Gastroduodenal Perforation

Question 1

What are the causes of GI perforation?

Answer 1

Trauma, Iatrogenic (e.g. Colonoscopy), Bowel Obstruction, Severe Infection (E.g. C. diff), Inflammatory bowel disease, Peptic Ulcer, Appendicitis, Diverticulitis

Question 2

What will you find on a history taking of GI perforation

Answer 2

Symptoms:
Abdominal Pain
Vomiting
Shoulder Pain/Hiccups – If perforated fluid irritates diaphragm 
Sepsis/Peritonitis

Risk Factors:
Acute GI condition
Recent Iatrogenic treatment/investigation
NSAID use – Predisposing to an ulcer

Question 3

What will you find on examination of GI perforation?

Answer 3

Assess for signs of fluid depletion and sepsis 
End of the bed:
Raised temperature
Reduced Skin turgidity
Hands:
Tachycardia
Hypo-tension with Postural Drop 
Increased Capillary refill time 
Cool peripheries
Face:
Dry Mucous Membranes
Sunken Eyes
Chest:
Tachypnoea
Abdomen:
Abdominal guarding - Abdominal muscle tensing on pressing of the abdominal wall
Rebound tenderness - Indicates inflammation of the parietal peritoneum. As the abdomen snaps back into place it causes pain
Reduced urine output
Legs:
Cool Peripheries

Question 4

What investigations will you order in GI perforation?

Answer 4

Bedside:
Full set of observations
Blood cultures - If septic
Urinary catheter to measure urine output – If septic

Bloods:
FBC – Looking for any anaemia due to bleeds or raised WCC indicating infection
U&E – Looking for any signs of dehydration as a result of the perforation, urea function will be affected if septic
LFT – Patient will require surgery and so pre-operative baseline useful

Imaging:
Erect CXR – Gas under the diaphragm is diagnostic of perforation

Special Tests:
Diagnostic Tap - to assess any ascites, blood or pus in the peritoneum

Question 5

What is the treatment of GI perforation?

Answer 5

Resuscitation:
A-E approach
Get IV Access /Give O2 to maintain sats of 94+ /Attach 12 lead ECG
Assessment with AMPLE history and brief examination
Get help – General Surgeons
Frequent Observations - Constant or 15 minutely
Keep Nil by mouth
If signs of sepsis start Prophylactic antibiotics

Surgery:
Surgical repair with peritoneal washout