Gastrointestinal perforation

Question 1

What sites can gastrointestinal perforation occur?

Answer 1

from the upper oesophagus to the anorectal junction

Question 2

How can gastrointestinal perforation progress?

Answer 2

Septic shock, multi organ dysfunction and death

Question 3

What are the most common causes of GI perforation?

Answer 3

Peptic ulcers (gastric or duodenal) and sigmoid diverticulum

Question 4

What are the chemical causes of GI perforation?

Answer 4

Peptic ulcer disease, foreign bodies

Question 5

What are the infectious causes of GI perforation?

Answer 5

Diverticulitis, Cholecystitis, Meckels diverticulum

Question 6

What are some ischaemic causes of GI perforation?

Answer 6

Mesenteric ischaemia, obstructing lesions like cancer or faeces, resulting in bowel distension and ischaemia and necrosis

Question 7

What are some colitis causes of GI perforation?

Answer 7

Toxic megacolon from C diff or UC

Question 8

What are some iatrogenic causes of GI perforation?

Answer 8

Recent surgery e.g. anastomotic leak, endoscopy or over zealous NG tube insertion

Question 9

What are some penetrating or blunt trauma causes of GI perforation?

Answer 9

Shear forces from acceleration- deceleration or high forces over small surface area e.g. handle bar

Question 10

What are some direct rupture causes of GI perforation?

Answer 10

Excessive vomiting leading to oesophageal perforation

Question 11

What are the main clinical features of GI perforation?

Answer 11

Pain, being systemically unwell (malaise, vomiting, lethargy)

Question 12

What would be found on examination of GI perforation?

Answer 12

look unwell and features of sepsis, peritonitis, localised or generalised rigid abdomen,

Question 13

How will a thoracic perforation present?

Answer 13

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

Question 14

What are some differential diagnosis for GI perforation?

Answer 14

Acute pancreatitis, myocardial infarction, tube-ovarian pathology or ruptured AAA

Question 15

What laboratory tests will be needed for someone with GI perforation?

Answer 15

baseline bloods and G and S, raised WCC and CRP, urinalysis to exclude other pathology

Question 16

What imaging will be needed for someone with GI perforation?

Answer 16

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

Question 17

What are the AXR features of GI perforation?

Answer 17

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

Question 18

What percentage of people have no signs of bowel perforation on an AXR?

Answer 18

30%

Question 19

How is GI perforation managed?

Answer 19

Early assessment and resucitation, antibiotics, nil by mouth, nasogastric tube, surgery and conservative treatment

Question 20

What is the surgical treatment for GI perforation?

Answer 20

repair perforated peptic ulcer with an mental patch, resect a perforated diverticular e.g. hartmann’s, thorough washout

Question 21

When is the conservative management for GI perforation used?

Answer 21

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

Question 22

What are the complications of GI perforation?

Answer 22

Infection, peritonitis, sepsis, haemorrhage