Perforation/peritonitis

Question 1

Organs which most commonly perforate

Answer 1

• Appendix
• Colon
• Stomach

Question 2

Define peritonitis

Answer 2

• Inflammation of peritoneum which is usually sterile
• Often due to peritoneal cavity becoming non-sterile due to leakage of GI contents from perforation

Question 3

Initial imaging for perforation

Answer 3

Erect CXR - pneumoperitoneum showed by free gas under diaphragm
* BUT only +ve in 70% of patients, 3 in 10 patients will have normal CXR but perf

Question 4

Imaging if erect CXR normal

Answer 4

CT scan with IV contrast

Question 5

Presentation of perforation

Answer 5

• Abdominal pain - severe, constant epigastric then generalised
• Abdo distension
• N+V
• Dyspepsia
• Constipation
• Shoulder tip pain - Kehrs sign, R shoulder or both

Question 6

Signs of perf

Answer 6

• Abdo tenderness
• Peritonitis - guarding, rigidity, rebound tenderness
• Fever
• Tachycardia

Question 7

Bloods for perforation/peritonitis

Answer 7

• routine + group and save and clotting
• Serum amylase/lipase to rule out pancreatitis

Question 8

Initial management perforation/peritonitis

Answer 8

Resuscitation:
* IV fluids
* NG tube drainage - reduce GIT contents that could leak
* Make NBM
* IV PPI to seal perforation
* Abx

Question 9

When is surgery done for perforation

Answer 9

• Continued deterioration
• Worsening symptoms

Question 10

Surgery for peritonitis

Answer 10

• Intra-operative washout
• Closure if small <2cm
• If larger/friable, resection of lesion with repair or omentum can be used to close area

Question 11

CXR sign of perf

Answer 11

• Free air under diaphragm
• Riglers sign - both sides of bowel visible

Question 12

Peptic ulcer perf surgery

Answer 12

• Open or laparoscopic
• Patch of omentum loosely over ulcer - Graham patch

Question 13

Small bowel perf surgery

Answer 13

• Bowel resection
• +/- primary anastomosis
• +/- stoma
• Sometimes small ones can be fixed by sewing perf

Question 14

Large bowel perf management

Answer 14

• Often large amount of contamination
• If surgery needed then bowel resection +/- stoma often used

Question 15

When is conservative management used and not surgery for perf

Answer 15

• Localised diverticular perf with localised peritonitis and tenderness, no evidence of contamination
• Sealed upper GI perf on CT with no generalised peritonism
• Elderly frail pts with co-morbids who wouldn’t likely survive surgery

Question 16

Complications

Answer 16

• Sepsis
• Post-op leak
• Significant haemorrhage

Question 17

Causes of perf upper GI tract

Answer 17

• PUD
• Oesophageal/gastric cancer
• Excessive vomitting eg Boerrhave syndrome
• Foreign body ingestion eg battery

Question 18

Lower GI tract cause of perf

Answer 18

• Diverticulitis
• Colorectal cancer
• Appendicitis
• Foreign body insertion
• Severe colitis eg Crohns
• Toxic megacolon (eg from C.diff or UC)

Question 19

Thoracic perforation presentation

Answer 19

• Eg in oesophageal rupture
• Pain
• Ranging from chest/neck pain or pain radiating to back
• Worsened on inspiration
• May have vomitting/resp symptoms
• Can get pleural effusion or palpable crepitus - subcutaneous emphysema