GI Perforation Flashcards
What is GI Perforation?
Perforation of the wall of the GI tract with spillage of bowel contents
Give 2 common causes of GI perforation
Peptic ulcers
Sigmoid diverticulum
What mnemonic can be used to remember causes of large bowel perforation?
CAD UV Colorectal cancer Appendicitis Diverticulitis UC Volvulus
Give 3 causes of small bowel perforation
Trauma
Infection (e.g. TB)
Crohn’s disease
What may cause oesophageal perforation?
Boerhaave’s perforation: rupture of oesophagus following forceful vomiting
Give 2 causes of gastroduodenal perforation
Perforated duodenal or gastric ulcer
Others: gastric cancer
What are the risk factors for GI perforation?
Risk factors of cause (e.g. gastroduodenal: NSAIDs, steroids, bisphosphonates)
Describe the epidemiology of GI perforation
Large bowel: common
Gastroduodenal: common
Small bowel: rare
Name a symptom of large bowel perforation. Thus, what differential should be excluded?
Peritonitic abdo pain
Exclude ruptured AAA
Give 2 symptoms of oesophageal perforation
Severe pain following an episode of violent vomiting
Neck/ chest pain + dysphagia develop soon afterwards
List 3 symptoms of gastroduodenal perforation
Sudden-onset severe epigastric pain: worse on movement
Pain becomes generalised
Gastric malignancy: may have weight loss + N+V
List 7 signs of GI perforation
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)
What scoring system is used to predict adverse outcomes following a GI perforation?
Rockall Score
Score >8 indicates a 40% risk of mortality.
What bloods are taken in suspected GI perforation?
FBC: neutrophilic leukocytosis
U+E: urea + creatinine raised
Amylase: raised (not hugely (as in pancreatitis))
ABG: Lactatic acidosis (if ischaemia)
What is the prognosis of large bowel perforations?
High risk of faecal peritonitis if left untreated
Can lead to DEATH from septicaemia + multiorgan failure
What is the resuscitation protocol for GI perforation?
Correct fluid + electrolytes
IV Abx (with anaerobic cover): cefuroxime + metronidazole
Nil by mouth + NG tube inserted
Describe management of gastroduodenal perforation
Laparotomy
Peritoneal lavage
Perforation is closed with an omental patch
Gastric ulcers are biopsied: malignancy
Helicobacter pylori eradication if test positive
List 4 complications of oesophageal perforation
Mediastinitis
Shock
Overwhelming sepsis
Death
What is the prognosis of gastroduodenal perforations?
Gastric ulcers have higher morbidity + mortality than duodenal ulcers
POOR prognosis for perforated gastric carcinomas
What may be seen on CXR in GI perforation?
Air under the diaphragm
What may be seen on AXR in GI perforation?
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
What investigation may be performed for suspected oesophageal perforation?
Gastrograffin Swallow
Describe the management of large bowel perforations
Identify site of perforation
Peritoneal lavage
Resection of perforated section (usually as part of a Hartmann’s procedure)
Describe the management of oesophageal perforations
Pleural lavage
Repair of ruptured oesophagus
Give 2 complications of large and small bowel perforation
Peritonitis
Septicaemia
