GI Perforation

Question 1

What is GI Perforation?

Answer 1

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

Question 2

Give 2 common causes of GI perforation

Answer 2

Peptic ulcers

Sigmoid diverticulum

Question 3

What mnemonic can be used to remember causes of large bowel perforation?

Answer 3

CAD UV
Colorectal cancer  
Appendicitis  
Diverticulitis  
UC
Volvulus

Question 4

Give 3 causes of small bowel perforation

Answer 4

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

Question 5

What may cause oesophageal perforation?

Answer 5

Boerhaave’s perforation: rupture of oesophagus following forceful vomiting

Question 6

Give 2 causes of gastroduodenal perforation

Answer 6

Perforated duodenal or gastric ulcer

Others: gastric cancer

Question 7

What are the risk factors for GI perforation?

Answer 7

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

Question 8

Describe the epidemiology of GI perforation

Answer 8

Large bowel: common
Gastroduodenal: common
Small bowel: rare

Question 9

Name a symptom of large bowel perforation. Thus, what differential should be excluded?

Answer 9

Peritonitic abdo pain

Exclude ruptured AAA

Question 10

Give 2 symptoms of oesophageal perforation

Answer 10

Severe pain following an episode of violent vomiting

Neck/ chest pain + dysphagia develop soon afterwards

Question 11

List 3 symptoms of gastroduodenal perforation

Answer 11

Sudden-onset severe epigastric pain: worse on movement
Pain becomes generalised
Gastric malignancy: may have weight loss + N+V

Question 12

List 7 signs of GI perforation

Answer 12

Very UNWELL
Signs of shock
Pyrexia
Pallor
Dehydration
Signs of peritonitis (guarding, rigidity, rebound tenderness, absent BS)
Loss of liver dullness (due to overlying gas)

Question 13

What scoring system is used to predict adverse outcomes following a GI perforation?

Answer 13

Rockall Score

Score >8 indicates a 40% risk of mortality.

Question 14

What bloods are taken in suspected GI perforation?

Answer 14

FBC: neutrophilic leukocytosis
U+E: urea + creatinine raised
Amylase: raised (not hugely (as in pancreatitis))
ABG: Lactatic acidosis (if ischaemia)

Question 15

What is the prognosis of large bowel perforations?

Answer 15

High risk of faecal peritonitis if left untreated

Can lead to DEATH from septicaemia + multiorgan failure

Question 16

What is the resuscitation protocol for GI perforation?

Answer 16

Correct fluid + electrolytes
IV Abx (with anaerobic cover): cefuroxime + metronidazole
Nil by mouth + NG tube inserted

Question 17

Describe management of gastroduodenal perforation

Answer 17

Laparotomy
Peritoneal lavage
Perforation is closed with an omental patch
Gastric ulcers are biopsied: malignancy
Helicobacter pylori eradication if test positive

Question 18

List 4 complications of oesophageal perforation

Answer 18

Mediastinitis
Shock
Overwhelming sepsis
Death

Question 19

What is the prognosis of gastroduodenal perforations?

Answer 19

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

Question 20

What may be seen on CXR in GI perforation?

Answer 20

Air under the diaphragm

Question 21

What may be seen on AXR in GI perforation?

Answer 21

Rigler’s sign: both sides of 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 22

What investigation may be performed for suspected oesophageal perforation?

Answer 22

Gastrograffin Swallow

Question 23

Describe the management of large bowel perforations

Answer 23

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

Question 24

Describe the management of oesophageal perforations

Answer 24

Pleural lavage

Repair of ruptured oesophagus

Question 25

Give 2 complications of large and small bowel perforation

Answer 25

Peritonitis

Septicaemia