GI Perforation Flashcards
Where can GI perforations occur?
All from upper oesophagus to anorectal junction
Complications
Delay in resus and surgery can leads to septic shock, multi organ dysfunction and death very rapidly.
Most common causes of GI perforation
Peptic ulcers gastric or duodenal
Sigmoid diverticulum
Inflammatory or ischaemic causes
Peptic ulcer disease
Foreign body
Diverticulitis
Cholecystitis
Meckel’s diverticulum
Mesenteric ischaemia
Obstructing lesions
Toxic megacolon from e.g. C. diff or UC
Traumatic causes
Recent surgery like anastomotic leak
Endoscopy
NG tube insertion
Blunt traua
Direct rupture from e.g. excessive vomiting (Boerhaave syndrome)
Clinical features
Rapid onset and sharp pain
Systematically unwell with malaise, vomiting and lethargy.
Examination findings
Look unwell and have features of sepsis commonly
Features of peritonism that can either be localised or generalised.
Clinical features of thoracic perforation
Pain from chest or neck radiating to the back
Typically worsened on inspiration
Usually associated with vomiting and resp symptoms
Examination findings of thoracic perforation
Auscultation and percussion may show signs of pleural effusion with palpable crepitus
Dx
Acute pancreatitis
MI
Tubo-ovarian pathology
Rupture AA
Laboratory tests
Routine bloods + G&S
Raised WCC and CRP are common features
Urinalysis should be done to exclude renal and tubo-ovarian pathology
Imaging
Erect CXR
Gold standard is however a CT scan
AXR can also be done but has limited use compared to CT
eCXR findings
Can show free air under diaphragm
Can have pneumomediastinum or widened mediastinum if it is a thoracic perforation.
CT findings
Free air presence
Will also show location of perforation as well as underlying cause
AXR findings
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 sharp delineation of the psoas muscle border, secondary to fluid in the retroperitoneum.
