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
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
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
Continuing Management
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
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.
