Viscus Perforation

Question 1

Where can viscus / GI perforation occur?

Answer 1

Any anatomical location from: upper oesophagus to Anorectal junction

Question 2

How can viscus perforation lead to peritonitis?

Answer 2

Leakage of enteric contents –> peritoneal cavity

Question 3

What are the causes of viscus perforation? (7 things)

Answer 3

1. PUD (most commonly duodenal ulcer)
2. Infection (diverticulitis / appendicitis / cholecystitis)
3. Diverticulosis (reduces bowel wall integrity)
4. Bowel ischaemia
5. Bowel obstruction
6. Trauma (iatrogenic)
7. Foreign bodies

Question 4

What are the clinical features of viscus perforation from the History? (2 things)

Answer 4

1. Abdominal pain (sudden, sharp)

2. Systemic symptoms: vomiting / lethargy

Question 5

What are the vital signs saying for a patient with viscus perforation? (5 things)

Answer 5

Early

1. Fever
2. Tachycardia
3. Tachypnoea

Late

4. Hypotension
5. Shock

Question 6

What are the clinical signs on Abdominal examination of a patient with viscus perforation? (6 things)

Answer 6

Early
1. Tenderness @ perforated area

Late = peritoneal signs

1. Patient lying still
2. Abdominal tenderness / rigidity
3. Rebound + guarding
4. Decreased bowel sounds
5. Lower abdominal pain
6. Shoulder pain

Question 7

Why is their lower abdominal pain in a patient with viscus perforation?

Answer 7

Fluid from stomach / biliary ducts drains down paracolic gutters –> lower quadrants –> localised irritation

Question 8

Why is their shoulder pain in a patient with viscus perforation?

Answer 8

Referred bc phrenic nerve irritation

Question 9

What other differentials present similar to viscus perforation? (4 things)

Answer 9

1. MI
2. Ruptured AAA
3. Acute Pancreatitis
4. Tubo-ovarian pathology

Question 10

What lab tests should be done for suspected viscus perforation?

Answer 10

1. FBC (raised WCC)
2. CRP (raised)
3. G&S (routine for acute abdomen)
4. Lactic acid (raised)
5. Amylase (mildly raised)
6. Urinalysis (to exclude renal / tubo-ovarian pathology)

Question 11

What do raised lactic acid levels indicate? (2 things)

Answer 11

1. Decreased blood flow

2. Possible infection

Question 12

How do you confirm a viscus perforation diagnosis with imaging?

Answer 12

Air outside GI tract

Question 13

What is the gold standard imaging for viscus perforation?

Why? (3 things)

Answer 13

CT scan

1. Confirms presence of air
2. Suggests location of perforation
3. Suggests possible underlying cause

Question 14

How do you manage a patient with viscus perforation? (8 things)

Answer 14

1. ABCDE
2. Analgesia
3. Broad spec abx
4. NBM
5. NG tube
6. IV Fluids (resus)
7. Blood products (@ haemodynamic instab.)
8. EARLY SURGERY

Question 15

What are the surgical methods of managing a viscus perforation? (4 things)

Answer 15

1. Early identification (exploratory laparotomy)
2. Graham Patch (piece of omentum used to cover perforation)
   OR
3. Resecting perforated diverticulae (Hartmann’s Procedure)
4. Thorough washout

Question 16

Which patients with a viscus perforation can be managed just conservatively? (3 things)

Answer 16

1. LOCALISED diverticular perforation w only LOCALISED peritonitis + tenderness + NO evidence of GENERALISED contamination @ CT
2. SEALED upper GI perforation @ CT w NO GENERALISED peritonism
3. ELDERLY frail w beh CO-MORBIDITIES who wont survive surgery

Question 17

What are the complications of viscus perforation? (2 things)

Answer 17

1. Infections (peritonitis / sepsis)

2. Haemorrhage