GI Perforations

Question 1

What is the complications of GI perforations if not treated promptly?

Answer 1

Septic shock
Multi-organ failure
Death

Question 2

What are the causes of GI perforation?

Answer 2

Diverticulitis - most common in high-income counties
Peptic ulcer disease
GI malignancy - gastric or colorectal
Iatrogenic - e.g. endoscopy
Trauma - penetrating or blunt injury
Foreign body - e.g. battery
Appendicitis or Meckels diverticulitis
Mesenteric ischaemia
Bowel obstruction
Severe colitis - Crohn’s disease - toxic mega colon, UC
Excessive vomiting - Boerhaave syndrome (oseophagus perforation)

Question 3

What are the clinical feature of GI perforation?

Answer 3

Localised or generalised pain
Features of peritonism
Look systemically unwell - associated malaise, vomiting and lethargy
Features of sepsis

Question 4

What clinical feature may be seen on thoracic perforation?

Answer 4

Pain ranging from chest to neck or radiating to the back - worse on inspiration.
Associated vomiting and resp symptoms

Examination may reveal signs of pleural effusion and palpable crepitus

Question 5

What investigations should be requested for suspected GI perforation?

Answer 5

Urgent bloods - raised WCC and CRP

Imaging:

• eCXR and AXR
• CT scan - GOLD standard

Question 6

What may be seen on a CXR that indicates GI perforation and how accurate is this?

Answer 6

Pnuemoperitoneum

Only seen in 70% of GI perforations

Question 7

What two signs may be see on a AXR that indicate GI perforation?

Answer 7

Riglers sign (both sides of bowel visible)

Psoas sign (loss of the sharp delineation of the psoas muscle border

Question 8

What is the initial management in suspected GI perforation?

Answer 8

A to E approach to stabilise pt

Early assessment an resuscitation, rapid diagnosis and early definitive treatment
Broad spec antibiotics and NBM - consider nasogastric tube

Appropriate IV fluids and analgesia

Question 9

What is the next step in management after stabilising the pt is GI perforation?

Answer 9

Highly individualistic approach depends on site of perforation and pt factors.

But generally would required theatre repair and control of contamination

Question 10

What are the key aspects of surgical management?

Answer 10

Identify the underlying cause
Appropriate management of perforation
Thorough washout

Question 11

Which pts may be managed conservatively in GI perforations?

Answer 11

Localised diverticular perforation - less the 5 cm on CT - may respond to antibiotics alone or may require percutaneous drainage.

Pts with a sealed upper GI perforation on CT imaging without generalised peritonism

Elderly frail pts with extensive co-morbidities who would unlikely survive surgery