths in elderly subjects, and it is suggested that risk stratification and greater caution in the use of definitive operations for perforated ulcer may result in a reduction in the high mortality rate in elderly subjects.

Of 152 consecutive patients with carcinoma of the right colon, 61 (40 per cent) suffered delays in treatment of more than 12 weeks from the onset of symptoms, with a mean delay of 48 weeks. The most common error was failure to initiate or complete the investigation of iron-deficiency anaemia (33 patients). False-negative barium enema investigations occurred in 16 cases. Patients with delays in diagnosis had survival rates not significantly different from those who presented early. Thirty-one patients with anaemia and no abdominal symptoms had a significantly higher survival rate than 30 presenting with abdominal symptoms, despite delays in treatment (P < 0.02). Greater vigilance is required in the investigation of patients presenting with iron-deficiency anaemia.

The factors affecting the prognosis of patients presenting with colonic obstruction caused by carcinoma were examined in a retrospective study of 66 patients undergoing emergency surgery for obstruction. The findings in these cases were compared with 176 patients with colonic cancer undergoing elective surgical treatment. Obstructed patients had a significantly higher surgical mortality (37.9 per cent) than elective cases (11.9 per cent). There was a significantly higher incidence of lymph node metastases in obstructed patients and those who survived surgery had a significantly lower 5-year survival rate (22.9 per cent) than elective cases (41.5 per cent). Primary resection of obstructing tumours was followed by a higher 5-year survival rate (31.8 per cent) than staged resections (7.7 per cent), but these operations were used selectively and the 5-year survivors following primary resection all had tumours of the proximal colon. Primary resection and anastomosis of the distal colon was associated with a surgical mortality of 50 per cent. Further progress in the cure of patients with obstructing cancer of the colon may be limited by the aggressive nature of the disease, but the use of primary resection in these cases should be examined in a prospective clinical trial.