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Year 3 > Gastrointestinal perforation (GI) > Flashcards

Gastrointestinal perforation (GI) Flashcards

1
Q

Define GI perforation.

A

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

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2
Q

Where can GI perforation occur?

A

Anywhere from upper oesophagus to anorectal junction –> septic shock –> multi-organ dysfunction

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3
Q

What are the causes of large bowel GI perforation? (5)

A
  • diverticulitis
  • colorectal cancer
  • appendicitis
  • ulcerative colitis (toxic megacolon)
  • volvulus
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4
Q

What are the causes of gastroduodenal GI perforation? (3)

A
  • perforated duodenal ulcer
  • perforated gastric ulcer
  • cancer
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5
Q

What are the causes of small bowel (rare) GI perforation? (3)

A
  • trauma
  • infection (TB)
  • Crohn’s disease
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6
Q

What are the types of oesophageal GI perforation? (2)

A
  • Boerhaave’s perforation
  • Mallory-Weiss tear
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7
Q

What are the types of inflammatory/ischaemic GI perforation? (3)

A
  • PUD
  • foreign bodies
  • mesenteric ischaemia
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8
Q

How can trauma cause GI perforation? (2)

A
  • recent surgery (anastomotic leaks)
  • penetrating/blunt trauma
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9
Q

What are the general clinical features of GI perforation? (7)

A
  • rapid onset sharp pain
  • shock
  • pyrexia
  • pallor
  • dehydration
  • systemically unwell with malaise, vomiting, lethargy
  • signs of peritonitis (guarding, rigidity, rebound tenderness)
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10
Q

What are some signs of peritonitis (seen in GI perforation)? (7)

A
  • guarding
  • rigidity
  • rebound tenderness
  • absent bowel sounds
  • motionless
  • unwilling to cough
  • small breaths
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11
Q

What is a symptom of a large bowel perforation?

A

Peritonitis-like abdominal pain

Must rule out ruptured AAA

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12
Q

What is a symptom of a gastroduodenal perforation?

A

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

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13
Q

What are some symptoms of oesophageal perforation? (2)

A
  • severe pain following an episode of violent vomiting
  • neck/chest pain and dysphagia develops soon after
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14
Q

What is the general first-line investigation for GI perforations?

A

Erect CXR to look for air under diaphragm (pneumoperitoneum) in bowel perforations especially

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15
Q

What would AXR show in bowel perforation?

A

Abnormal gas shadowing, may see Rigler’s sign (double wall sign)

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16
Q

What is the gold standard investigation for bowel perforation?

A

CT with IV contrast

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17
Q

What does ABG show in gastroduodenal perforation?

A

Metabolic acidosis

18
Q

What is the gold standard investigation for oesophageal perforations?

A

Gastrograffin swallow

19
Q

What bloods do we do for GI perforation? (4)

A
  • FBC - normocytic anaemia, high WCC
  • U&Es - raised urea indicates upper GI bleed rather than lower
  • LFTs
  • amylase (slightly raised in perforation)
20
Q

What is the general management for GI perforation?

A
  • IV fluids - correct fluid and electrolytes
  • IV Abx - cefuroxime + metronidazole
  • surgery - depends on site
21
Q

What is the surgical management of a large bowel perforation?

A

Resection of perforated section (usually part of Hartmann’s procedure) and peritoneal lavage for evaluating bleeding in abdominal cavity

22
Q

What is the surgical management of a gastroduodenal perforation?

A

Peritoneal lavage
Laparotomy and omental patch

H. pylori eradication if +ve

23
Q

What is the surgical management of an oesophageal perforation?

A

Repair of ruptured oesophagus

24
Q

What are some complications of GI perforations? (4)

A
  • peritonitis (large and small bowel)
  • mediastinitis
  • shock
  • severe sepsis (oesophageal)
25
Q

What is a Boerhaave’s perforation?

A

Spontaneous full-thickness rupture of oesophagus from repeated vomiting and long-standing alcohol use

26
Q

What are the symptoms of Boerhaave’s perforation? (5)

A
  • 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
27
Q

What might be found on examination of Boerhaave’s perforation?

A

‘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

28
Q

What is the first-line investigation for Boerhaave’s perforation?

A

CT contrast - Gastrograffin swallow

Avoid OGD due to risk of worsening perforation

29
Q

How do we treat Boerhaave’s perforation?

A

Pleural lavage and repair

30
Q

What is a complication of Boerhaave’s perforation?

A

Severe sepsis secondary to mediastinitis –> death

31
Q

What is the difference between a Boerhaave’s perforation and a Mallory-Weiss tear?

A
  • 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
32
Q

What is a Mallory-Weiss tear?

A

Longitudinal mucous membrane tear at GOJ (limited to mucosa and submucosa), causing haematemesis

33
Q

What are the symptoms of a Mallory-Weiss tear? (5)

A
  • after an episode of forceful/recurrent retching, vomiting, coughing or straining
  • haematemesis
  • retrosternal, epigastric or back pain
  • dysphagia
  • odynophagia
34
Q

What is definitive diagnosis of Mallory-Weiss tear made by?

A

OGD (upper GI endoscopy)

35
Q

How do we treat a Mallory-Weiss tear? (3)

A
  • self-limiting: supportive Rx + resuscitation
  • angiography with embolisation of arteries supplying the region
  • surgical repair to control bleeding
36
Q

How does perforated diverticulitis present? (7)

A
  • persistent LLQ pain
  • fever
  • anorexia
  • N&V
  • abdominal distension (ileus)
  • known Hx of diverticulosis
  • frank blood in stool
37
Q

What investigations do we do for perforated diverticulitis? (3)

A
  • FBC
  • CTAP with contrast
  • ultrasound
38
Q

How do we treat perforated diverticulitis? (6)

A
  • laparoscopy
  • emergency colectomy
  • Hartmann’s procedure
  • IV Abx
  • analgesia
  • low-residue diet (refined bread, cereals, white rice, vegetable/fruit juice without pulp, dairy)
39
Q

Describe the prognosis of large bowel perforations.

A

High risk of faecal peritonitis if left untreated, leads to death from septicaemia and multi-organ failure

40
Q

Describe the prognosis of perforated gastroduodenal ulcers.

A

Gastric ulcers have higher morbidity and mortality than duodenal ulcers

Year 3 (164 decks)

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