GI perforation

• A gastrointestinal perforation can occur at any anatomical location of the alimentary canal, from the upper oesophagus to the anorectal junction.
• Delay in resuscitation and definitive surgery of any perforation will progress rapidly into septic shock, multi organ dysfunction, and death, hence it should be one of the first diagnoses considered in all patients who present with acute abdominal pain.
• Upper GI causes:

  • Peptic ulcer disease
  • Oesophageal and gastric cancer
  • Foreign body ingestion
  • Excessive vomiting (Boerhaave syndrome)
• Lower GI causes:

  • Diverticulitis
  • Colorectal cancer
  • Appendicitis
  • Meckel's Diverticulitis
  • Foreign body insertion
  • Severe colitis
  • Toxic megacolon e.g. from C.diff or ulcerative colitis
• Any part of the GI tract causes:

  • Iatrogenic - such as during colonoscopy
  • Trauma, either through penetrating or blunt mechanisms
  • Mesenteric ischaemia
  • Obstructing lesions (e.g. cancer, faeces) leading to bowel obstruction with subsequent ischaemia and necrosis
• Clinical features:

  • Abdominal pain - severe and rapid onset
  • Systemically unwell - often have features of sepsis
  • Signs of peritonism - can be localised or generalised (rigid abdomen)
  • Generalised peritonitis implies diffuse contamination of the abdomen and the patient will be very unwell
• Any thoracic region perforation (such as a oesophageal rupture) will present with pain, ranging from chest or neck pain to pain radiating to the back, typically worsening on inspiration. There may be associated vomiting and respiratory symptoms.
• Lab tests:

  • Urgent
  • FBC - raised WCC
  • U+Es
  • LFTs
  • CRP - raised
  • Clotting
  • Group and save
  • May show evidence of organ dysfunction such as AKI or a coagulopathy developing secondary to sepsis
• Imaging:

  • Gold standard is CT with contrast
  • Confirms presence of free air and suggests a location of the perforation
  • In cases of suspected upper GI perforation a CT scan with oral contrast may be used
  • CXR can show air under the diaphragm but is much less sensitive and specific
• AXR signs:

  • Rigler's sign - both sides of the bowel visible
  • Psoas sign - loss of the sharp delineation of the psoas muscle border
• Management:

  • Early resuscitation and prompt diagnosis
  • Broad spectrum antibiotics started early
  • NBM and NG tube if required
  • Appropriate analgesia
  • Most patients will require theatre for washout, locate the underlying cause and suitable repair
  • E.g. bowel resection +/- primary anastomosis +/- stoma formation