Gastrointestinal perforation (GI) Flashcards
Define GI perforation.
Perforation of the wall of the GI tract with spillage of bowel contents
Where can GI perforation occur?
Anywhere from upper oesophagus to anorectal junction –> septic shock –> multi-organ dysfunction
What are the causes of large bowel GI perforation? (5)
- diverticulitis
- colorectal cancer
- appendicitis
- ulcerative colitis (toxic megacolon)
- volvulus
What are the causes of gastroduodenal GI perforation? (3)
- perforated duodenal ulcer
- perforated gastric ulcer
- cancer
What are the causes of small bowel (rare) GI perforation? (3)
- trauma
- infection (TB)
- Crohn’s disease
What are the types of oesophageal GI perforation? (2)
- Boerhaave’s perforation
- Mallory-Weiss tear
What are the types of inflammatory/ischaemic GI perforation? (3)
- PUD
- foreign bodies
- mesenteric ischaemia
How can trauma cause GI perforation? (2)
- recent surgery (anastomotic leaks)
- penetrating/blunt trauma
What are the general clinical features of GI perforation? (7)
- rapid onset sharp pain
- shock
- pyrexia
- pallor
- dehydration
- systemically unwell with malaise, vomiting, lethargy
- signs of peritonitis (guarding, rigidity, rebound tenderness)
What are some signs of peritonitis (seen in GI perforation)? (7)
- guarding
- rigidity
- rebound tenderness
- absent bowel sounds
- motionless
- unwilling to cough
- small breaths
What is a symptom of a large bowel perforation?
Peritonitis-like abdominal pain
Must rule out ruptured AAA
What is a symptom of a gastroduodenal perforation?
Sudden onset severe epigastric pain worse on movement + food
Pain becomes generalised (spreading upper abdominal pain)
Dyspepsia with N&V, anorexia, fever, referred pain to shoulder
What are some symptoms of oesophageal perforation? (2)
- severe pain following an episode of violent vomiting
- neck/chest pain and dysphagia develops soon after
What is the general first-line investigation for GI perforations?
Erect CXR to look for air under diaphragm (pneumoperitoneum) in bowel perforations especially
What would AXR show in bowel perforation?
Abnormal gas shadowing, may see Rigler’s sign (double wall sign)
What is the gold standard investigation for bowel perforation?
CT with IV contrast
What does ABG show in gastroduodenal perforation?
Metabolic acidosis
What is the gold standard investigation for oesophageal perforations?
Gastrograffin swallow
What bloods do we do for GI perforation? (4)
- FBC - normocytic anaemia, high WCC
- U&Es - raised urea indicates upper GI bleed rather than lower
- LFTs
- amylase (slightly raised in perforation)
What is the general management for GI perforation?
- IV fluids - correct fluid and electrolytes
- IV Abx - cefuroxime + metronidazole
- surgery - depends on site
What is the surgical management of a large bowel perforation?
Resection of perforated section (usually part of Hartmann’s procedure) and peritoneal lavage for evaluating bleeding in abdominal cavity
What is the surgical management of a gastroduodenal perforation?
Peritoneal lavage
Laparotomy and omental patch
H. pylori eradication if +ve
What is the surgical management of an oesophageal perforation?
Repair of ruptured oesophagus
What are some complications of GI perforations? (4)
- peritonitis (large and small bowel)
- mediastinitis
- shock
- severe sepsis (oesophageal)
What is a Boerhaave’s perforation?
Spontaneous full-thickness rupture of oesophagus from repeated vomiting and long-standing alcohol use
What are the symptoms of Boerhaave’s perforation? (5)
- severe pain following an episode of violent vomiting
- neck/chest pain and dysphagia develops soon after
- sudden-onset severe chest pain
- subcutaneous emphysema
- may have signs suggestive of pneumonia
What might be found on examination of Boerhaave’s perforation?
‘Rice krispies’ crepitus - subcutaneous emphysema; barotrauma (usually from severe, repeated vomiting) causes a full-thickness oesophageal tear –> air travels up the fascial planes in the mediastinum to the subcutaneous tissues
What is the first-line investigation for Boerhaave’s perforation?
CT contrast - Gastrograffin swallow
Avoid OGD due to risk of worsening perforation
How do we treat Boerhaave’s perforation?
Pleural lavage and repair
What is a complication of Boerhaave’s perforation?
Severe sepsis secondary to mediastinitis –> death
What is the difference between a Boerhaave’s perforation and a Mallory-Weiss tear?
- Boerhaave’s perforation - more severe, causes distorted obs and abnormal CXR, transmural rupture in distal 1/3 of oesophagus
- Mallory-Weiss tear - longitudinal mucous membrane tear at GOJ (limited to mucosa and submucosa) and causes haematemesis
What is a Mallory-Weiss tear?
Longitudinal mucous membrane tear at GOJ (limited to mucosa and submucosa), causing haematemesis
What are the symptoms of a Mallory-Weiss tear? (5)
- after an episode of forceful/recurrent retching, vomiting, coughing or straining
- haematemesis
- retrosternal, epigastric or back pain
- dysphagia
- odynophagia
What is definitive diagnosis of Mallory-Weiss tear made by?
OGD (upper GI endoscopy)
How do we treat a Mallory-Weiss tear? (3)
- self-limiting: supportive Rx + resuscitation
- angiography with embolisation of arteries supplying the region
- surgical repair to control bleeding
How does perforated diverticulitis present? (7)
- persistent LLQ pain
- fever
- anorexia
- N&V
- abdominal distension (ileus)
- known Hx of diverticulosis
- frank blood in stool
What investigations do we do for perforated diverticulitis? (3)
- FBC
- CTAP with contrast
- ultrasound
How do we treat perforated diverticulitis? (6)
- laparoscopy
- emergency colectomy
- Hartmann’s procedure
- IV Abx
- analgesia
- low-residue diet (refined bread, cereals, white rice, vegetable/fruit juice without pulp, dairy)
Describe the prognosis of large bowel perforations.
High risk of faecal peritonitis if left untreated, leads to death from septicaemia and multi-organ failure
Describe the prognosis of perforated gastroduodenal ulcers.
Gastric ulcers have higher morbidity and mortality than duodenal ulcers
