Bowel Perforation

Question 1

Give some possible causes of GI perforation

Answer 1

Chemical - PUD, foreign body e.g. battery
Infection: appendicitis, diverticulitis, cholecystitis, Meckel’s diverticulum
Ischaemia: mesenteric ischaemia, obstructive lesions
Colitis: fistula formation (Crohn’s), toxic megacolon (C.diff, UC)
Iatrogenic - surgery, anastomotic leak, NG tube
Penetrated or blunt trauma
Direct rupture - excessive vomting leading to oesophageal perforation -Boerhaave syndrome

Question 2

Describe intraperitoneal GI rupture presentation

Answer 2

Abdominal pain, crescendo in nature.
Generalised pain and then focused to the affected region, before spreading as the organ perforates.
Abdo tenderness, rose on movement t–> rigid abdomen
OE - distended and perotinic
Palpable mass may be present

Question 3

Describe retroperitoneal GI perforation presentation

Answer 3

Insidious in onset
Right shoulder tip pain referred from diaphragm irritation, back pain or right iliac fossa pain representing retroperitoneal duodenal ulcer (gastric content settles in right parabolic gutter due to gravity) OR pelvic/left lower quadrant pain suggesting diverticulitis.
May only be minimal focal tenderness on palpation

Question 4

Where does diaphragm irritation refer pain?

Answer 4

Right shoulder tip

Question 5

What does right iliac fossa pain suggest in terms of bowel perforation

Answer 5

Appendicitis

Retroperitoneal duodenal ulcer

Question 6

What does pelvic or left lower quadrant pain suggest?

Answer 6

Diverticulitis

Question 7

Describe thoracic GI perforation presentation

Answer 7

Pain: chest pain, neck pain to pain radiating to back or pain on inspiration
May be associated vomiting and respiratory symptoms
May be a pleural effusion

Question 8

What investigations for GI perforation?

Answer 8

Imaging:
Plain erect CXR can show free air under the diaphragm. Pneumomediastinum may be present if perforation is thoracic

AXR:
Rigler’s sign - bothe sides of bowel wall can be seen due to free intra-abdominal air acting as additional contrast
Psoas sign - loss of the sharp delineation of the posts muscle border secondary to fluid in the retroperitoneum

Gold standard = CT with contrast

Question 9

What is Rigler’s sign?

Answer 9

AXR shows both sides of bowel wall visible due to free intra-abdominal air acting as additional contrast

Question 10

What is PSoas sign?

Answer 10

AXR - loss of the sharp delineation of the posts muscle border secondary to fluid in the retroperitoneum.

Question 11

How is GI perforation managed?

Answer 11

Broad spectrum antibiotics
NG tube, NBM
IV fluid support
Analgesia

Conservative:
Oesophageal - endoscopically placed stent or simple bowel rest with alternate feeding
PUD perforation - bowel rest and PPI
Diverticular abscess - <5cm antibiotics, guided percutaneous drainage

Surgical:
Thorough washout
Relief of obstruction
Repair of perforation
Resection of disease, stoma formation

Question 12

What are the complications of GI perforation

Answer 12

Peritonitis
Sepsis
Haemorrhage