(A&E) (Surgery)

Overview

• Perforation of the wall of the GI tract with spillage of bowel contents

Causes:

• Large Bowel → diverticulitis, colorectal cancer, appendicitis
• Gastroduodenal → perforated duodenal or gastric ulcer
• Small Bowel (Rare) → trauma, infection (TB), crohn's disease
• Oesophagus → boerhaave's perforation (rupture of the oesophagus following forceful vomiting)
  • Boerhaave’s Perforation ⇒ spontaneous full thickness rupture of the oesophagus that occurs as a result of repeated episodes of vomiting and long-standing alcohol use. Sudden onset severe chest pain and subcutaneous emphysema (may have signs suggestive of pneumonia). Diagnosis via CT contrast swallow (avoid OGD due to risk of worsenening perforation). Severe sepsis may occur secondary to mediastinitis.
  • Mallory-Weiss Tear vs Boerhaave’s ⇒ boeerhaave’s is more severe and will cause distorted observations and may have abnormal CXR. Mallory-weiss is longitudinal mucous membrane tear (limited to mucosa and submucosa) at GOJ and causes haematemesis, Boerhaave’s is transmural rupture in distal 1/3 of oesophagus.

Making Diagnosis

Clinical Features:

Depends on cause

• Large Bowel → peritonitic abdominal pain (rule out ruptured AAA)
• Gastroduodenal → sudden onset severe epigastric pain (worse on movement. Pain becomes generalised.
• Oesophageal → severe pain following an episode of violent vomiting. Neck/chest pain and dysphagia develop soon after

Patients will be very unwell → signs of shock, pyrexia, pallor, dehydration & have signs of peritonitis (guarding, rigidity, rebound tenderness)