GI Perforation - Edubirdie

University:
Western Sydney University
Course:
MEDI 2003 | Clinical Sciences 2
Academic year:

2024
Views:

204

Pages:

7
Author:

Mariam A. A.

GI Perforation Causes Upper GI Lower GI Any Part of GIT Diverticulitis Peptic ulcer Most common cause in high income countries Overall, most common cause Colorectal cancer Gastric cancer Appendicitis Oesophageal cancer Meckel’s diverticulum Foreign body ingestion Foreign body insertion Excessive vomit (Boerhaave syndrome) Severe colitis E.g. Crohn’s disease Toxic megacolon Clinical Features Abdominal pain Rapid onset and severe Systemically unwell Malaise Vomit Lethargy Vary based on cause Examination Appear unwell Decreased bowel sounds Loss of liver dullness of RUQ on percussion Features of sepsis Iatrogenic E.g. during gastroscopy or colonoscopy Trauma Mesenteric ischemia Bowel ischemia Obstructing lesions E.g. cancer, faeces -> bowel obstruction Fever Tachycardia Confusion/drowsiness Decrease in urine output Features of peritonism Most common and most severe presentation May be localised or generalised Rigid abdomen Tenderness of percussion Guarding Investigations Lab: Blood tests FBC U&E -> features of AKI LFTs CRP Clotting factors -> coagulopathies Group and hold Blood culture Inflammatory markers WCC, ESR and CRP CT with IV Gold standard and first line Most sensitive Identification of location and cause If upper GI -> with oral contrast Finding: Pneumoperitoneum If bowel -> thickened bowel walls Localised inflammation -> fat stranding, abscess, phlegmon Fluid collection ABX and CXR Pneumoperitoneum Rigler’s sign Both sides of the bowel are visible Psoas sign Loss of sharp delineation of the psoas muscle Ultrasound This and plain films are only done if the patients are too unstable to undergo a CT scan Management Urgent surgical consult Determine if conservative management or surgical management is needed Bowel rest -> NPO Two large cannulas IV lines IV broad spectrum antibiotics Patients with signs of shock or sepsis Aggressive IV resus Urgent critical care consult Analgesics Opioids or NSAIDs Opioids are contraindicated in patients with suspected bowel obstruction perforation Antiemetics E.g. ondansetron NGT With continuous or intermittent suction If suspected perforated peptic ulcer IV PPI Serial abdominal examination When doing only conservative management: If there are clinical signs of improvement : Obtain an abdominal x-ray with water-soluble contrast to confirm that the perforation has sealed. Urgent explorative laparotomy Indications For most patients with GI perforation Features of generalised peritonitis Signs of sepsis Obtain peritoneal fluid for cultures If feasible -> closure of perforation If appendicitis -> appendectomy If malignancy -> curative resection and biopsy and anastomosis Other causes -> manage accordingly -> consider resection of perforated segment and then anastomosis and formation of a stoma if needed Post operative care IV fluids and NGT with suction until bowel function returns Complications Delay in resuscitation and definitive surgery can rapidly progress into: Septic shock Multi organ dysfunction Death Peritonitis Most common and severe complication Subhepatic abscess Pyogenic liver abscess Postoperative complications Intraabdominal adhesions