CT scan abdomen is the gold standard and more sensitive than plain films so should be considered where there is a suspected perforation
- Perforation of gas and bacteria-containing GI tract at any point from the upper oesophagus to the anus
- Gas will rise and be seen trapped under the diaphragm in erect CXR
- Perforation of gas containing GI tract at any point from the upper oesophagus to the anus
- It should be a diagnosis considered in all patients with an acute abdomen.
- Bowel contains air and faecalent materials
- Free air means overwhelming bacterial peritonitis and sepsis
- Oesophagus: Ingested chemical or physical substance causing perforation, oesophageal biopsy or dilation, severe vomiting (Boerhaave Syndrome), oesophageal tumour, Perforating chest trauma
- Gastric: Ulcer disease and chemical erosion. Perforating abdominal trauma
- Small bowel: ischaemic and erosion, Fistula formation (e.g. Crohn's Disease), Perforating abdominal trauma
- Large bowel: Fistula formation (e.g. Crohn's Disease), Toxic Megacolon (e.g. Clostridioides difficile or Ulcerative Colitis), Procedure - polypectomy, Perforating abdominal trauma
- Generalised abdominal pain.
- Rigid abdomen, lack of bowel sounds
- Fever, hypotension, tachycardia
- Acute pancreatitis
- Myocardial infarction
- Tubo-ovarian pathology
- Ruptured aortic aneurysm.
- FBC, U&E, LFTs, Amylase: raised WCC/CRP
- CXR/AXR: Free air under diaphragm. Rigler sign air on both sides of the bowel wall can be seen, due to free intra-abdominal air acting as an additional contrast. Psoas sign loss of the sharp delineation of the psoas muscle border, secondary to fluid in the retroperitoneum.
- A contrast swallow is also useful for confirming any suspected oesophageal perforation.
- CT scan abdomen is the gold standard
- ABC, Resuscitation, IV fluids, Antibiotics, Analgesia
- Surgical repair or resection of the mucosal defect as needed - in somewhere the patient is well and perforation contained then conservative care may be appropriate