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)
