gastric perf Flashcards
definition of gi perf
full thickness loss of bowel wall integrity that results in perforation peritonitis
Perforation of the wall of the GI tract with spillage of bowel contents.
path of gi perf
Most perforations of the large bowel occur in the sigmoid colon, as this is a common site of diverticular disease and colorectal cancer.
In most cases a pericolic abscess develops, followed by perforation.
approx 15% of cases occur in the caecum following distal obstruction with a competent ileocaecal valve, as this is the most vulnerable part of the colon (Laplace’s Law).
The most frequent site of perforation of duodenal ulcers is in the anterior wall.
In 80% of Boerhaave’s syndrome there is a longitudinal tear in the left posterolateralwall of the distal oesophagus.
aetiology gi perf
ulcerative/erosive disease
- peptic ulcer disease
- most common cause of stomach and duodenal perforation
- duodenal ulcers of anterior wall are more likely to perforate
- malignancy
- IBD
infections
- diverticulities
- acute appendicites
- thyphoid
- GI TB
- toxic megacolon
bowel ischemia
- bowel obstruction ie adhesions, volvulus, malignancy
- acute mesenteric ischemia
trauma
- penetrating trauma - stab injury/iatrogenic
- blunt abdo trauma
foreign body ingestion
drug induced - NSAIDs, glucocorticoids, cocaine
radiation to the abdominopelvic or lower thoracic region
post renal transplant
rf gi perf
Gastroduodenal: Use of NSAIDs, steroids. Curling’s ulcer is associated with severe trauma, surgery or burns.
large bowel perf
most common: diverticulitis and colorectal carcinoma (80%)
perforated appendix is common complication of appendicitis
volvulus
UC (toxic megacolon)
trauma
radiation enteritis and complications of post-op anastomotic dehiscence or colonoscopy
gastroduodenal perf
most common: perforated duodenal or gastric ulcer
more rarely gastric carcinoma
small bowel perf - rare
trauma
infection (typhoid, TB)
crohn’s
lymphoma
vasculitis
radiation enteritis
oesophagus perf
Boerhaave’s syndrome is rupture following forcible vomitingagainst a closed glottis
Iatrogenic perforation rarely occurs during OGD but more commonly when dilatation of benign or malignant strictures is being carried out.
epi gi perf
incidence depends on the cause
Presentation with abdominal pain due to bowel perforation is, however, a relatively common and potentially life-threatening emergency.
sx of gi perf
sudden onset abdominal pain and distension
nausea, vomiting, obstipation (severe or complete constipation)
fever
involuntary guarding
rebound tenderness
rigid
hx of perf peptic ulcer
sudden onset of intense stabbing pain
followed by diffuse abdo pain and distension (beginning peritonitis)
referred pain to shoulder due to irritation of the diaphragm
history of recurrent epigastric pain
chronic use of NSAIDs
perforation of chronic ulcers might only cause mild symptoms
hx perf diverticulitis
constipation
previous LLQ pain
localisation of pain in perf
diffuse in pts with free intraperitoneal perforation
localised RLQ - contained perforated appendicities
Localised LLQ - contained perforated diverticulitis
large bowel perf hx
presents with abdominal pain due to peritonitis
ruptured AAA should be considered when presented with sudden onset abdo pain and shock
gastroduodenal perf hx
sudden onset severe epigastric pain, then more generalised
worse on movement
in elderly the presentation might not be as acute
- epigastric discomfort
- or in gastric malignancy of pain, weight loss or vomiting
oesophageal perf hx
sever pain following an episode of violent vomiting
endoscopic perforations are seen at time of procedure
or pain in the neck or chest and dysphagia develops soon after
signs GI perf
rigidity, quiet bowel sounds, guarding - classical features of peritonitis. GENERALISED peritonitis in an unwell pt usually indicates that an abdominal viscus has perforated
tachycardia
tachypnea
hypotension
(Perforation peritonitis typically results in third-spacing of fluid and paralytic ileus, which can cause significant hypovolemia. In patients with sepsis, hypotension may signify the onset of septic shock.)
signs of peritonitis or shock, pyrexia, pallor, dehydration
decreased or absent bowel sounds (due to paralytic ileus)
loss of liver dullness on RUQ percussion (because of presence of air between the diaphragm and the liver)
In oesophageal perforations there may be SC emphysema or signs of a hydro- or pneumothorax.
ix perf
U&E
LFT
amylase - level may be raised in perforations
clotting
blood count - neutrophilic leukocytosis
raised blood urea nitrogen, and creatinine - indicate prerenal kidney injury due to prolonged hypovolaemia and hypotension which accompanies perforation peritonitis
blood gas analysis - lactic acidosis (in ischemic perforation)
imaging perf
erect CXR - air under the diaphragm and/or between the liver and the lateral abdominal wall, which rises up from the abdomen as the pt sits for the exam
AXR upright and supine - can show abnormal gas shadows in tissues or in the bowel wall, alternatively a lateral decubitus film can demonstrate intraperitoneal gas
gastrograffin swallow - for suspected oesophageal perforations. Alternatively, any coexisting pleural effusion aspirate would test positive for amylase.
[[CT abdo with IV contrast
indications - acute, non-localised abdominal pain
findings - pneumoperitoneum, signs of perforated bowel (loss of bowel wall continuity, localised mesenteric fat stranding)
IV contrast is preferred if bowel perforation is suspected. If oral contrast must be used, a water-soluble contrast agent is preferred
indication for XR - pts with contraindications to contrast
US abdo
- preferred in pts with CI to radiation eg in pregnancy
- findings: pneumoperitoneum, localised fluid collection, localised thickening of bowel segment ]] - amboss
resus mx perf
vital preop with treatment of shock
oxygen
insert a cannula
perform emergency blood tests
administer IV normal saline - correction of fluid and electrolyte abnormalities
Give IV morphine and an anti-emetic
antibiotics - metronidazole, cefuroxime - organisms causing sepsis are likely to be normal bowel pathogens (are a mixture of Gram +ve, Gram –ve, and anaerobic bacteria, eg. Enterococcus , E. Coli, and Bacterioides, respectively.) . Cefuroxime is effective against both. Metronidazole is usually added because of its excellent anti-anaerobic cover.
urinary catheter
central line
conservative mx perf
reserved for those that are a high anaesthetic risk (ASA 4 or 5)
NBM
high dose PPI
IV fluids
IV AB
NG tube and close monitoring
surgery mx perf
laparotomy to repair the breach in the mucous membrane
bowel perforation is a surgical emergency - in some cases the clinical features are enough to warrant an emergency explorative laparotomy
large bowel laparotomy
- identification of the site of perforation and peritoneal lavage
- resection of the involved colon - usually as part of Hartmann’s procedure with formation of an end colostomy and closure of the distal stump or exteriorisation as a mucous fistula
- A localised perforation of the right colonmay allow resection and a primary anastomosis.
- In toxic megacolon of ulcerative colitis, a subtotal colectomy is performed with a terminal ileostomy and preservation of the rectal stump (allows future reconstruction of ileoanal pouch).
gastroduodenal laparotomy and peritoneal lavage
- the perforation is closed and an omental patch placed
- gastric ulceers should be biopsied (4 quadrant frozen section if possible) to examine for carcinoma
- Closure is more difficult than duodenal ulcers and Billroth I partial gastrectomy with gastroduodenal anastomosis can be done. Post-op: H. pylori eradication if positive.
oesophageal
- depends on the pathology and time of the presentation
- If occurs during dilation of a malignant stricture, coverage by an expandable stent may be possible.
- If spontaneous and<24h from onset, should be treated surgically using a left thoracotomy with pleural lavage and primary repair, or oesophagectomy.
complications GI perf
peritonitis
bacteraemia
sepsis
multiorgan dysfunction
intra-abdo abscess
intra-abdo adhesions
subhepatic abscess
pyogenic liver abscess
pelvic abscess
postop complications
large and small bowel - peritonitis
oesophageal - mediastinitis, shock, overwhelming sepsis and death
Px gi perf
Gastroduodenal: Higher morbidity and mortality in perforated gastric ulcers than duodenal; perforated gastric carcinomas have a very poor prognosis.
Large bowel: Untreated colonic perforation has a high risk of faecal peritonitis and death from septicaemia and multiorgan failure.
