Gastrointestinal perforation Flashcards
What is gastrointestinal perforation?
Perforation in any anatomical location of the GI tract from upper oesophagus to the anorectal junction.
What are the complications of GI perforation?
- Septic shock
- Multi organ dysfunction
- Death
SO must be excluded
What are the most common causes of GI perforation?
- Peptic ulcers (gastric/duodenal)
- Sigmoid diverticulum
What are the causes of GI perforation (by type of injury)?
Inflammatory/ischaemic:
- Chemical - PUD, foreign body
- Infection - diverticulitis, cholecystitis, toxic megacolon (e.g. C. difficile or UC)
- Ischaemia - mesenteric ischaemia, obstructing lesions (e.g. cancer, bezoar, faeces)
Traumatic:
- Iatrogenic - recent surgery, endoscopy or overzealous NG tube insertion
- Penetrating/blunt trauma - shear force from acceleration-deceleration/high forces over small surface area
- Direct rupture - excessive vomiting –> oesophageal perforation (Boerhaave Syndrome)
What are the causes of GI perforation (by anatomy)?
Upper GI tract
- Peptic ulcer disease
- Gastric cancer or oesophageal cancer
- Foreign body ingestion (e.g. battery or caustic soda)
- Excessive vomiting (Boerhaave Syndrome)
Lower GI tract
- Diverticulitis (most common in higher-income countries)
- Colorectal cancer
- Appendicitis or Meckel’s Diverticulitis
- Foreign body insertion
- Severe colitis, such as Crohn’s Disease
- Toxic megacolon (e.g. from Clostridum Difficile or Ulcerative Colitis)
Any part of the GI tract
- Iatrogenic, such as during gastroscopy or colonoscopy
- Trauma, either through penetrating or blunt mechanisms
- Mesenteric ischaemia
- Obstructing lesions (e.g. cancer, bezoar, or faeces/sterocoral), leading to bowel obstruction, with subsequent ischaemia and necrosis
What is the name of the syndrome caused by excessive vomiting leading to oesophageal perforation?
Boerhaave Syndrome
What are the symptoms of perforation?
Pain - rapid onset and sharp in nature
Systemically unwell - malaise, vomiting, lethargy
Thoracic perforation - chest/neck pain radiating to back and worse on inspiration, may be respiratory symptoms
Hx of UC, travel (typhoid fever) peptic ulcer disease
Hiccup - late symptoms of perforated peptic ulcer
Shoulder pain - e.g. perforated painless peptic ulcer when taking steroids causing involvement of the parietal peritoneum of the diaphragm
What are the signs of perforation on physical examination?
- Generally unwell , poor vital signs
- Features of sepsis - fever, tachycardia
- Peritonism may be localised or generalised - if peritonitic throughout then generalised contamination and almost always requiring urgent surgery. If generalised, bowel sounds will be absent.
- Thoracic perforation - pleural effusion, palpable crepitus
- External signs of injury e.g. stab wound
- Perforated peptic ulcer disease - patients lie immobile, occasionally with knees flexed, and the abdomen is described as boardlike
What investigations should you do for GI perforation?
DIAGNOSTIC: CT with IV contrast - oral contrast may be used in UGI perforation.
Other:
Bloods:
FBC - WCC and CRP raised, Hct raised due to a shift in intravascular fluid
Urinalysis - exclude renal and tubo-ovarian pathology
Imaging - CXR/AXR no longer used as much as less specific
CXR (erect) - free air under diaphragm, peumomediastinum/widened mediastinum. Best in PUD but in 30% no free gas will be identified so not sufficiently sensitive to ruleout pneumoperitoneum
AXR - Rigler’s sign (both sides of bowel wall seen due to free air), Psoas sign (loss of delineation of the psoas muscle border, secondary to fluid in retroperitoneum)
CT scan - DIAGNOSTIC but does not show perforated Meckel diverticulitis
How do you manage GI perforation?
-
Resuscitation:
- Broad spectrum antibiotics - pre-surgery
- Nil by mouth, consider NG tube
- IV fluid support and analgesia
-
Surgery for repair and control of contamination
- Identification of cause
- Management e.g
- peptic ulcer can be repaired with an omental patch
- perforated diverticulae can be resected (via Hartmann’a procedure)
- Thorough washout
-
Conservative management may be sufficient for those with localised peritonitis:
- Localised diverticular abscess (<5cm), no evidence of generalised contamination
- Sealed UGI perforation on CT and no generalised peritonism
- Elderly frail patient with extensive co-morbidities, unlikely to survive surgery
What are the complications of gastrointestinal perforation?
- Infection (sepsis and peritonitis)
- Haemorrhage
Prognosis - early recognition and promp resuscitation is essential
What is the most important aspect of any surgery for perforation?
Washout
How are stomach/duodenal perforations assessed?
Via upper midline incision and patch of omentum is used to close over an ulcer which would otherwise be difficult to sew over. All gastric ulcers should be biopsied to exclude malignancy.
How are small bowel perforations assessed?
Midline laparotomy, small perforations are oversewn if bowel is viable otherwise the bowel is resected with primary anastomosis +/- stoma formation
How are large bowel perforations assessed?
Midline laparotomy
Anastomosis in in the presence of faecal cintamination in an unstable patient is not recommended and so a resection with stoma formation is the preferred option
