Bowel Perforation

Question 1

Common causes of bowel perforation

Answer 1

Peptic ulcers and sigmoid diverticulum

Question 2

Ischaemic and inflammatory causes of bowel perforation

Answer 2

Chemical
- peptic ulcer disease
- foreign body
Infection
- diverticulitis
- cholecystitis
- meckel's diverticulum
Ischaemia
- mesenteric ischaemia
- obstructing lesions
Colitis
- toxic megacolon

Question 3

Traumatic causes of bowel perforation

Answer 3

Iatrogenic
- recent surgery
- endoscopy or NG tube insertion
Penetrating of blunt trauma
- shear forces from acceleration-deceleration
- high forces over small surface area
Direct rupture
- excessive vomiting -> oesophageal perforation

Question 4

Clinical features of bowel perforation

Answer 4

Pain
Systemically unwell
Features of peritonism

Question 5

Bowel perforation investigations

Answer 5

Baseline bloods - raised WCC and CRP
Erect chest x-ray - free gas under diaphragm
CT scan
Abdominal x-ray

Question 6

AXR signs of bowel perforation

Answer 6

Rigler’s sign - both sides of bowel wall can be seen due to free intra-abdominal air acting as a contrast
Psoas sign - loss of sharp delineation of psoas muscle border secondary to fluid in retroperitoneum

Question 7

Initial management of bowel perforation

Answer 7

Broad spectrum antibiotics
NBM and NG tube insertion
IV fluid support
Analgesia

Question 8

Surgical management of bowel perforation

Answer 8

Identify underlying cause
Management of perforation
- omental patch for peptic ulcer
- resecting perforated diverticulae
Thorough washout

Question 9

When are patients with bowel perforation conservatively managed?

Answer 9

Localised diverticular abscess/perforation with no evidence of generalised peritonitis, tenderness and contamination on CT
Sealed upper GI perforation without generalised peritonism
Elderly frail patients with extensive co-morbities who would be very unlikely to survive surgery

Question 10

Complications of bowel perforation

Answer 10

Infection

Haemorrhage