Gastrointestinal perforation Flashcards
What sites can gastrointestinal perforation occur?
from the upper oesophagus to the anorectal junction
How can gastrointestinal perforation progress?
Septic shock, multi organ dysfunction and death
What are the most common causes of GI perforation?
Peptic ulcers (gastric or duodenal) and sigmoid diverticulum
What are the chemical causes of GI perforation?
Peptic ulcer disease, foreign bodies
What are the infectious causes of GI perforation?
Diverticulitis, Cholecystitis, Meckels diverticulum
What are some ischaemic causes of GI perforation?
Mesenteric ischaemia, obstructing lesions like cancer or faeces, resulting in bowel distension and ischaemia and necrosis
What are some colitis causes of GI perforation?
Toxic megacolon from C diff or UC
What are some iatrogenic causes of GI perforation?
Recent surgery e.g. anastomotic leak, endoscopy or over zealous NG tube insertion
What are some penetrating or blunt trauma causes of GI perforation?
Shear forces from acceleration- deceleration or high forces over small surface area e.g. handle bar
What are some direct rupture causes of GI perforation?
Excessive vomiting leading to oesophageal perforation
What are the main clinical features of GI perforation?
Pain, being systemically unwell (malaise, vomiting, lethargy)
What would be found on examination of GI perforation?
look unwell and features of sepsis, peritonitis, localised or generalised rigid abdomen,
How will a thoracic perforation present?
Pain from the chest or neck to radiate to the back, worse on inspiration, vomiting and respiratory symptoms, may be signs of pleural effusion and have palpable crepitus
What are some differential diagnosis for GI perforation?
Acute pancreatitis, myocardial infarction, tube-ovarian pathology or ruptured AAA
What laboratory tests will be needed for someone with GI perforation?
baseline bloods and G and S, raised WCC and CRP, urinalysis to exclude other pathology
What imaging will be needed for someone with GI perforation?
Erect chest radiograph will show free air under the diaphragm, if thoracic origin will have widened mediastinum, AXR will show perforation but CT imaging better
What are the AXR features of GI perforation?
Riglers sign- both sides o the bowel can be seen due to free into-abdominal air acting as an additional contrast, Psoas sig- loss of sharp delineation of the psoas muscle border secondary to fluid in the retroperitoneum
What percentage of people have no signs of bowel perforation on an AXR?
30%
How is GI perforation managed?
Early assessment and resucitation, antibiotics, nil by mouth, nasogastric tube, surgery and conservative treatment
What is the surgical treatment for GI perforation?
repair perforated peptic ulcer with an mental patch, resect a perforated diverticular e.g. hartmann’s, thorough washout
When is the conservative management for GI perforation used?
If localised perforation smaller than 5cm, patients with a sealed upper GI perforation on CT imaging without generalised peritonism, Elderly frail patients with extensive co-morbidities who would be very unlikely to survive
What are the complications of GI perforation?
Infection, peritonitis, sepsis, haemorrhage