Visceral Perforation

Question 1

What are some causes of GI perforation?

Answer 1

Upper GI - Peptic ulcer disease, gastric/oesophageal cancer, excessive vomiting or foreign body ingestion.
Lower GI - Diverticulitis, colorectal cancer, appendicitis, severe colitis, toxic megacolon.
Any part: Iatrogenic, trauma, mesenteric ischaemia, obstructive lesions

Question 2

What are the clinical features of GI perforation?

Answer 2

Rapid onset of severe abdominal pain.
Malaise, vomiting, lethargy, often signs of sepsis,
Peritonism.
Perforation in the thoracic region will have pain in chest/neck which radiated to the back and is typically worse on inspiration.

Question 3

What are the investigations for a patient with suspected GI perforation?

Answer 3

Lab tests - FBC, UEs, LFTs, CRP, clotting, Group and save, amylase, beta-HCG (think ectopic)
Gold standard imaging is CT with IV/oral contrast. Can also use CXR to show pneumoperitoneum or Rigler’s sign

Question 4

What is the management of GI perforation?

Answer 4

• ABCDE assessment and resuscitation,
• Sepsis 6 (triple therapy)
• Broad spectrum abx and nil by mouth
• Surgical management: 1. Washout, 2. locate underlying cause and 3. surgical repair (Graham patch for peptic ulcers, bowel resection for bowel perfs)
• Conservative management only for those who are well.

Question 5

What are the complications of bowel perforation?

Answer 5

• Haemorrage and shock
• Sepsis and shock,
• Abscess formation

Question 6

What is Boerhaave syndrome?

Answer 6

Full thickness rupture of the oesophagus, normally because of repeated vomiting. Other causes of oesophageal rupture are: caustic substances, OGD or trauma

Question 7

What are the signs and symptoms of Boerhaave syndrome?

Answer 7

• Severe tearing chest pain which is worse on swallowing,
• Minimal/no hematemesis
• Signs of shock
• Subcutaneous emphysema
• Pneumomediatsinum, pleural effusions, pneumothorax

Question 8

How can you diagnose Boerhaave syndrome?

Answer 8

CT +/- oral contrast.
CXR can show pneumomediastinum

Question 9

What is the management of Boerhaave syndrome?

Answer 9

IV fluid resus to manage shock
IV abx for potential mediastinitis
Keep NBM
Surgical correction - Thoracotomy, laparotamy (intra-abdominal oesophagela perf), stents or percuatneous drainage

Question 10

What are some potential causes for stomach/duodenal perforations?

Answer 10

infection - h.pylori infection
Neoplasm - gastric carcinoma
Trauma - stab wounds
Iatrogenic - ERCP/OGD
Endocrine - Zollinger-ellison syndrome which can causes excess gastrin

Question 11

What is triple therapy in general surgery?

Answer 11

Amoxicillin, metronidazole and gentamicin