This morning I wrote up a post for appendicitis but my internet went wack and I lost it. Hate it when that happens. It’s like when my old computer broke and I lost my teenage angst poetry and was left with verses at the edges of my memory. I was too upset to write any more poetry for a while after. But, no time for moaning now, here’s a post on GI perforation. Nowhere as interesting as my post on appendicitis would have been but…
Definition: perforation of the wall of the GI tract with spillage of bowel contents
Aetiology/ risk factors:
Gastroduodenal: perforated duodenal or gastric ulcer, or rarely, gastric carcinoma.
Large bowel: diverticulitis, colorectal carcinoma, perforated appendix in appendicitis. Less commonly: Volvulus, ulcerative colitis (toxic megacolon), trauma, radiation enteritis, post-op anastomotic leak, colonoscopy complication.
Small bowel (rare): trauma, infection (typhoid, TB), Crohn’s disease, lymphoma, vasculitis, radiation enteritis.
Oesophagus: Boerhaave’s syndrome (oesophageal rupture following forceful vomiting). Iatrogenic- dilatation of strictures, OGD.
Epidemiology: depends on cause
-abdominal pain, sudden onset
-nausea & vomiting
Oesophageal perforation =
-odynophagia (painful swallowing)
-localised or generalised peritonitis:
board-like abdominal rigidity
guarding (involuntary tensing of abdominal muscles)
rebound tenderness (more pain when hand is removed from abdomen than when it gently presses down)
pain upon coughing
-reduced or absent bowel sounds
-loss of liver dullness (due to overlying gas)
-shock: tachycardia, hypotension, cold peripheries
-pyrexia, pallor, dehydration
Oesophageal perforation =
-surgical emphysema (crackling sensation felt on palpating the skin over the chest or neck caused by air tracking from the lungs)
Bloods: FBC, U&Es, LFTs, amylase (amylase levels may be raised), ABG, clotting
Erect CXR- may show air under the diaphragm (70% of cases in perforated peptic ulcer)
AXR- can show abnormal gas shadows in tissues.
Rigler’s sign-gas on either side of the bowel wall, viewed as a double wall, bowel wall is very clear
A lateral decubitus (lying down) film can show intraperitoneal gas
CT- very sensitive for free intraperitoneal gas, and may also diagnose underlying pathology
-broad spectrum IV antibiotics
-urinary catheter + central line (assess volume status and give fluids/ABx)
Conservative treatment if not severe or not suitable for surgery-
Gastroduodenal perforation- bowel rest (NBM), NG tube, high dose PPIs (e.g. omeprazole), IV fluids, antibiotics, monitor.
Gastroduodenal– laparoscopy or laparotomy and peritoneal lavage. Perforation closed and an omental (fatty peritoneum) patch is placed.
Gastric ulcers should be biopsied for malignancy, post-op Helicobacter pylori (main culprit of gastroduodenal ulcers) eradication if positive for the bacterium.
Gastric perforation may require partial gastrectomy with gastroduodenal anastomosis (take a bit of the stomach out and then connect what’s left to the duodenum).
Large bowel- laparoscopy or laparotomy and peritoneal lavage. Resection of involved colon, usually as part of Hartmann’s procedure (temporary stoma with anastomosis at a later date). Other options- resection and primary anastomosis +/- defunctioning ileostomy.
In toxic megacolon of UC- subtotal colectomy with a terminal ileostomy and preservation of the rectal stump for future reconstruction of ileoanal pouch.
Conservative for iatrogenic rupture– NG tube, PPI, antibiotics
Others: resuscitation, PPI, antibiotics, antifungals, surgical debridement of mediastinum and placement of T-tube for drainage and formation of a controlled oesophago-cutaenous fistula.
-fistula formation (abnormal connection between two hollow viscus)
Higher morbidity and mortality in perforated gastric ulcers than duodenal; perforated gastric carcinomas have a very poor prognosis.
Large bowel perforation has a better prognosis if there is limited or local contamination, with faecal peritonitis carrying a mortality of > 50%.