GI perforation

Question 1

define gastrointestinal perforation?

Answer 1

perforation of wall of GI tract with spillage of bowel contents

Question 2

what are the common causes of GI perforation?

Answer 2

peptic ulcers and sigmoid diverticulum

Question 3

what are common causes of perforation of large bowel?

Answer 3

CAD UV

colorectal cancer

appendicitis

diverticulitis

UC

volvulus

Question 4

what are the causes of gastroduodenal perforation?

Answer 4

common: perforated duodenal or gastric ulcer
others: gastric cancer

Question 5

what are the causes of perforation of the small bowel?

Answer 5

( rare)
trauma

infection ( TB)

crohns disease

Question 6

what are the causes of perforation of oesophagus?

Answer 6

Boerrhave’s perforation-> rupture of oesophagus after forceful vomiting

Question 7

what are the risk factors of gastroduodenal perforation?

Answer 7

NSAIDs, steroids, bisphosphonates

Question 8

what are the symptoms of GI perforation?

Answer 8

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 9

what are the signs of GI perforation on physical examination?

Answer 9

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 10

what is the scoring system for GI bleeds?

Answer 10

ROCKALL SCORE

Used to predict adverse outcome following upper gastrointestinal bleeds by combining a number of independent risk factors (see below). A score of >8 indicates a 40% risk of mortality.

Question 11

Describe a typical presentation for GI perforation

Answer 11

shock, peritonitis ( rigidity, decreased BS, guarding), pyrexia, pallor, dehydration

Question 12

what are the appropriate investigations for GI perforation?

Answer 12

FBC, U&E – urea raised after upper GI bleed, LFTs

Amylase - will be raised with perforation (but should not be astronomical (as seen in pancreatitis)

Erect CXR- shows air under diaphragm

AXR- Rigler’s signs and psoas sign

Gatrograffin swallow- suspected oesophageal perforations

Question 13

what can be seen on the AXR for a GI perforation?

Answer 13

Rigler’s sign – both sides of the bowel wall can be seen, due to free intra-abdominal air acting as an additional contrast

Psoas sign – loss of the sharp delineation of the psoas muscle border, secondary to fluid in the retroperitoneum

Question 14

outline the management plan for GI

Answer 14

Resuscitation

• Correct fluid and electrolytes
• IV antibiotics (with anaerobic cover) – cefuroxime and metronidazole
• Nil by mouth + NG tube inserted

Surgical

1. Large Bowel

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

2. Gastroduodenal

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

3. Oesophageal

• Pleural lavage
• Repair of ruptured oesophagus

Question 15

what are the possible complications of GI perforation?

Answer 15

Large and Small Bowel – peritonitis, septicaemia

Oesophagus - mediastinitis, shock, overwhelming sepsis and death

Question 16

summarise the prognosis for patients with GI perforation?

Answer 16

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