Gastrointestinal perforation

Question 1

Types of gastrointestinal perforation?

Answer 1

Oesophageal
Gastroduodenal
Small bowel perforation (rare!)
Large bowel perforation

Question 2

Aetiology of gastrointestinal perforation?

Answer 2

Oesophageal perforation:
- Boehaave’s perforation: following episode of forceful vomiting
- Iatrogenic

Gastroduodenal perforation:
- Ulcers: NSAIDs, steroids, bisphosphonates (prevent loss of bone density)
- Gastric cancer

Small bowel perforation:
- Trauma
- Crohn’s
- Infection (i.e: TB)

Large bowel perforation:
- Diverticulitis
- Colon cancer
- Appendicitis
- Rare: toxic megacolon, volvulus

Question 3

Signs of gastrointestinal perforation? (all types)

Answer 3

• Pyrexia
• Hypotension (septic shock)
• Tachycardia
• Peritonism: rebound tenderness, rigidity + guarding
• Absent bowel sounds
• Heart sounds heard all over

Question 4

Symptoms of gastrointestinal perforation?

Answer 4

Oesophageal
- Severe retrosternal pain
- Dysphagia
- Preceded by vomiting
Gastroduodenal
- Severe sudden onset epigastric pain
- Becomes diffuse
- Accompanying signs of ulcers/malignancy
Large bowel
- Peritonism
- Distension
- Must USS to rule out AAA

Question 5

Investigations for gastrointestinal perforation?

Answer 5

Bloods
- FBC: high WCC
- High CRP
- U&Es
- LFTs
- VBG
- Amylase raised

Erect CXR→ pneumoperitoneum
AXR→ Rigler’s sign
CT→ find perforation
Gastrograffin swallow (oesophageal)

Question 6

Management of gastrointestinal perforation?

Answer 6

ABCDE: inclu IV fluids, ABs, analgesia, NBM

Longterm:
- Oesophageal:
- Pleural lavage
- Resection
- GI:
- Peritoneal lavage
- Repair
- Treat cause
- Large bowel:
- Peritoneal lavage
- Resection

Question 7

Complications of gastrointestinal perforation?

Answer 7

• Peritonitis
• Septic shock
• AKI
• Electrolyte imbalances
• Death