GASTRO/GENSURG
PERFORATION
Prompt
Response
Intraperitoneal free air
Intraperitoneal free fluid
(L = fat stranding stomach , thick wall stomach, defect stomach, multiple gallstones)
Intraperitoneal free air
Intraperitoneal free fluid
(L = fat stranding stomach , thick wall stomach, defect stomach, multiple gallstones)
PromptDifferential cause for pneumoperitoneum
ResponsePerforated duodeal ulcer
Perforated peptic ulcer
Ruptured diverticulum
Perforated peptic ulcer
Ruptured diverticulum
PromptBedside imaging and how it alters management
ResponseErect CXR - Free gas under diaphragm - Urgent surgical referral + commencement of IV antibiotics, fluids, analgesia
Bedside U/S - AAA (but won’t see free fluid if retroperitoneal/contained rupture) - Maintain BP ~90 systolic, IV fluids, blood if needed, titrated analgesia
AXR - Free gas on lateral decubitus view, Rigler’s sign (free gas on both sides of bowel wall) - IV antibiotics, fluids, analgesia, Urgent surgical review.
Bedside U/S - AAA (but won’t see free fluid if retroperitoneal/contained rupture) - Maintain BP ~90 systolic, IV fluids, blood if needed, titrated analgesia
AXR - Free gas on lateral decubitus view, Rigler’s sign (free gas on both sides of bowel wall) - IV antibiotics, fluids, analgesia, Urgent surgical review.
PromptManagement of perforation
ResponseIV fluids aiming SBP >100, Reduction in HR (ideally to normal) and adequate perfusion
Analgesia - Morphine 2.5mg aliquots
IVantibiotics - Amp/gent/metro
Urgent surgical attendance for exploratory laparotomy +/- ICU postop
Analgesia - Morphine 2.5mg aliquots
IVantibiotics - Amp/gent/metro
Urgent surgical attendance for exploratory laparotomy +/- ICU postop