Perforated hollow viscus Flashcards
what are the causes of a perforated hollow viscus?
Perforated:
* Peptic ulcer
* Diverticulitis
* Appendicitis
* Small bowel 2° Small bowel obstruction
* GI Malignancy
How would you manage someone with an acute abdomen?
- Do an ABCDE assessment to determine if the patient is unstable or stable
* Airway: ensure a patent airway
* Breathing: assess breathing, RR, SpO2 & auscultate lungs. Provide O2 if required.
* Circultion: assess BP, HR, CRT & auscultate heart sounds. Gain IVA, take bloods. Provide resuscitation IVFs if required
* Disability: assess LOC using GCS / AVPU. Check blood glucose.
* Exposure: abdominal exam - If unstable, stabilized thier Airway, Breathing & Circulation
- Once stable, Take a focused History & Physical exam
What are the signs & symptoms of an Acute Abdomen?
Symptoms:
* Sever Acute abdominal pain
* Nausea & Vomiting
* Fever
* Chills
* Bowel changes
* Malaise
Signs:
* Abdominal distention
* Tenderness
* Rebound tenderness
* Guarding
* Rigidity
* Decreased / Absent bowel sounds
If the clinical exam indicates an Acute abdomen, what’s your next step in management and why?
Series Abdominal X ray: may show dilated bowel loops, indicating bowel obstruction
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Erect Chest X ray: may show Pneumoperitoneum (i.e., air under the diaghram), indicating bowel perforation
If the CXR findings suggest a Pneumoperitoneum, what’s the next step in management?
- Since a Pneumoperitoneum is a surgical emergency, don’t waste time ordering more test, intstead use elements in your clinical history to guide your differential diagnosis.
- Consult with surgery
What elements in your history suggest a perforated peptic ulcer?
started out with:
* Post Prandial Epigatric pain
* H/O GERD
* Unable to lie Supine
with rupture:
* Sudden intense stabbing pain, that may radiate to the shoulder due to irritation of the diaphragm (innervated by the phrenic nerve: C3-C5)
- Followed by diffuse abdominal pain, which is the beginning of peritonitis.
What elements in your history suggest a perforated diverticulitis?
- Middle aged patient
- LLQ pain
- Chronic Constipation
- H/O Diverticulitis
What elements in your history suggest perforated Appendicitis?
- Young otherwise healthy patient
- Stared out with RLQ pain, Periumbilical pain
- Followed by temporary pain relief or worsening Periumbilical pain
What elements in your history suggest bowel perforation due to GI malignancy?
- Age > 60
- H/O smoking
- Anorexia / Loss of appetite
- Unintended weight loss
- Fatigue
- Personal / Family H/O cancer
what elements in your history suggest a perforated small bowel?
- Elderly patient
- Bilious vomiting
- PO intolerance
- Constipation, Obstipation or Overflow diarrhea
How do you treat a perforated hollow viscus?
- Schedule Urgent Explorative Laparotomy to identify the cause and repair accordingly.
- Provide Supportive care:
* NPO / Bowel rest until midnight
* 2 large bore IVA
* NG tube with continuous or intermittent suction
* Opioids (contraindicated in cases suspected of bowel obstruction)OR
- NSAIDs: Diclofenac 37.5mg IV q 6hry / PRN (Ketorolac is contraindicated in cases suspected of bowel perforation)
- Antiemetics
- Omez/Panto 40mg IV BD if suspecting perforated Peptic Ulcer
- Prep for surgery:
* Order the following Labs: CBC, LFTs, U&Es, CRP, Coag screen, Amylase, ABG, Group & Save, HCG, consider Blood cultures if suspecting infection
- ECG
- CT Abdomen & Pelvis: to determine the cause of acute abdomen
- Abdominal U/S: check for gallsones, biliary duct dilation & gyn pathologies
During surgery:
1. Begin with a midline incision.
2. Obtain peritoneal fluid for cultures
- Resect perforated bowel:
* Appendix→ Appendectomy
* GI malignancy→ resection or biopsy if resection not possible
* Small bowel → resection of bowel with primary anastomosis or create a temporary stoma - Place peritoneal drains and close the abdomen.
Postoperatively:
Continue NPO, Maintainance fluids & NG tube with suction until bowel function returns.
