- Commonly due to either perforated peptic ulcer or colon (cancer, diverticulitis, ischamia etc).
- Plain erect CXR is not always diagnostic, esp. if the abdomen is full of fluid. The patient must be sat up at 90-degrees for at least 10 mins before you do the CXR. If there is doubt CT is far more sensitive.
- Upper GI perforations (stomach, duodenum) are usually 'sterile', but cause chemical peritonitis
- Colonic perforations usually cause severe sepsis
- Any penetrating injury below the nipples can cause abdominal organ perforation
- Careful history is essential
- Penetrating injury or blunt trauma (RTA, seat belt injury etc) to the lower chest or abdomen
- Aspirin, NSAIDs, or steroid intake - elderly
- Alcohol & drugs - younger
- known history of PUD,Crohns, UC, Cancer etc
- Usually sharp & stabbing
- Localised pain - may be walled off by abdominal organs &/or omentum
- Generalised pain with free perforation (also board rigid abdomen, pal, sweaty etc)
- May be shocked due to sepsis - remember this presents differently in young and old patients
- Abdominal examination
- knees drawn up
- brusing, injuries etc
- listening to bowel sounds - probably little use
- Knowledge of abdominal anatomy is essential to formulating a sensible differential diagnosis
- Like many surgical emergencies this is mainly fluid balance in the first instance
- These patients are usually in agony from the chemical / bacterial peritonitis and require sensible doses of morphine. Use 10mg of Morphine in 10mls H2O and give in 3-4ml doses every 10-15 mins until comfortable if required.
- Large bore 14G (brown) venflon, 2 litres of crystalloid to be run in relatively quickly
- NG tube to empty stomach, catheter
- Blood for G+S, FBC, U&E, ABG, and blood cultures
- Erect CXR,
- Consider CT. USS can be very useful in experienced hands
- Peritoneal lavage in blunt trauma has a role, CT first though
- If fluid balance is a problem make arrangements to insert a central line to guide replacement
- Antibiotics are indicated - use local policies
- Laparotomy is usually indicated – inform theatre and anaesthetist
- Initial laparoscopy if experienced enough may prevent the need for laparotomy at al or at least target the incision
- If space is available and in appropriate circumstances the patient can be transferred pre-operatively to the HDU for optimisation.
- Don’t forget DVT prophylaxis
Potential Post-operative Complications
- more common in colonic perforation than upper GI perforation.
- prophylactic antibiotics will reduce wound infections.
- Partial - skin opens
- Total - full abdominal dehiscence
- Late - Incisional hernia
- Malnutrition, Sepsis, Uremia & renal failure, DM, Steroids & immunosuppresants, Obesity & poor surgical technique all contribute to wound dehiscence.
- Chest & other infections
- Abdominal abscess
- Multiorgan failure / septic shock
- Renal failure