Gastrointestinal perforation Flashcards

1
Q

Aetiology of upper GI tract perforation

A

Peptic ulcer disease
Gastric cancer or oesophageal cancer
Foreign body ingestion (e.g. battery or caustic soda)
Excessive vomiting (Boerhaave Syndrome)

Iatrogenic, such as during gastroscopy or colonoscopy
Trauma, either through penetrating or blunt mechanisms
Mesenteric ischaemia
Obstructing lesions (e.g. cancer, bezoar, or faeces/sterocoral), leading to bowel obstruction, with subsequent ischaemia and necrosis

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2
Q

Aetiology of lower GI perforation

A

Diverticulitis (most common in higher-income countries)
Colorectal cancer
Appendicitis or Meckel’s Diverticulitis
Foreign body insertion
Severe colitis, such as Crohn’s Disease
Toxic megacolon (e.g. from Clostridum Difficile or Ulcerative Colitis)

Iatrogenic, such as during gastroscopy or colonoscopy
Trauma, either through penetrating or blunt mechanisms
Mesenteric ischaemia
Obstructing lesions (e.g. cancer, bezoar, or faeces/sterocoral), leading to bowel obstruction, with subsequent ischaemia and necrosis

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3
Q

Symptoms and signs of GI perforation

A

Abdominal pain: sudden and severe
Malaise, lethargy
Nausea and vomiting

Looks unwell (generalised)
Fever, hypotension, tachycardia
Abdo: peritonism (tense, rigid), rebound tenderness

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4
Q

Investigations for gastrointestinal perforation

A

Urine dip + MC&S
Urine pregnancy

VBG/ABG
FBC
U&Es
LFTs
CRP
Blood cultures
Cross match/ G&S/ Clotting

AXR:
- Rigler’s sign (both sides of bowel visible)
- Psoas sign (loss of sharp delineation of the psoas muscle border
CXR: pneumoperitoneum
CT contrast: free air

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5
Q

Management for GI perforation

A
  1. A-E
  2. Abx
  3. NBM + NG tub insertion
  4. IV fluids
  5. Analgesia
  6. Treat according to cause/site

Surgery
- Identification of the underlying cause
- Appropriate management of perforation
- Thorough washout

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6
Q

Management for peptic ulcer perforation

A

Surgical
either open or laparoscopically and a patch of omentum (termed a “Graham patch”) is tacked loosely over the ulcer

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7
Q

Management for small bowel perforation

A

Surgical
bowel resection ± primary anastomosis ± stoma formation; on occasion, small perforations (e.g. a fish bone perforation) can be managed by oversewing the defect

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8
Q

Management for large bowel perforation

A

bowel resection ± stoma formation is typically the preferred option (large risk of contamination)

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9
Q

Complications of surgical treatment for GI perforation

A

Infection
Bleeding
Anastomotic leakage
Hernia formation
Pulmonary
Thromboembolic
CVD

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