Perforated viscus Flashcards

1
Q

What is perforated viscus?

A

Perforation of GI tract anywhere from upper oesophagus to the anorectal junction.

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2
Q

What is the most common cause of perforated viscus?

A

Peptic ulcers (gastric or duodenal) and sigmoid diverticulum

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3
Q

What are the inflammatory or ischaemic causes of perforated viscus?

Include examples of chemical, infectious, ischaemic causes.

A

Chemical:

  1. Peptic ulcer disease
  2. Foreign body (e.g. battery)

Infection:

  1. Diverticulitis
  2. Cholecystitis
  3. Meckel’s diverticulum

Ishchaemia:

  1. Mesenteric ischaemia
  2. Obstructing lesions (e.g. cancer, bezoar, faeces) leading to bowel distension & subsequent ischaemia and necrosis.

Toxic megacolon e.g. C.diff or ulcerative colitis

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4
Q

What are the traumatic causes of perforated viscus?

A

Recent surgery

Endoscopy/NG tube insertion

Penetrating or blunt trauma

Excessive vomiting leading to oesophageal perforation

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5
Q

What are the clinical features of viscus perforation?

A

Pain - rapid onset & sharp

Systemically unwell - malaise, vomiting, lethargy

Features of sepsis

Features of peritonism - localised or generalised (rigid abdomen)

Urgent surgery for generalised peritonism - implies contaminated everywhere

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6
Q

How do thoracic perforations (oesophageal rupture) present?

A

Pain - chest or neck pain radiating to the back

Pain worse on inspiration

Associated vomiting & respiratory symptoms.

Signs of pleural effusion possible on examination

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7
Q

What are the important differential diagnosis for perforated viscus?

A

Acute pancreatitis

Myocardial infarction

Tubo-ovarian pathology

Ruptured abdominal aortic aneurysm

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8
Q

Investigations: Which lab tests would you conduct?

Which common features are raised?

A

Acute abdomen patients require:

Routine baseline blood tests + group & save blood test

Urinalysis to exclude renal & tuba-ovarian pathology

Raised WCC and CRP
Amylase mildly raised in perforation

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9
Q

Investigation: Which imaging is needed to confirm the diagnosis?

A

Gold standard = CT scan confirming free air presence & location of the perforation (+ possible underlying cause)

A plain film erect chest X-ray - free air under diaphragm. Pneumomediastinum or widened mediastinum may iso be present if the perforation is thoracic.

Abdominal Xray (CT preferred):

  1. Rigler’s sign: both sides of the bowel wall can be seen, due to free intra-abdominal air acting as an additional contrast
  2. Psoas sign: loss of sharp delineation of the psoas muscle border, secondary to fluid in the retroperitoneum.
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10
Q

What sign are you looking for in imaging to confirm the diagnosis?

A

Air outside the GI tract

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11
Q

What is the initial management for suspected/early perforated viscus?

A

Early assessment & resuscitation, rapid diagnosis and early definitive treatment.

Broad-spectrum antibiotics started early especially in patients who need surgery for contamination

Patients should be nil by mouth + NG tube considered.

IV fluid and analgesia.

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12
Q

What is the surgical intervention for perforation?

A

Identify & manage underlying cause.

Repairing perforated peptic ulcer with an metal patch

Resecting a perforated diverticular e.g. via a Hartmann’s procedure.

(Hartmann’s procedure = surgical resection of the rectosigmoid colon with closure of the anorectal stump and formation of an end colostomy)

Thorough intra-operative washout.

Most patients with perforation treated surgically.

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13
Q

Who is selected for conservative management for perforated viscus?

A

Selected physiologically well patients without generalised peritonitis:

  1. Localised diverticular abscess/perforation with only localised peritonitis & tenderness ; no evidence of generalised contamination on CT
  2. Patients with a sealed upper GI perforation on CT without generalised peritonism
  3. Elderly frail patients with multiple co-morbidities, unlikely to survive surgery.
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14
Q

A size less than 5cm on CT scan is the cut off for conservative treatment. How are they treated?

A

Antibiotics alone

May get a guided percutaneous drainage

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15
Q

What are the complications of a GI perforation?

A

Infection (peritonitis & sepsis)
Haemorrhage

Delay in resuscitation and surgery = septic shock, multi-organ dysfunction and death.

Should be one of the first diagnosis considered in patients with abdominal pain

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16
Q

How is a stomach or duodenum perforation treated surgically?

A

Accessed via a midline incision (can be done laparoscopically too)

Patch of omentum (Graham patch) attached loosely over the ulcer so it’s easy to oversew ; otherwise difficult due to tissue inflammation

All gastric ulcer biopsied to exclude malignancy

17
Q

How is a small bowel perforation treated surgically?

A

Accessed via a midline laparotomy

Small perforations can be oversewn if the bowel is viable

Any doubt about the bowel = resection & primary anastomosis ± stoma

18
Q

How is a large bowel perforation treated surgically?

A

Accessed via midline laparotomy

Anastomosis not recommended in presence of faecal contamination and in an unstable patient

A resection with stoma formation = preferred choice