Page 164 - Medicine and Surgery

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160 Chapter 4: Gastrointestinal system

particularly on a full stomach or after large amounts of mediastinitis; subdiaphragmatic perforation causes
alcohol. peritonitis.

Clinical features
Investigations
Patients present with haematemesis which is usually
CXR may reveal air in the mediastinum or soft tissues
small. The bleeding typically occurs after a number of
(surgical emphysema).
retches, i.e. not on the first vomit.
Investigations Management
Young patients with a typical history do not require in- Small perforations occurring in the neck are managed
vestigation. Other patients with an upper gastrointesti- with broad-spectrum antibiotics and nasogastric tube.
nalbleedrequireendoscopytoconfirmthediagnosisand Large thoracic perforations are repaired with a gastric
exclude oesophageal varices (see page 199). fundus patch. Oesophageal perforation secondary to
malignancy at or above the lower oesophageal sphincter
Management can be treated with a covered metal stent placed endo-
Almostallstopspontaneously.Continuingbleedingsug- scopically.
gests other causes.

Oesophageal perforation Disorders of the stomach

Definition
Perforation of the oesophagus resulting in leakage of the Gastritis
contents.
Gastritis is inflammation of the gastric mucosa, which
Aetiology can be considered as acute or chronic and by the under-
Arare complication of endoscopy, foreign bodies and lying pathology (see Fig. 4.6).
trauma. Occasionally a rupture following forceful vom- Thereislittlecorrelationbetweenthedegreeofinflam-
iting may occur (Boerhaave’s syndrome). mation and symptomatology. Patients may complain of
epigastric burning pain and occasionally vomiting. En-
Pathophysiology doscopy can be performed to confirm the diagnosis but
Perforationusuallyoccursatthepharyngeo-oesophageal is rarely indicated in acute gastritis.
junction. It results in release of secretions into the me-
diastinum.
Acute erosive gastritis

Clinical features Definition
Presentations include surgical emphysema of the neck; Superficial ulcers and erosions of the gastric mucosa de-
intense retrosternal pain, tachycardia and fever in velop after major surgery, trauma or severe illness.

Gastritis

Acute Chronic

Acute gastritis Acute erosive Autoimmune Bacterial Reflux
Ingested Atrophic gastritis
e.g. Shock, stress, Helicobacter Reflux of
chemicals e.g. (pernicious
NSAIDs, alcohol acute burns anaemia) pylori duodenal alkali
Figure 4.6 Causes of gastritis.