1.11.2 Perforated Viscus

Question 1

Which organs are ‘hollow viscus’ organs?

Why does perforation occur?

Answer 1

• Organs
  
  • Bladder
  • Stomach, incl Esophagus
  • Gallbladder
  • Small bowel
  • Large bowel
  • Uterus
• Perforation
  
  • Often due to full thickness tissue injury or disruption
    
    • Partial thickness insults can progress, though

Question 2

Describe the 4 main etiologies of perforated viscus, and describe specific types within each category

Answer 2

• Ischemia
  
  • Bowel obstruction
  • Embolism
  • Hypotension/poor perfusion
  • Strangulation hernia
• Infection/Inflammation
  
  • Appendicitis (look for pneumoperitoneum)
  • Diverticulitis (look for pnptnm)
  • Sepsis
  • Chron’s/IBD
  • Connective tissue d/o’s
• Erosion
  
  • Corrosive chemical ingestion
  • GERD
  • Gastric/peptic ulcers
  • Tumors
• Physical Disruption
  
  • Intrumentation (EGD, colo, electrocaudery)
  • Trauma (blunt, penetrating, forgein body ingestion)
  • Pressure (Borhaave’s syndrome, bowel obstruction)
  • Post-op leak at anastromosis site

Question 3

Describe clinical presentation for perforated viscus

Describe the history you will take for this patient

Answer 3

• Presentation
  
  • Chest vs. back vs. abd pain
    
    • Depends on location of perf
  • N/v, tachycardia, fever
  • S/s sepsis, hotn
• History
  
  • OLDCARTS
  • Recent procedures: EGD, colo, intubation
  • Recent trauma
  • Medications: large pills, osteoporosis meds
  • Hx of odynophagia, GERD, PUD, ETOH, bowel obstruction
  • Personal/family hx GI malignancy
• Physical Exam
  
  • Full, with special attention to neck, chest, abdomen
    
    • Signs of sub q air
      
      • Puffy face, puffy neck, voice quality (esophageal perf)
    • Evaluate for crepitus, peritonitis, sepsis
    • Rectal exam to check for blood
      
      • Tumors, GI pathology

Question 4

Describe diagnostic workup for perforated viscus

Answer 4

• Labs
  
  • BMP
  • CBC w diff
  • Coags (if possible surgery)
  • LFTs, lipase
    
    • Biliary tree, upper abd source
  • Lactic acid
    
    • If septic/concern for ischemia
• Imaging
  
  • 3 View Abd Xray
    
    • Upright chest (eval for pneumomediastinum)
    • May miss pneumoperitoneum
  • CT Scan
    
    • Gold standard for catching pneumoperitoneum
    • Better delineation of anatomical causes of free air

Question 5

You get a CT scan when working up perforated viscus patient, what might you find and what’s going on there?

What is general management for both problems?

Answer 5

• Pneumomediastinum
  
  • Can occur with positive pressure ventilation
  • If septic/anastomotic leak, this would be pathological
  • If not from pathologic cause, no intervention needed typically
• Pneumoperitoneum
  
  • Common after abd surgery
    
    • Espected - typically not pathological
    • Resolves in 3-6d post op
  • Can see after cardiac surgery if peritoneum violated
• Management
  
  • NPO
  • IV hydration
  • IV analgesia
  • Surgical consult

Question 6

How will you work up c/f pneumomediastinum specifically?

Answer 6

• Gastrograffin swallow: Water-soluable contrast
  
  • If no obvious contrast extravasation, repeat w barium
    
    • If good, cleared to eat, no problem
  • Contrast extravasation requires surgical evaluation
    
    • Don’t want barium in mediastinum

Question 7

Contrast a perforation in the upper versus lower GI tract.

What are antibiotic considerations?

Answer 7

• Upper GI
  
  • Structures proximal to ligament of Trietz
  • Less bacterial contamination of peritoneal cavity
• Lower GI
  
  • Distal to ligament of Trietz
  • Greater bacterial contamination of peritoneal cavity
    
    • Quickly septic
• Empiric Abx Therapy
  
  • Initial: Broad-spectrum gram neg and anerobic agents
    
    • Pip Tazo
  • Add broad spectrum gram positive
    
    • Vanco
  • Consider adding fluconazole to cover yeast
    
    • DM, immunosuppressed - esophageal candidiasis
• Esophageal/Upper Perforation
  
  • Acute mediastinitis usually cased by anaerobic or mixed aerobic-anaerobic flora
    
    • Can also be facultative bacteria
  • Common anaerobes:
    
    • Prevotella, porphyromonas, peptostreptococcus, B fragilis
  • Common aerobes: alpha hemolytic strep, s aureus, k pneumoniae

Question 8

Describe complications of perforation

Answer 8

• Pharyngeal or esophageal
  
  • Mediastinitis
  • Sepsis
• Ruptured gastric/peptic ulcer
  
  • Peritonitis
  • Abscess
  • Sepsis
• Small/large bowel perf
  
  • Peritonitis
  • Abscess
  • Sepsis