Overview

• 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

Clinical Features

• 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
• Abdominal pain
  • 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)
• Vomiting
• May be shocked due to sepsis - remember this presents differently in young and old patients
• Abdominal examination
• board rigid
  • 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

Initial Management

1. Like many surgical emergencies this is mainly fluid balance in the first instance
2. 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.
3. Large bore 14G (brown) venflon, 2 litres of crystalloid to be run in relatively quickly
4. NG tube to empty stomach, catheter
5. Blood for G+S, FBC, U&E, ABG, and blood cultures
6. Erect CXR,
7. Consider CT. USS can be very useful in experienced hands
8. Peritoneal lavage in blunt trauma has a role, CT first though
9. If fluid balance is a problem make arrangements to insert a central line to guide replacement
10. Antibiotics are indicated - use local policies

Continuing Management

1. Laparotomy is usually indicated – inform theatre and anaesthetist
2. Initial laparoscopy if experienced enough may prevent the need for laparotomy at al or at least target the incision
3. If space is available and in appropriate circumstances the patient can be transferred pre-operatively to the HDU for optimisation.
4. Don’t forget DVT prophylaxis

Potential Post-operative Complications

• Wound infection
  • more common in colonic perforation than upper GI perforation.
  • prophylactic antibiotics will reduce wound infections.
• Wound dehiscence
  • 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