Gastrointestinal perforation

Question 1

Define gastrointestinal perforation

Answer 1

Perforation of the wall of the GI tract w/ spillage of bowel contents

Question 2

Locations of gastrointestinal perforations

3 + 1 rare

Answer 2

Large bowel
Gastroduodenal
Oesophageal

Small bowel

Question 3

Aetiology of gastrointestinal perforations - large bowel

3 common, 2 other

Answer 3

Common:
Diverticulitis
Colorectal cancer
Appendicitis

Others:
Volvulus
Ulcerative colitis (toxic megacolon)

Question 4

Aetiology of gastrointestinal perforations - gastroduodenal

1 common, 1 other

Answer 4

Common:
Perforated duodenal or gastric ulcer

Others:
Gastric cancer

Question 5

Aetiology of gastrointestinal perforations - small bowel

3

Answer 5

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

Question 6

Aetiology of gastrointestinal perforations - oesophageal

1

Answer 6

Boerhaave’s perforation

Question 7

Risk factors for gastroduodenal perforation

3

Answer 7

NSAIDS
Steroids
Bisphosphonates

Question 8

Epidemiology of gastrointestinal perforation

Answer 8

Incidence depends on cause

Question 9

Presenting symptoms of gastrointestinal perforation - large bowel
(1 + important)

Answer 9

Peritonitic abdo pain

IMPORTANT to rule our ruptured AAA

Question 10

Presenting symptoms of gastrointestinal perforation - gastroduodenal
(3)

Answer 10

Sudden onset severe epigastric pain - worse on movement
Pain becomes generalised
Gastric malignancy may have accompanying weight loss & N/V

Question 11

Presenting symptoms of gastrointestinal perforation - oesophageal
(2)

Answer 11

Severe pain following episode of violent vomiting

Neck/chest pain & dysphagia develop soon after

Question 12

Signs of gastrointestinal perforation on examination

7

Answer 12

Very UNWELL
Signs of shock
Pyrexia
Pallor
Dehydration
Signs of peritonitis
Loss of liver dullness

Question 13

Investigations for gastrointestinal perforation

4

Answer 13

Bloods
Erect CXR
AXR
Gastrograffin swallow

Question 14

Investigations for gastrointestinal perforation - bloods

4

Answer 14

FBC
U&Es
LFTs
Amylase - raised w/ perforation but not astronomical

Question 15

Investigations for gastrointestinal perforation - erect CXR

1

Answer 15

Shows air under diaphragm

Question 16

Investigations for gastrointestinal perforation - AXR

1

Answer 16

Shows abnormal gas shadowing

Question 17

Investigations for gastrointestinal perforation - gastrograffin swallow
(1)

Answer 17

For suspected oesophageal perforations

Question 18

Branches of management of gastrointestinal perforation

2

Answer 18

Resuscitation

Surgery

Question 19

Management of gastrointestinal perforation - resuscitation

2

Answer 19

Correct fluid & electrolytes
IV antibiotics (w/ anaerobic cover)

Question 20

Management of gastrointestinal perforation - surgery

3 large bowel, 5 gastroduodenal, 2 oesophageal

Answer 20

Identify site of perforation
Peritoneal lavage
Resection of perforated section (usually part of Hartmann’s procedure)

Gastroduodenal
Laparotomy
Peritoneal lavage
Perforation closed w/ omental patch
Gastric ulcers biopsied
H. pylori eradication if positive

Oesophageal
Pleural lavage
Repair of ruptured oesophagus

Question 21

Complications of gastrointestinal perforation

1 large/small bowel, 4 oesophageal

Answer 21

Large & small bowel - peritonitis

Oesophagus - mediastinitis, shock, overwhelming sepsis & death

Question 22

Prognosis of gastrointestinal perforation

2 gastroduodenal, 2 large bowel

Answer 22

Gastroduodenal
Gastric ulcers have higher morbidity & mortality than duodenal
POOR prognosis for perforated gastric carcinomas

Large bowel
High risk of faecal peritonitis if left untreated
Can lead to DEATH from septicaemia & multi organ failure