Perforation

Question 1

what are some of the causes of perforation?

Answer 1

Chemical :

• peptic ulcer perforation
• foreign body e.g battery)

infection:

• diverticulitis
• Meckel’s diverticulum
• cholecystitis

Ischaemia:

• mesenteric ischaemia
• obstructing lesion
• cancer

Colitis: toxic megacolon

trauma:

• Boerhaave
• iatrogenic (endoscopy/ recent surgery/NG tube)

Question 2

how do patients present in bowel perforation?

Answer 2

these patients will present with signs of peritonism.

• sharp pain with rapid onset
• systemically unwell

If widespread/ generalised:

• patients lie completely still ‘board-like rigidity’
• tachycardia (potentially drop with bp)
• percussion tenderness
• involuntary guarding
• recent/absent bowel sounds

Question 3

what investigations are performed?

Answer 3

lab tests:
bloods: FBC, LFTS, U&Es, CRP, amylase, group and save
typically find raised WBC and CRP
urinalysis –> for renal colic

Imaging:

• CXR (pneumoperitoneum or rigler’s sign)
• CT abdopelvis –> location of perforation

Question 4

how do patients present with thoracic perforation?

Answer 4

• present with chest/neck pain radiating to the back.
• may also have associated vomiting and resp symptoms

*refer to oesophageal tears

Question 5

how are patients with bowel perforation managed?

Answer 5

• resuscitation
• broad-spectrum Abx
• NBM and NG tube considered
• IV fluids and pain relief

surgical intervention: highly dependant on patient

Question 6

when is surgery not performed in perforation?

Answer 6

• frail elderly patients who wouldn’t be able to survive the surgery
• perforated diverticulitis with small local abscess (local peritonitis and tenderness) and no sign of generalised contamination
• sealed upper GI perforation without generalised peritonism