Aetiology
- Diverticulitis (most common in higher-income countries)
- Peptic ulcer disease
- Gastrointestinal malignancy, mainly gastric or colorectal
- Iatrogenic, such as during routine endoscopy
- Trauma, either through penetrating or blunt mechanisms
- Foreign body (e.g. battery or caustic soda)
- Appendicitis or Meckel’s Diverticulitis
- Mesenteric ischaemia
-
Obstructing lesions (e.g. cancer, bezoar, or faeces/sterocoral)
- Results in bowel obstruction, with subsequent ischaemia and necrosis
-
Severe colitis, such as Crohn’s Disease
- Includes toxic megacolon from ClostridumDifficile or Ulcerative Colitis)
- Excessive vomiting (Boerhaave Syndrome), leading to oesophageal perforation.
- The main feature of gastrointestinal perforation is pain. Typically this is rapid onset and sharp in nature. Patients are systemically unwell and may also have associated malaise, vomiting, and lethargy.
- On examination, patients will look unwell and often have features of sepsis. They will have features of peritonism, which may be localised or generalized (a rigid abdomen); generalised peritonitis implies diffuse contamination of the abdomen and the patient will be very unwell.
- Laboratory Tests
- Any patient with an acute abdomen will require urgent blood tests, including FBC, U&Es, LFTs, CRP, clotting, and G&S.
- Raised WCC and CRP are common features, dependent on timing and degree of contamination, and amylase is often mildly elevated in perforation (although non-specific).
- Imaging
- The gold standard for Diagnosis of any perforation is with a CT scan (Fig. 2) confirming the presence of free air and suggesting a location of the perforation (as well as a possible underlying cause).
- Historically, both a plain film erect chest radiograph (eCXR) and abdominal radiograph (AXR) were used for Diagnosis, however are much less specific* compared to CT imaging. As such, in suspected cases, a CT scan should always be performed.
