Gastrointestinal perforation

Question 1

What is GI perforation?

Answer 1

• hole in your digestive tract
• Medical emergency
  Perforation of the wall of the GI tract with spillage of bowel contents.  

Question 2

What are some causes of GI perforation?

Answer 2

1. Large Bowel → diverticulitis, colorectal cancer, appendicitis
2. Gastroduodenal → perforated duodenal or gastric ulcer
3. Small Bowel (Rare) → trauma, infection (TB), crohn’s disease
4. Oesophagus →
   - Boerhaave’s Perforation ⇒ spontaneous full thickness rupture of the oesophagus that occurs as a result of repeated episodes of vomiting and long-standing alcohol use.

Question 3

What are some risk factors for GI perforation?

Answer 3

Risk factors of cause (e.g. gastroduodenal - NSAIDs, steroids, bisphosphonates)

Question 4

Summarise the epidemiology of gastrointestinal perforation

Answer 4

Incidence depends on cause

Question 5

What are the presenting symptoms of a GI perforation?

Answer 5

Depends on CAUSE
1. Large Bowel
- Peritonitic abdominal pain
- IMPORTANT: make sure you rule out ruptured AAA
2. Gastroduodenal
- Sudden-onset severe epigastric pain - worse on movement
- Pain becomes generalised
- Gastric malignancy - may have accompanying weight loss and nausea/vomiting
3. Oesophageal
- Severe pain following an episode of violent vomiting
- Neck/chest pain and dysphagia develop soon afterwards

Question 6

What signs of a GI perforation can be found on physical examination?

Answer 6

• Very UNWELL
• Signs of shock
• Pyrexia
• Pallor
• Dehydration
• Signs of peritonitis (guarding, rigidity, rebound tenderness, absent bowel sounds)
• Loss of liver dullness (due to overlying gas)

Question 7

What investigations are used to diagnose/ monitor a GI perforation?

Answer 7

1. Erect CXR (1st line) → air under diaphragm (pneumoperitoneum)
2. CT with IV Contrast → gold standard for bowel perforation
3. Bloods → FBC (normocytic anaemia), U&E, LFTs, Amylase (raised in perforation but not as much as in pancreatitis)
   - Raised Urea - suggests upper GI bleed rather than lower GI bleed
4. AXR →
   - Rigler’s Sign (AXR) ⇒ double-wall sign, due to gas outlining both sides of the bowel wall
5. Gastrograffin Swallow → for suspected oesophageal perforation

Question 8

How is a GI perforation managed?

Answer 8

1. IV Fluids + IV Antibiotics.
2. Surgical:
   - Large Bowel → resection of a perforated section (usually as part of a Hartmann’s procedure). Peritoneal Lavage (bedside procedure for evaluating bleeding in the abdominal cavity)
   - Gastroduodenal → laparotomy, perforation is closed with an omental patch. H.pylori eradication if positive (cause of ulcer).
   - Oesophagus → repair of ruptured oesophagus

Question 9

What complications may arise from a GI perforation?

Answer 9

peritonitis(large & small bowel). Mediastinitis, shock, severe sepsis(oesophageal)

Question 10

Describe the prognosis of GI perforation?

Answer 10

• Gastroduodenal → gastric ulcers have higher morbidity and mortality than duodenal ulcers
• Large bowel → high risk of faecal peritonitis if left untreated, leads to death from septicaemia and multiorgan failure

Question 11

What is Boerhaave’s Perforation?

Answer 11

• Spontaneous full thickness rupture of the oesophagus that occurs as a result of repeated episodes of vomiting and long-standing alcohol use.
• Sudden onset severe chest pain and subcutaneous emphysema (may have signs suggestive of pneumonia).
• Diagnosis via CT contrast swallow (avoid OGD due to risk of worsenening perforation).
• Severe sepsis may occur secondary to mediastinitis.

Question 12

What is the difference between Boerhaave’s Perforatio and Mallory-Weiss Tear?

Answer 12

• Boeerhaave’s is more severe and will cause distorted observations and may have abnormal CXR.
• Mallory-weiss is longitudinal mucous membrane tear (limited to mucosa and submucosa) at GOJ and causes haematemesis, Boerhaave’s is transmural rupture in distal 1/3 of oesophagus.