Perforated viscus

Question 1

Define what a perforated viscus is.

Answer 1

A hollow organ that has been perforated causing acute abdominal pain.

Question 2

What are the most common perforations in the abdomen?

Answer 2

Duodenal ulcer perforations.

Question 3

What is the pathophysiology of a perforated viscus?

Answer 3

· Loss of GI wall integrity with subsequent leakage of enteric contents.
· Exposure of the sterile peritoneal cavity to intraluminal contents causes either a chemical peritonitis or secondary bacterial peritonitis.
· Proximal perforations are often chemical leaking acidic, biliary or pancreatic.

Question 4

What is the mortality rate?

Answer 4

High at 30-50%.

Question 5

What are the associated risk factors?

Answer 5

· Chemical:

• Peptic ulcer disease.
• Foreign body such as batteries.

· Infections:

• Appendicitis.
• Diverticulitis.
• Cholecystitis.
• Meckel’s diverticulum.

· Ischaemia:

• Mesenteric ischaemia.
• Obstructive lesions - cancer, bezoar, faeces.

· Colitis:

• Fistula formation (CD).
• Toxic megacolon (UC).

· Iatrogenic:

• Recent surgery.
• Endoscopy or overzealous NG tube insertion.

· Penetrating or blunt trauma.
· Direct rupture.
· Stab or gunshot wound.

Question 6

What are the common signs and symptoms of a perforated viscus?

Answer 6

· Abdominal pain:
- Sudden and severe.
- May begin with a focal location, but a generalised peritonitis follows.
· Rigid abdomen.
· Involuntary guarding.
· Rebound tenderness.
· Hypotensive, tachycardic, tachypnoeic and febrile - SEPTIC.

Question 7

What investigations would you request if you suspected a patient had a perforated viscus?

Answer 7

· Erect CXR.
· CT - most sensitive and specific.
· Bloods - FBC, U&Es, LFTs, CRP, group and save, cross match, coagulation profile, blood gas.

Question 8

List some differential diagnoses.

Answer 8

· Bowel obstruction. 
· Pancreatitis.
· MI
· AAA
· Volvulus.
· Mesenteric ischaemia. 
· Infection. 
· Ruptured ectopic pregnancy.

Question 9

What treatment options are available?

Answer 9

· Resuscitation. 
· Abx. 
· Fluids. 
· NG tube. 
· Surgery.

Question 10

What complications can occur?

Answer 10

· Infection - peritonitis and sepsis.

· Haemorrhage.