GI Perforation

Question 1

Define

Answer 1

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

Question 2

Causes

Answer 2

Large Bowel

COMMON:

• Diverticulitis
• Colorectal cancer
• Appendicitis

Others: volvulus, ulcerative colitis (toxic megacolon)

Gastroduodenal

COMMON:

• Perforated duodenal or gastric ulcer
• Others: gastric cancer

Small Bowel (RARE)

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

Oesophagus

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

Question 3

Risk factors

Answer 3

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

smoking, excessive alcohol

Question 4

Symptoms

Answer 4

Depends on CAUSE : fevers, chills, nausea, vomiting

Large Bowel

• Peritonitic abdominal pain

IMPORTANT: make sure you rule out ruptured AAA

Gastroduodenal

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

Oesophageal

• Severe pain following an episode of violent vomiting
• Neck/chest pain and dysphagia develop soon afterwards

Question 5

Signs

Answer 5

• 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 6

Investigations

Answer 6

Bloods

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

Erect CXR

• Shows air under the diaphragm

AXR

• Shows abnormal gas shadowing

Gastrograffin Swallow

• For suspected oesophageal perforations

Question 7

Management

Answer 7

Resuscitation

• Correct fluid and electrolytes
• IV antibiotics (with anaerobic cover)

Surgical

Large Bowel

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

Gastroduodenal

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

Oesophageal

• Pleural lavage
• Repair of ruptured oesophagus

Question 8

Complciations

Answer 8

Large and Small Bowel - peritonitis

Oesophagus - mediastinitis, shock, overwhelming sepsis and death

Question 9

Prognosis

Answer 9

Gastroduodenal

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

Large Bowel

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