Visceral perforation

Question 1

Where can GI perforation occur?

Answer 1

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

Question 2

How will it progress without intervention?

Answer 2

septic shock, multi organ dysfunction, and death

Question 3

Most common causes

Answer 3

peptic ulcers (gastric or duodenal) and sigmoid diverticulum.

Question 4

Chemical causes?

Answer 4

Peptic ulcer disease
Foreign body (e.g. battery or caustic soda)

Question 5

Infectious causes?

Answer 5

Diverticulitis
Cholecystitis
Meckel’s Diverticulum

Question 6

Ischaemic Causes

Answer 6

Mesenteric ischaemia
Obstructing lesions (e.g. cancer*, bezoar, or faeces (sterocoral)), resulting in bowel distension and subsequent ischaemia and necrosis

Question 7

Colitis causes

Answer 7

Toxic Megacolon (e.g. Clostridum Difficile or Ulcerative Colitis)

Question 8

Traumatic causes

Answer 8

Iatrogenic 
Recent surgery (including anastomotic leak)
Endoscopy or overzealous NG tube insertion

Penetrating or blunt trauma
Shear forces from acceleration-deceleration or high forces over small surface area (e.g. a handle bar)

Direct rupture
Excessive vomiting leading to oesophageal perforation (Boerhaave Syndrome)

Question 9

Clinical presentation

Answer 9

Pain!
systemically unwell therefore may also have associated malaise, vomiting, and lethargy.
features of peritonism- localised or generalized (a rigid abdomen).
(peritonitic throughout their abdomen, then this implies generalised contamination and they will almost always need urgent surgery.)

Question 10

Thoracic Perforation Presentation

Answer 10

Any thoracic region perforation (such as a oesophageal rupture) will present with pain, ranging from chest or neck pain to pain radiating to the back, typically worsening on inspiration. There may be associated vomiting and respiratory symptoms.

On examination, auscultation and percussion may reveal signs of a pleural effusion, with the potential for palpable crepitus.

Question 11

DDx

Answer 11

acute pancreatitis, myocardial infarction, tubo-ovarian pathology, or a ruptured aortic aneurysm.

Question 12

LAb Tests

Answer 12

Raised WCC and CRP are common features, dependent on timing and degree of contamination, and amylase is often mildly elevated in perforation (although non-specific).

A urinalysis should also be routinely performed to exclude both renal and tubo-ovarian pathology.

Question 13

Chest x-ray

Answer 13

A plain film erect chest radiograph (eCXR) can show free air under the diaphragm. Pneumomediastinum or widened mediastinum may also be present if the perforation is thoracic in origin.

Question 14

Best imaging modality?

Answer 14

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

Question 15

AXR - Rigler’s sign

Answer 15

both sides of the bowel wall can be seen, due to free intra-abdominal air acting as an additional contrast

Question 16

AXR- Psoas sign

Answer 16

loss of the sharp delineation of the psoas muscle border, secondary to fluid in the retroperitoneum

Question 17

Management

Answer 17

Broad spectrum antibiotics should be started early, especially in patients deemed to need surgery for contamination.
Patients should be placed nil by mouth and an nasogastric tube considered. Provide adequate IV fluid support and appropriate analgesia.

Question 18

Surgical Intervention

Answer 18

Identification and (where possible) management of underlying cause
Appropriate management of perforation, such as: Repairing perforated peptic ulcer with an omental patch
Resecting a perforated diverticulae (e.g. via a Hartmann’s procedure)

Thorough washout

Question 19

Complications

Answer 19

infection (peritonitis and sepsis) and haemorrhage