Gastrointestinal perforation

Question 1

Aetiology of upper GI tract perforation

Answer 1

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

Question 2

Aetiology of lower GI perforation

Answer 2

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

Question 3

Symptoms and signs of GI perforation

Answer 3

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

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

Question 4

Investigations for gastrointestinal perforation

Answer 4

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

Question 5

Management for GI perforation

Answer 5

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

Question 6

Management for peptic ulcer perforation

Answer 6

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

Question 7

Management for small bowel perforation

Answer 7

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

Question 8

Management for large bowel perforation

Answer 8

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

Question 9

Complications of surgical treatment for GI perforation

Answer 9

Infection
Bleeding
Anastomotic leakage
Hernia formation
Pulmonary
Thromboembolic
CVD