Visceral Perforation

Question 1

Shoulder tip pain following a visceral perforation suggests irritation of where?

Answer 1

Diaphragm

Question 2

What artery provides the blood supply to the ascending colon?

Answer 2

Superior mesenteric artery

Question 3

Which is not radiographic evidence of pnuemoperitoneum?

a) Air under diaphragm
b) Rigler’s sign
c) Psoas sign
d) Murphy’s sign

Answer 3

d) Murphy’s sign

Murphy’s sign is associated with acute cholecystitis

Question 4

What is visceral perforation

Answer 4

Defined as a hole through the wall of the GI tract

Also known as GI perforation

Question 5

At what point in the GI tract does a visceral perforation occur?

Answer 5

May occur at any anatomical location from the upper oesophagus to the anorectal junction

Question 6

What is the most common cause of visceral perforation in high income countries

Answer 6

Diverticulitis (inflammation of the diverticula)

Question 7

Name some of the causes of visceral perforation

Answer 7

Diverticulitis [most common in high income countries]

Peptic ulcer disease

GI malignancy e.g. gastric or colorectal

Iatrogenic e.g. during surgery

Trauma e.g. ingestion of a foreign body

Appendicitis

Meckel’s Diverticulitis

Severe colitis such as Crohn’s Disease

Oesophageal perforation secondary to vomiting (Boerhaave’s syndrome)

Question 8

What are some of the clinical features of visceral perforation

Answer 8

Sudden onset sharp pain

Systemically unwell – associated malaise, vomiting and lethargy

Features of peritonism

Question 9

Name the two features of peritonism

Answer 9

Rigid abdomen and involuntary guarding

Rebound tenderness (pressing on the abdomen elicits less pain than releasing the hand)

Question 10

Define Involuntary guarding

Answer 10

Refers to the involuntary tensing of the abdominal wall muscles in response to pressure on the abdomen

Question 11

What is the gold standard investigation for visceral perforation

Answer 11

CT scan

Question 12

CT scan is the gold standard investigaton for visceral perforation.

What are the CT scan features for visceral perforation?

Answer 12

The presence of free air and suggesting a location of the perforation (as well as a possible underlying cause)

Question 13

CT scan is the gold standard investigaton for visceral perforation.

What are the two imaging modalities that can be useful but less specific than CT

Answer 13

Erect chest radiograph (eCXR) and abdominal radiograph (AXR)

Question 14

What is a good blood test to remember for any bleeding

Answer 14

G&S

Question 15

What is the difference between a group and save and a crossmatch?

Answer 15

Group and Save: Sample processing. Consists of a blood group and an antibody screen to determine the patients group and whether or not they have atypical red cell antibodies in their blood.

Crossmatch: When the laboratory actually provides red cells products for the patient. It is not possible for the laboratory to provide crossmatched blood without having processed a group and save sample first.

Question 16

Define pnuemoperitoneum

Answer 16

Air in the abdominal cavity

Radiological sign of visceral perforation

Question 17

Pnuemoperitoneum is the key radiographic feature of visceral perforation.

What are the 3 radiological signs of pneumoperitoneum

Answer 17

Free air under the diaphragm (double bubble)

Rigler’s sign (double wall sign; both sides of the bowel visible)

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

Question 18

(1) Define the double bubble radiological sign and (2) in which condition is it present in

Answer 18

(1) Free air under the diaphragm
(2) Visceral perforation

Question 19

(1) Define the Rigler’s sign and (2) in which condition is it present in

Answer 19

(1) Radiological features - double wall sign; both sides of the bowel visible
(2) Visceral perforation

Question 20

(1) Define the Psoas sign and (2) in which condition is it present in

Answer 20

(1) Radiological feature - loss of the sharp delineation of the psoas muscle border
(2) Visceral perforation

Question 21

Name some of the management options for visceral perforation

Answer 21

Broad spectrum antibiotics e.g. Gentamicin

IV fluids

Analgesia

Nil by mouth

Consider nasogastric (NG) tube

Question 22

What is the definitive management for visceral perforation

Answer 22

Most patients require surgical repair and control of contamination

However selected physiologically well patients without generalised peritonitis or those not suitable for surgery may be managed conservatively

Question 23

Most patients require urgent surgery to definitivity manage visceral perforation.

What are the 3 key surgical aspects to this surgery?

Answer 23

Washing

Locate underlying cause

Suitable management of the perforation

Question 24

Name some of the complications of visceral perforation

Answer 24

Delay in resuscitation and definitive surgery will progress rapidly into:

• Septic shock
• Multi organ dysfunction
• Death