GI Perforation

Question 1

def

Answer 1

perforation of the wall of the GI tract with spillage of bowel contents

Question 2

aetiology

Answer 2

1 gastroduodenal
-commonly perforated gastric or duodenal ulcer
2 large bowel
-commonly diverticulitis + colorectal carcinoma
-perforated appendix is a common complication of appendicitis
-UC (toxic megacolon)
3 small bowel (rare)
-infection (typhoid, TB)
-CD
4 oesophagus
-boerhaaves syndrome
-iatrogenic perforation (OGD)

Question 3

what is boerhaaves syndrome

Answer 3

rupture of oesphageal wall

Question 4

epi

Answer 4

incidence depends on cause

presentation with abdominal pain is common

Question 5

history

Answer 5

dependent on cause
sudden onset abdominal pain
nausea + vomiting

Question 6

examination

Answer 6

signs of peritonitis
guarding
decreased bowel sounds
loss of liver dullness on percussion due to overlying gas

Question 7

investigations

Answer 7

1 bloods
-FBC, UEs, LFTs, amylase (may be raised), ABGs, clotting
2 erect CXR
-may show gas under diaphgragm (70% of cases in perforated peptic ulcer)
3 AXR
-abnormal gas shadows in tissues
-riglers sign (gas on either side of bowel wall)
4 CT scan
-sensitive for free intraperitoneal gas
-may diagnose underlying pathology

Question 8

management

Answer 8

1 resuscitation
-IV rehydration
-correction of electrolyte abnormalities
-broad spectrum IV antibiotics
2 conservative
-for those with limited signs, minimal contamination, high anaesthetic risk
-for gastroduodenal perforations bowel rest, PPIs, IV fluids + antibiotics
3 surgical
gastroduodenal
-perforation is closed
-gastric ulcers should be biopsied for carcinoma
large bowel
-removal of involved colon

Question 9

complications

Answer 9

sepis
peritonitis
fistula formation
death

Question 10

prognosis

Answer 10

gastroduodenal
-higher morbidity + mortality in perforated gastric ulcers than duodenal ulcers
-perforated gastric carcinomas have poor prognosis
large bowel
-better prognosis limited contamination
-faecal peritonitis >50% mortality