Gastrointestinal Perforation

Question 1

Define gastrointestinal perforation

Answer 1

Complete penetration of any part of the wall of the GI tract (stomach, small or large bowel)
resulting in the intestinal contents entering the abdominal cavity -> bacterial or chemical
peritonitis

Question 2

What are the causes/risk factors of gastrointestinal perforation?

Answer 2

• Peptic ulcer disease (gastric and duodenal ulcers)
• IBD
• NSAIDs
• Ingestion of corrosives e.g. batteries
• Surgery/investigations e.g. ERCP

Large Bowel Perforation: 
• Diverticulitis 
• Colorectal Carcinoma (These 2 are responsible for 80%). 
• Appendicitis 
• Toxic Megacolon in Ulcerative Colitis 
• Trauma 
• Iatrogenic: Post-op and Colonoscopy 

Gastroduodenal Perforation:
• Perforated Duodenal and Gastric Ulcers.
*NB: Perforation of posterior duodenal ulcers can erode the gastroduodenal artery; gastric ulcers can erode the left gastric artery –this causes severe bleeding.

Small Bowel Perforation: 
*These are very rare. 
• Trauma 
• Infection –TB and typhoid 
• Crohn’s Disease 

Oesophageal Perforation:
• Boerhaave’s Perforation as a complication of Mallory-Weis Tears.
• Iatrogenic during an OGD

Question 3

What are the symptoms of gastrointestinal perforation?

Answer 3

• Severe abdominal pain originating at site of perforation
• Nausea
• Vomiting
• Fever

Question 4

What are the signs of gastroinetsinal perforation?

Answer 4

• Rigid abdomen
• Tenderness/guarding
• Rebound tenderness
• Lying still
• Silent abdomen
• Tachycardia

Question 5

What investigations are carried out for gastrointestinal perforation?

Answer 5

• FBC - anaemia (if bleeding); leucocytosis (abscess and peritonism)
• U&E’s - may show signs of dehydration
• LFTs - normal
• Blood culture - may show bacteraemia if there are signs of sepsis and pyrexia
• Amylase - usually raised; if >3x the normal range, suspect pancreatitis.
• ABG - metabolic alkalosis and raised lactate.
• Clotting Screen - to ensure there isn’t an underlying bleeding disorder co-existing, which can lead to severe blood loss.
• CXR - erect; pneumoperitoneum.
• CT Abdomen - may show the perforated organ
• AXR - can show abnormal gas shadows in tissues or in the bowel wall.
- a lateral decubitus film can demonstrate intraperitoneal gas.
• Gastrograffin Swallow - shows Boerhaave’s rupture.

Question 6

What is the management for gastrointestinal perforation?

Answer 6

Resuscitation: 
• Treat shock; Correct fluid and electrolyte imbalance 
• IV antibiotics: metronidazole 
• Analgesia PRN 
• Catheter 

Conservative for gastroduodenal perforations in patients with a high anaesthetic risk: 
• NBM 
• PPIs 
• IV Fluids 
• IV Antibiotics  

Surgical:
• Large Bowel Perforation:
• Laparotomy to identify site.
• Peritoneal Lavage
• Resection –Usually a Hartmann’s Procedure with end colostomy.
• In Right colon perforations: Resection and primary anastomosis.
• Toxic Megacolon: In UC, Subtotal colectomy with a terminal ileostomy; future connection of the ileoanal pouch.

Gastroduodenal Perforation:
• Laparotomy to identify site.
• Peritoneal Lavage
• Perforation is closed and an omental patch is placed.
• Biopsy of gastric ulcers: 4 quadrant biopsy; frozen section –for pathological identification of gastric carcinoma.

Oesophageal Perforation:
• If occurs during dilation of a malignant stricture: coverage by an expandable stent may be possible.
• If spontaneous and <24 h from onset, should be treated surgically:
• Left thoracotomy with pleural lavage and primary repair
• Oesophagectomy.

Question 7

What are the complications of gastrointestinal perforation?

Answer 7

• Bowel perforation: Peritonitis
• Oesophageal Perforation: Mediastinitis
• Any: Sepsis, shock, MOF and death.