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AIP: Abdominal pain > Viscus rupture > Flashcards

Viscus rupture Flashcards

1
Q

What is gastrointestinal perforation?

A

full-thickness loss of bowel wall integrity that results in perforation peritonitis

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2
Q

What is the most common cause of perforation peritonitis?

A

perforation of a duodenal ulcer

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3
Q

What are 5 groups of causes of GI perforation?

A
  1. Ulcerative/erosive disease
  2. Infections
  3. Bowel ischaemia
  4. Trauma
  5. Miscellaneous: foreign body, drug induced, radiation therapy, post renal transplant
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4
Q

What are 3 examples of ulcerative/erosive disease leading to viscus perforation?

A
  1. Peptic ulcer disease (most common)
  2. Malignancy
  3. Inflammatory bowel disease
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5
Q

What location of duodenal ulcers are more likely to perforate?

A

duodenal ulcers of the anterior wall

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6
Q

What are 5 examples of infections which may cause viscus perforation?

A
  1. Diverticulitis (colonic diverticula, Meckel diverticulum)
  2. Acute appendicitis
  3. Typhoid
  4. Gastrointestinal tuberculosis
  5. Toxic megacolon
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7
Q

What are 2 examples of causes of bowel ischaemia which can lead to perforation?

A
  1. Bowel obstruction (adhesions, volvulus, malignancy)
  2. Acute mesenteric ischaemia
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8
Q

What are 2 examples of trauma that can lead to viscus perforation?

A
  1. Penetrating trauma (e.g. stab injury, iatrogenic perforations)
  2. Blunt abdominal trauma
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9
Q

What are 4 miscellaneous causes of GI perforation?

A
  1. Foreign body ingestion
  2. Drug-induced: NSAIDs, glucocotricoids, cocaine
  3. Radiation therapy to the abdominopelvic or lower thoracic region
  4. Post renal transplant
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10
Q

What are 7 symptoms/signs of GI perforation?

A
  1. sudden onset abdominal pain and abdominal distension
  2. nausea, vomiting
  3. obstipation (severe or complete constipation)
  4. fever, tachycardia, tachypnoea, hypotension
  5. signs of peritonitis or shock
  6. decreased or absent bowel sounds
  7. loss of liver dullness on RUQ percussion
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11
Q

What are 3 signs of peritonitis on examination?

A
  1. decreased bowel sounds
  2. diffuse or localised abdominal guarding
  3. rebound tenderness
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12
Q

What are 4 features in the history suggestive of a perforated peptic ulcer?

A
  1. sudden onset of intense, stabbing pain, followed by diffuse abdominal pain and distension (beginning peritonitis)
  2. referred pain to the shoulder due to irritation of the diaphragm
  3. history of recurrent epigastric pain, chronic NSAID use
  4. perforation of chronic ulcers may only cause mild symptoms
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13
Q

Why can you get referred pain to the shoulder in peritonitis followin GI perforation?

A

irritation of diaphragm which is innervated by phrenic nerve (C3-5); shoulder skin is innervated by supravlacivular nerves C3/C4

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14
Q

What is suggested by a history that sounds like perforation, with localised RLQ pain?

A

contained perforated appendicitis

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15
Q

What is suggested by a history that sounds like perforation, with localised LLQ pain?

A

contained perforated diverticulitis

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16
Q

What are 3 key blood tests to perform when investigating GI perforation?

A
  1. FBC
  2. U+Es
  3. Venous blood gas (VBG)
17
Q

What is the first line imaging modality for suspected GI perforation?

A

CT abdomen and pelvis with IV contrast

18
Q

What are 2 possible signs of GI perforation on CT-AP?

A
  1. Pneumoperitoneum
  2. Signs of perforated bowel: loss of bowel wall continuity, localised mesenteric fat stranding
19
Q

What are 2 alternative imaging modalities to CT-AP in suspected GI perforation?

A
  1. AXR and CXR: upright and supine AXR, upright CXR
  2. USS abdomen
20
Q

When might AXR+CXR be indicated instead of CT-AP in suspected perforation?

A

patients with contraindications to IV contrast

21
Q

What findings may be present on AXR/CXR in GI perforation?

A

free intraperitoneal air (pneumoperitoneum) under diaphragm, and/or between liver and lateral abdominal wall

22
Q

When might an USS abdomen be indicated rather than CT-AP or xray in suspected GI perforation?

A

in patients with contraindications to radiation exposure e.g. pregnancy

23
Q

What findings may be present on USS abdomen in GI perforation?

A

pneumoperitoneum, localised fluid collection, localised thickening of a bowel segment

24
Q

During your A-E assessment of someone with GI perforation, what are 8 things you should do?

A
  1. Nil by mouth
  2. IV access with 2 large bore peripheral cannulae
  3. Start broad spectrum IV antibiotics: see severe infection in empiric antibiotic therapy for intra-abdominal infection
  4. Aggressive IV fluid resuscitation
  5. Determine whether indications for surgery are present i.e. generalised peritonitis, sepsis, or whether can be managed conservatively
  6. Supportive care with analgesics, antiemetics
  7. Consider IV PPI
  8. NG tube with continuous or intermittent suction
25
Q

What type of analgesics are likely to be appropriate in GI perforation?

A

IV opioids e.g. morphine, tramadol(?)

26
Q

What are 2 examples of antiemetics which may be given in GI perforation?

A

IV ondansetron or promethazine

27
Q

Why is it best to give IV analgesics and antiemetics in GI perforation?

A

presence of perforation means they may not be absorbed properly - GI tract isn’t closed off. Can also lead to ileus, and also pt may be vomiting

(note: NBM patients for surgery can still receive oral medications)

28
Q

When are opioids contraindicated as analgesia in GI perforation?

A

in suspected bowel obstruction

29
Q

What is the overall aim of treatment in GI perforation?

A

most patients should be managed with urgent explorative laparotomy - if signs of peritonitis, sepsis

30
Q

What does the procedure for urgent explorative laparotomy involve?

A
  • midline incision
  • obtain peritoneal fluid for cultures
  • thorough peritoneal lavage with saline
  • closure of perforation if feasible - primary closure with/without omental pedicle, resection of perforated segment of bowle with primary anastomosis or temporary stoma creation
31
Q

What should be done if malignancy is identified during exploratory laparotomy? 3 possible things

A
  1. consider curative resection
  2. obtain intraoperative biopsies of the mass if resection is not possible
  3. place peritoneal drains and close the abdomen
32
Q

What are 4 aspects of postoperative care following exploratory laparotomy for GI perforation?

A
  1. Continue bowel rest
  2. IV fluids
  3. NG tube with suction until normal bowel function returns
  4. Identify and treat underlying condition
33
Q

Which patients with GI perforation may be candidates for conservative management?

A

those with only localised peritonitis and no signs of sepsis

34
Q

What are 6 aspects of conservative management of GI perforation?

A
  1. NBM
  2. IV fluids
  3. IV PPI
  4. IV broad spectrum antibiotics
  5. If imaging shows evidence of abscess, consider image-guided percutaneous drainage of abscess
  6. Serial abdominal examination
  7. If clinical signs of improvement, obtain AXR with water-soluble contrast to confirm perforation has sealed
35
Q

What imaging should you perform to determine if a perforation has healed with conservative management, and what should you do based on the findings?

A

abdominal x-ray with water-soluble contrast

  • no leakage of contrast: initiate enteral feeds and switch to oral antibiotics
  • if clinical signs of deterioration: exploratory laparotomy
36
Q

Where should a patient with GI perforation be managed?

A

(surgical) ITU/ HDU

37
Q

What are 10 possible complications of GI perforation?

A
  1. Peritonitis
  2. Bacteraemia
  3. Sepsis
  4. Multiorgan dysfunction
  5. Intra-abdominal abscess
  6. Intra-abdominal adhesions
  7. Subhepatic abscess
  8. Pyogenic liver abscess
  9. Pelvic abscess
  10. Postoperative complications

AIP: Abdominal pain (20 decks)

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