GI Perforation

Question 1

What are the causes of upper GI tract perforation?

Answer 1

• Oesophageal or gastric malignancies
• Peptic ulcer disease
• Boerhaave syndrome
• Ingestion of sharp or caustic materials
• Iatrogenic causes (e.g. during surgery or endoscopy)

Boerhaave syndrome refers to oesophageal rupture secondary to forceful vomiting.

Question 2

What are the causes of lower GI tract perforation?

Answer 2

• Diverticulitis
• Colorectal cancer
• Bowel obstruction
• Colitis (e.g. inflammatory bowel disease)
• Appendicitis
• Infection (e.g. toxic megacolon secondary to C. difficile infection)
• Iatrogenic causes (e.g. abdominal surgery or colonoscopy)
• Mesenteric ischaemia
• Invasion of the bowel by other tumours

Lower GI perforations can be caused by various conditions, including infections and malignancies.

Question 3

What are the common symptoms of gastrointestinal perforation?

Answer 3

• Abdominal pain (sudden and severe)
• Nausea and vomiting
• Malaise
• Lethargy

Symptoms can vary, but severe abdominal pain is a key indicator of perforation.

Question 4

What are the signs of gastrointestinal perforation on examination?

Answer 4

• Peritonism (guarding, rebound tenderness, rigidity)
• Hypotension
• Tachycardia
• Tachypnoea
• Fevers

These signs indicate irritation of the peritoneum and possible systemic infection.

Question 5

What bedside tests are used to assess gastrointestinal perforation?

Answer 5

• Blood gas to measure lactate and acid-base status
• Pregnancy test in women of childbearing age

These tests help identify underlying issues related to perforation and rule out other causes of abdominal pain.

Question 6

What blood tests are relevant for gastrointestinal perforation?

Answer 6

• FBC and CRP for inflammatory markers
• LFTs and U&Es which may be deranged in sepsis
• Clotting screen and group and saves for possible surgery
• Blood cultures if febrile or signs of infection

Blood tests are crucial for assessing the patient’s condition and preparing for potential surgical intervention.

Question 7

What imaging techniques are used to confirm gastrointestinal perforation?

Answer 7

• CT with contrast for free air and site of perforation
• Chest X-ray for air under diaphragm (pneumoperitoneum)
• Abdominal X-ray for Rigler’s sign

CT is the most sensitive test for confirming perforation and identifying the cause.

Question 8

What conservative management strategies are used for gastrointestinal perforation?

Answer 8

• Make the patient nil by mouth
• Urgent surgical review
• Consider nasogastric tube insertion if severe vomiting
• May require critical care input

Conservative management aims to stabilize the patient before surgical intervention.

Question 9

What medical management is provided for gastrointestinal perforation?

Answer 9

• Start IV broad spectrum antibiotics
• IV fluid resuscitation as required
• Provide analgesia and antiemetics
• Consider medical treatment for localized diverticular perforation in well patients

Medical management may suffice in certain cases, particularly when the patient is stable.

Question 10

What surgical management is typically required for gastrointestinal perforation?

Answer 10

• Most cases require laparotomy
• Involves thorough washout, identifying cause, and repairing defect
• Bowel resection and temporary stoma formation for bowel perforation

Surgical intervention is often critical to prevent complications and promote recovery.

Question 11

What is a classic presentation of bowe perforation?

Answer 11

Acute severe abdominal pain with shoulder radiation due to diaphragm irritation from perforation

Question 12

How to definitively manage bleeding from peptic ulcer?

Answer 12

Endoscopic clipping, with thermal coagulation, fibrin or thrombin

Question 13

What should not be offered prior to endoscopy?

Answer 13

Drugs for acid suppression should not be offered prior to endoscopy in patients where non-variceal bleed is suspected

Question 14

What to give for patients who re-bleed with non variceal bleed aafter intial endoscopic clipping?

Answer 14

Percutaneous angiography with embolisation

Question 15

How to definitively manage oesophageal variceal bleeds?

Answer 15

Band ligation

Question 16

How to definitively manage gastric variceal bleeds?

Answer 16

N-butyl-2-cyanoacrylate injections (sclerotherapy

Question 17

What to give for patients who re-bleed with variceal bleed aafter intial therapy?

Answer 17

Sengstaken-Blakemore tube insertion (a bridging therapy) or a transjugular intrahepatic portosystemic shunt

Question 18

Which infective agent csuses constipation with GI perforation?

Answer 18

Salmonella typhi can cause necrosis of Peyer’s patches in the distal ileum, leading to intestinal perforation and peritonitis

The main symptoms of typhoid fever include: fever, headache, constipation, cough, fatigue and myalgi

Question 19

What investigation must be done before definitve management for acute epigastric pain with peptic ulcer risk?

Answer 19

an erect chest X-ray is the best initial step to detect pneumoperitoneum before definitive management