Gastrointestinal perforation Flashcards
What is GI perforation?
GI perforation = rupture in the wall of part of the gastrointestinal tract (oesophagus, stomach, intestines)
Most common = small bowel
Blunt trauma = spleen
Penetrating trauma = liver
How is GI perforation managed?
Emergency medical IV access and crystalloid therapy Catheterise Bloods IV ABs (if sepsis) NBM
Surgical – correct underlying anatomic problem/removal
Ulcer – sutured closure with omental patch, or local excision if body
Carcinoma – gastrectomy (usually palliative)
Trauma – sutured closure
Volvulus with ischamia – subtotal gastrectomy
Post-operative medical IV replacement therapy NG drainage ABs Analgesics
What is the aetiology of GI perforation?
GI-related conditions
Diverticulitis, carcinoma, UC, Crohn’s, toxic megacolon, strangulated hernia, PUD, forceful vomiting, appendicitis, ischaemia, ruptured ovarian cyst
Trauma
Surgical, endoscopy, penetrating injury, blunt trauma, swallowed object (e.g. fish bone), swallowed corrosive substance/NSAIDs, kidney transplant
What are the risk factors for GI perforation?
Abdominal surgery
NSAID use
Diverticulitis
PUD
What is the epidemiology of GI Perforation?
Children are at greater risk of blunt trauma
Vechicle trauma, handlebar injury, seatbelt syndrome
1-7% incidence – increasing
Duodenal ulcer perforations 2-3x more common than gastric
1/3 of gastric perforations due to gastric carcinoma
10% of patients with acute diverticulitis develop perforation
30% mortality due to complications of septic shock and multi-organ failure
Rare complication of endoscopy (1%)
What are the symptoms of GI perforation?
Upper GI Acute onset upper abdominal pain Severe, constant and worse with breathing/moving Radiate to back or shoulders Vomiting Suggestive of ulceration Prodrome of upper abdominal pain Suggestive of volvulus Copious vomiting Upper abdominal distention Suggestive of carcinoma Weight loss Dyspepsia Anorexia
Lower GI
Acute onset of lower abdominal pain
What are the signs of GI perforation?
Generalised peritonism = board-like generalised rigidity with marked guarding and tenderness
Absent bowel sounds
Percussion tenderness - Suggests peritoneal inflammation
Mild fever
Pallor
Tachycardia
Hypotension
What are appropriate investigations for GI Perforation?
Bloods WCC, CRP Group and save Amylase LFTs
Blood cultures
ABG
Lactate for mesenteric ischaemia
CXR
Air under the diaphragm
Plain AXR
Rigler’s sign
Visible falciform ligament RUQ
Air fluid level
Ultrasound
Localised gas collection
Thickened bowel loop
What are the consequences of GI Perforation?
Death Severe haemorrhage Wound failure Localised abdominal abscess Sepsis Bowel infarction
What is the prognosis of GI Perforation?
Increased risk of death if Advanced age Underlying disease Malnutrition Nature of cause Complications
30% mortality rate in elderly appendicitis
