GI Perforation

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…


GI Perforation

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

Symptoms:

-abdominal pain, sudden onset

-nausea & vomiting

Oesophageal perforation =

-odynophagia (painful swallowing)

-fever

 

Signs:

-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)

lying still

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 =

-tachypnoea

-dyspnoea

-fever

-shock

-surgical emphysema (crackling sensation felt on palpating the skin over the chest or neck caused by air tracking from the lungs)

 

Investigations:

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)

Image result for erect cxr air gi perforation

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

Image result for lateral decubitus (lying down) film

CT- very sensitive for free intraperitoneal gas, and may also diagnose underlying pathology

Management:

Resuscitation:

-IV fluids/electrolytes

-broad spectrum IV antibiotics

-analgesia

-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.

 

Surgery:

Gastroduodenal– laparoscopy or laparotomy and peritoneal lavage. Perforation closed and an omental (fatty peritoneum) patch is placed.

 

Image result for omental patch

 

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.

 

Oesophageal rupture

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.

Image result for esophageal perforation t tube

 

Complications:

-sepsis

-peritonitis

-fistula formation (abnormal connection between two hollow viscus)

-death

Prognosis:

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%.

References: Rapid surgery, Cheese & Onion
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