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GI perforation
GI perforation

GI perforation

GI perforation is a medical emergency that rapidly will lead to septic shock, multi-organ dysfunction and death. Due to its severity it needs to be one of the first differential diagnoses considered for acute abdominal pain.

Pathophysiology

There are a wide variety of causes of GI perforation:

  1. Diverticulitis
  2. PUD
  3. Malignancy (gastric or CRC)
  4. Iatrogenic
  1. Trauma
  2. Foreign body
  3. Appendicitis or Meckel’s Diverticulitis
  4. Mesenteric ischaemia
  1. Obstruction
  2. Severe colitis
  3. Excessive vomiting (Boerhaave syndrome)
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Boerhaave syndrome:

This occurs when there is rupture of the oesophagus due to excessive or forceful vomiting. The disorder may present with vague symptoms, or one may note the classic Mackler triad of vomiting chest pain and subcutaneous emphysema.

😷 Presentation

  • Pain - rapid onset and sharp.
  • Systemically unwell - malaise, vomiting, lethargy
  • Sepsis features - clammy, pale, tachycardic, hypotensive
  • Peritonism - a localised or generalised pain (percussion tenderness, rebound tenderness), rigid abdomen.

Investigations

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Imaging 🏆 CT scan is the gold standard. Confirmation is seen by free air in the abdomen. eCXR and AXR are also good, but less specific. They may also show some signs:
  • Rigler’s sign (where we can see both walls of the bowel)
  • Psoas sign (loss of sharp delineation of the psoas muscle border)
  • Pneumoperitoneum (air under the diaphragm)
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Laboratory tests Urgent bloods are needed. WCC and CRP are commonly raised ⬆️.

🧰 Management

  • Broad spectrum antibiotics
  • NBM
  • NG tube potentially
  • IV fluids
  • Analgesia
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This is the general initial approach, but after this the management will depend on the diagnosis and cause of perforation. Most patients will require surgical intervention which requires identification, thorough washout and appropriate management.

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Let’s look at some examples for surgical techniques.
  • Peptic ulcer perforation - upper midline incision with patch of omentum (Graham patch) over the ulcer.
  • Small bowel perforation - midline laparotomy. The perforation can be oversewn but often resection with anastomosis/stoma formation is needed.
  • Large bowel perforation - midline laparotomy. Resection with stoma is preferred.
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Some patients may be managed conservatively (antibiotics + percutaneous drainage):

  1. Localised diverticular perforations (<5cm)
  2. Sealed upper GI perforation without generalised perotinism
  3. Elderly frail patients who are unlikely to survive surgery