Gastrointestinal perforation Flashcards
Aetiology of upper GI tract perforation
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
Aetiology of lower GI perforation
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
Symptoms and signs of GI perforation
Abdominal pain: sudden and severe
Malaise, lethargy
Nausea and vomiting
Looks unwell (generalised)
Fever, hypotension, tachycardia
Abdo: peritonism (tense, rigid), rebound tenderness
Investigations for gastrointestinal perforation
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
Management for GI perforation
- A-E
- Abx
- NBM + NG tub insertion
- IV fluids
- Analgesia
- Treat according to cause/site
Surgery
- Identification of the underlying cause
- Appropriate management of perforation
- Thorough washout
Management for peptic ulcer perforation
Surgical
either open or laparoscopically and a patch of omentum (termed a “Graham patch”) is tacked loosely over the ulcer
Management for small bowel perforation
Surgical
bowel resection ± primary anastomosis ± stoma formation; on occasion, small perforations (e.g. a fish bone perforation) can be managed by oversewing the defect
Management for large bowel perforation
bowel resection ± stoma formation is typically the preferred option (large risk of contamination)
Complications of surgical treatment for GI perforation
Infection
Bleeding
Anastomotic leakage
Hernia formation
Pulmonary
Thromboembolic
CVD