Gastrointestinal Perforation

Question 1

Definition

Answer 1

Perforation of the wall of the GI tract with spillage of bowel contents

Question 2

Aetiology (large bowel)

Answer 2

o COMMON:
• Diverticulitis
• Colorectal cancer
• Appendicitis

o Others: volvulus, ulcerative colitis (toxic megacolon)

Question 3

Aetiology (gastroduodenal)

Answer 3

o COMMON:
• Perforated duodenal or gastric ulcer

o Others: gastric cancer

Question 4

Aetiology (small bowel)

Answer 4

RARE

o Trauma
o Infection (e.g. TB)
o Crohn’s disease

Question 5

Aetiology (oesophagus)

Answer 5

o Boerhaave’s perforation - rupture of the oesophagus following forceful vomiting

Question 6

Risk factors

Answer 6

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

Question 7

Epidemiology

Answer 7

Incidence depends on the cause

Question 8

Presenting symptoms (large bowel)

Answer 8

Depends on the CAUSE

o Peritonitic abdominal pain

o IMPORTANT: make sure you rule out ruptured AAA

Question 9

Presenting symptoms (gastroduodenal)

Answer 9

o Sudden-onset severe epigastric pain - worse on movement
o Pain becomes generalised
o Gastric malignancy - may have accompanying weight loss and nausea/vomiting

Question 10

Presenting symptoms (oesophageal)

Answer 10

o Severe pain following an episode of violent vomiting

o Neck/chest pain and dysphagia develop soon afterwards

Question 11

Signs on physical examination

Answer 11

• 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 12

Investigations (bloods)

Answer 12

o FBC, U&E, LFTs
o Amylase - will be raised with perforation (but should not be astronomical (as
seen in pancreatitis))

Question 13

Investigations (other)

Answer 13

• Erect CXR
o Shows air under the diaphragm

• AXR
o Shows abnormal gas shadowing

• Gastrograffin Swallow
o For suspected oesophageal perforations

Question 14

Management plan (resuscitation)

Answer 14

o Correct fluid and electrolytes

o IV antibiotics (with anaerobic cover)

Question 15

Management plan (surgical)

Answer 15

o Large Bowel
• Identify site of perforation
• Peritoneal lavage
• Resection of perforated section (usually as part
of a Hartmann's procedure)

o Gastroduodenal
• Laparotomy
• Peritoneal lavage
• Perforation is closed with an omental patch
• Gastric ulcers are biopsied
• Helicobacter pylori eradication if positive for H. pylori

o Oesophageal
• Pleural lavage
• Repair of ruptured oesophagus

Question 16

Possible complications

Answer 16

• Large and Small Bowel - peritonitis

* Oesophagus - mediastinitis, shock, overwhelming sepsis and death

Question 17

Prognosis

Answer 17

• Gastroduodenal
o Gastric ulcers have higher morbidity and mortality than duodenal ulcers
o POOR prognosis for perforated gastric carcinomas

• Large Bowel
o High risk of faecal peritonitis if left untreated
o This can lead to DEATH from septicaemia and multiorgan failure