Gastrointestinal perforation

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Gastrointestinal perforation
Other namesRuptured bowel, [1] gastrointestinal rupture
Free air2010.JPG
Free air under the right diaphragm from a perforated bowel.
Specialty Gastroenterology, emergency medicine
Symptoms Abdominal pain, tenderness [2]
Complications Sepsis, abscess [2]
Usual onsetSudden or more gradual [2]
Causes Trauma, following colonoscopy, bowel obstruction, colon cancer, diverticulitis, stomach ulcers, ischemic bowel, C. difficile infection [2]
Diagnostic method CT scan, plain X-ray [2]
Treatment Emergency surgery in the form of an exploratory laparotomy [2]
Medication Intravenous fluids, antibiotics [2]

Gastrointestinal perforation, also known as gastrointestinal rupture, [1] is a hole in the wall of the gastrointestinal tract. The gastrointestinal tract is composed of hollow digestive organs leading from the mouth to the anus. [3] Symptoms of gastrointestinal perforation commonly include severe abdominal pain, nausea, and vomiting. [2] Complications include a painful inflammation of the inner lining of the abdominal wall and sepsis.

Contents

Perforation may be caused by trauma, bowel obstruction, diverticulitis, stomach ulcers, cancer, or infection. [2] A CT scan is the preferred method of diagnosis; however, free air from a perforation can often be seen on plain X-ray. [2]

Perforation anywhere along the gastrointestinal tract typically requires emergency surgery in the form of an exploratory laparotomy. [2] This is usually carried out along with intravenous fluids and antibiotics. [2] Occasionally the hole can be sewn closed while other times a bowel resection is required. [2] Even with maximum treatment the risk of death can be as high as 50%. [2] A hole from a stomach ulcer occurs in about 1 per 10,000 people per year, while one from diverticulitis occurs in about 0.4 per 10,000 people per year. [1] [4]

Signs and symptoms

Gastrointestinal perforation results in sudden, severe abdominal pain at the site of perforation, which then spreads across the abdomen. [5] The pain is intensified by movement. Nausea, vomiting, hematemesis, and increased heart rate are common early symptoms. Later symptoms include fever and or chills. [6] On examination, the abdomen is rigid and tender. [1] After some time, the bowel stops moving, and the abdomen becomes silent and distended.

The symptoms of esophageal rupture may include sudden onset of chest pain.

Complications

A hole in the intestinal tracts allows intestinal contents to enter the abdominal cavity. [2] The entry of bacteria from the gastrointestinal tract into the abdomen results in peritonitis or in the formation of an abscess. [2]

Patients may develop sepsis, a life-threatening response to infection, which may appear as an increased heart rate, increased breathing rate, fever, and confusion. [2] This may progress to multi-level organ dysfunction, including acute respiratory and kidney failure. [5]

Posterior gastric wall perforation may lead to bleeding due to the involvement of gastroduodenal artery that lies behind the first part of the duodenum. [7] The death rate in this case is 20%. [7]

Causes

The gastrointestinal wall is composed of four layers surrounding a central lumen. 2402 Layers of the Gastrointestinal Tract.jpg
The gastrointestinal wall is composed of four layers surrounding a central lumen.

Gastrointestinal perforation is defined by a full-thickness injury to all layers of the gastrointestinal wall, resulting in a hole in the hollow GI tract (esophagus, stomach, small intestine, or large intestine). A hole can occur due to direct mechanical injury or progressive damage to the bowel wall due to various disease states.

Trauma or accidental perforations during medical procedures

Penetrating trauma such as from a knife or gunshot wound can puncture the bowel wall. Additionally, blunt trauma, such as in a motor vehicle accident may abruptly increase the pressure within the bowel, resulting in bowel rupture. Perforation can also be a very rare complication of certain medical procedures such as upper gastrointestinal endoscopy and colonoscopy. [8]

Infection or inflammatory disease

Appendicitis and diverticulitis are conditions in which a small, tubular area in bowel becomes inflamed and may burst. [9] A number of infections including C. difficile [10] infection can lead to full-thickness disruption of the bowel wall. In patients with inflammatory bowel disease, prolonged inflammation of the bowel wall can eventually result in perforation.

Bowel obstruction

Bowel obstruction is a blockage of the small or large intestine which prevents the normal movement of the products of digestion. [11] It may occur due to scar tissue after surgery, twisting of the bowel around itself, hernias, or gastrointestinal tumors. Reduced forward movement of bowel contents results in a build up of pressure within the part of the bowel just before the site of obstruction. This increased pressure may prevent blood flow from reaching the bowel wall, resulting in bowel ischemia (lack of blood flow), necrosis, and eventually perforation. [5]

Eating multiple magnets can also lead to perforation if the magnets attract and stick to one another through different loops of the intestine. [12]

Erosion

A peptic ulcer is a defect in the inner lining of the stomach or duodenum typically due to excessive stomach acid. Extension of the ulcer through the lining of the digestive tract results in spillage of the stomach or intestinal contents into the abdominal cavity, leading to an acute chemical peritonitis. [13] [14] Helicobacter pylori infection and overuse of non-steroidal anti-inflammatory drugs [15] [16] may contribute to formation of peptic ulcers. Ingestion of corrosives [17] can lead to esophageal perforation.

Indirect causes

An often overlooked indirect cause of obstruction leading to perforation is the chronic use of opioids, which can create severe constipation and damage to the colon, often termed stercoral perforation. [18]

Diagnosis

A hole in the gastrointestinal tract causes leakage of gas into the abdominal cavity. In intestinal perforation, gas may be visible under the diaphragm on chest x-ray while the patient is in an upright position. While x-ray is a fast and inexpensive to screen for perforation, an abdominal CT scan with contrast is more sensitive and specific for establishing a diagnosis as well as determining the underlying cause. [19] Both CT and x-ray may initially appear normal, in which case diagnosis can be made by open or laparoscopic exploration of the abdomen.

White blood cells and blood lactate levels may also be elevated, particularly in the case of advanced disease including peritonitis and sepsis. [20]

Differential diagnoses of gastrointestinal perforation includes other causes of an acute abdomen, including appendicitis, diverticulitis, ruptured ovarian cyst, or pancreatitis. [21]

Treatment

Surgical intervention is nearly always required in the form of open or laparoscopic exploration. The goals of surgery are to remove any dead tissue and close the hole in the gastrointestinal wall. Peritoneal wash is performed and a drain may be placed to control any fluid collections that may form. [22] A Graham patch may be used for duodenal perforations. [23]

Conservative treatment (avoiding surgery) may be sufficient in the case of a contained perforation. It is indicated only if the person has normal vital signs and is clinically stable. [21]

Regardless of whether surgery is performed, all patients are offered pain therapy and placed on bowel rest (avoiding all food and fluids by mouth), intravenous fluids, and antibiotics. [21] A number of different antibiotics may be used such as piperacillin/tazobactam or the combination of ciprofloxacin and metronidazole. [24] [25]

Related Research Articles

<span class="mw-page-title-main">Peritonitis</span> Medical condition

Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One part or the entire abdomen may be tender. Complications may include shock and acute respiratory distress syndrome.

<span class="mw-page-title-main">Bowel obstruction</span> Medical condition

Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel or large bowel may be affected. Signs and symptoms include abdominal pain, vomiting, bloating and not passing gas. Mechanical obstruction is the cause of about 5 to 15% of cases of severe abdominal pain of sudden onset requiring admission to hospital.

<span class="mw-page-title-main">Upper gastrointestinal series</span> Radiographs used to examine abnormalities of the digestive system excluding the colon

An upper gastrointestinal series, also called a barium swallow, barium study, or barium meal, is a series of radiographs used to examine the gastrointestinal tract for abnormalities. A contrast medium, usually a radiocontrast agent such as barium sulfate mixed with water, is ingested or instilled into the gastrointestinal tract, and X-rays are used to create radiographs of the regions of interest. The barium enhances the visibility of the relevant parts of the gastrointestinal tract by coating the inside wall of the tract and appearing white on the film. This in combination with other plain radiographs allows for the imaging of parts of the upper gastrointestinal tract such as the pharynx, larynx, esophagus, stomach, and small intestine such that the inside wall lining, size, shape, contour, and patency are visible to the examiner. With fluoroscopy, it is also possible to visualize the functional movement of examined organs such as swallowing, peristalsis, or sphincter closure. Depending on the organs to be examined, barium radiographs can be classified into "barium swallow", "barium meal", "barium follow-through", and "enteroclysis". To further enhance the quality of images, air or gas is sometimes introduced into the gastrointestinal tract in addition to barium, and this procedure is called double-contrast imaging. In this case the gas is referred to as the negative contrast medium. Traditionally the images produced with barium contrast are made with plain-film radiography, but computed tomography is also used in combination with barium contrast, in which case the procedure is called "CT enterography".

<span class="mw-page-title-main">Abdominal pain</span> Stomach aches

Abdominal pain, also known as a stomach ache, Is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given that, approaching the examination of a person and planning of a differential diagnosis is extremely important.

<span class="mw-page-title-main">Diverticulitis</span> Digestive disease of the large intestine

Diverticulitis, also called colonic diverticulitis, is a gastrointestinal disease characterized by inflammation of abnormal pouches—diverticula—that can develop in the wall of the large intestine. Symptoms typically include lower-abdominal pain of sudden onset, but the onset may also occur over a few days. There may also be nausea; and diarrhea or constipation. Fever or blood in the stool suggests a complication. Repeated attacks may occur.

<span class="mw-page-title-main">Diverticulosis</span> Condition of the wall of the intestine

Diverticulosis is the condition of having multiple pouches (diverticula) in the colon that are not inflamed. These are outpockets of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall. Diverticula do not cause symptoms in most people. Diverticular disease occurs when diverticula become clinically inflamed, a condition known as diverticulitis.

<span class="mw-page-title-main">Meckel's diverticulum</span> Medical condition

A Meckel's diverticulum, a true congenital diverticulum, is a slight bulge in the small intestine present at birth and a vestigial remnant of the vitelline duct. It is the most common malformation of the gastrointestinal tract and is present in approximately 2% of the population, with males more frequently experiencing symptoms.

<span class="mw-page-title-main">Gastrointestinal disease</span> Medical condition

Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum, and the accessory organs of digestion, the liver, gallbladder, and pancreas.

<span class="mw-page-title-main">Ileus</span> Medical condition

Ileus is a disruption of the normal propulsive ability of the intestine. It can be caused by lack of peristalsis or by mechanical obstruction. The word 'ileus' is from Ancient Greek eileós. The term 'subileus' refers to a partial obstruction.

<span class="mw-page-title-main">Percutaneous endoscopic gastrostomy</span> Feeding tube going into the stomach through the abdominal wall

Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate. This provides enteral nutrition despite bypassing the mouth; enteral nutrition is generally preferable to parenteral nutrition. The PEG procedure is an alternative to open surgical gastrostomy insertion, and does not require a general anesthetic; mild sedation is typically used. PEG tubes may also be extended into the small intestine by passing a jejunal extension tube through the PEG tube and into the jejunum via the pylorus.

Colic in horses is defined as abdominal pain, but it is a clinical symptom rather than a diagnosis. The term colic can encompass all forms of gastrointestinal conditions which cause pain as well as other causes of abdominal pain not involving the gastrointestinal tract. What makes it tricky is that different causes can manifest with similar signs of distress in the animal. Recognizing and understanding these signs is pivotal, as timely action can spell the difference between a brief moment of discomfort and a life-threatening situation. The most common forms of colic are gastrointestinal in nature and are most often related to colonic disturbance. There are a variety of different causes of colic, some of which can prove fatal without surgical intervention. Colic surgery is usually an expensive procedure as it is major abdominal surgery, often with intensive aftercare. Among domesticated horses, colic is the leading cause of premature death. The incidence of colic in the general horse population has been estimated between 4 and 10 percent over the course of the average lifespan. Clinical signs of colic generally require treatment by a veterinarian. The conditions that cause colic can become life-threatening in a short period of time.

<span class="mw-page-title-main">Volvulus</span> Twisting of part of the intestine, causing a bowel obstruction

A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. Onset of symptoms may be rapid or more gradual. The mesentery may become so tightly twisted that blood flow to part of the intestine is cut off, resulting in ischemic bowel. In this situation there may be fever or significant pain when the abdomen is touched.

<span class="mw-page-title-main">Pneumoperitoneum</span> Medical condition

Pneumoperitoneum is pneumatosis in the peritoneal cavity, a potential space within the abdominal cavity. The most common cause is a perforated abdominal organ, generally from a perforated peptic ulcer, although any part of the bowel may perforate from a benign ulcer, tumor or abdominal trauma. A perforated appendix seldom causes a pneumoperitoneum.

<span class="mw-page-title-main">Abdominal distension</span> Physical symptom

Abdominal distension occurs when substances, such as air (gas) or fluid, accumulate in the abdomen causing its expansion. It is typically a symptom of an underlying disease or dysfunction in the body, rather than an illness in its own right. People with this condition often describe it as "feeling bloated". Affected people often experience a sensation of fullness, abdominal pressure, and sometimes nausea, pain, or cramping. In the most extreme cases, upward pressure on the diaphragm and lungs can also cause shortness of breath. Through a variety of causes, bloating is most commonly due to buildup of gas in the stomach, small intestine, or colon. The pressure sensation is often relieved, or at least lessened, by belching or flatulence. Medications that settle gas in the stomach and intestines are also commonly used to treat the discomfort and lessen the abdominal distension.

Valentino's syndrome is pain presenting in the right lower quadrant of the abdomen caused by a duodenal ulcer with perforation through the retroperitoneum.

An acute abdomen refers to a sudden, severe abdominal pain. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need immediate surgical treatment.

<span class="mw-page-title-main">Bowel resection</span> Surgical procedure in which a part of an intestine is removed

A bowel resection or enterectomy is a surgical procedure in which a part of an intestine (bowel) is removed, from either the small intestine or large intestine. Often the word enterectomy is reserved for the sense of small bowel resection, in distinction from colectomy, which covers the sense of large bowel resection. Bowel resection may be performed to treat gastrointestinal cancer, bowel ischemia, necrosis, or obstruction due to scar tissue, volvulus, and hernias. Some patients require ileostomy or colostomy after this procedure as alternative means of excretion. Complications of the procedure may include anastomotic leak or dehiscence, hernias, or adhesions causing partial or complete bowel obstruction. Depending on which part and how much of the intestines are removed, there may be digestive and metabolic challenges afterward, such as short bowel syndrome.

<span class="mw-page-title-main">Epiploic appendagitis</span> Medical condition

Epiploic appendagitis (EA) is an uncommon, benign, self-limiting inflammatory process of the epiploic appendices. Other, older terms for the process include appendicitis epiploica and appendagitis, but these terms are used less now in order to avoid confusion with acute appendicitis.

Abdominal guarding is the tensing of the abdominal wall muscles to guard inflamed organs within the abdomen from the pain of pressure upon them. The tensing is detected when the abdominal wall is pressed. Abdominal guarding is also known as 'défense musculaire'.

<span class="mw-page-title-main">Abdominal x-ray</span>

An abdominal x-ray is an x-ray of the abdomen. It is sometimes abbreviated to AXR, or KUB.

References

  1. 1 2 3 4 Domino, Frank J.; Baldor, Robert A. (2013). The 5-Minute Clinical Consult 2014. Lippincott Williams & Wilkins. p. 1086. ISBN   9781451188509. Archived from the original on 17 August 2016. Retrieved 4 August 2016.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Langell, JT; Mulvihill, SJ (May 2008). "Gastrointestinal perforation and the acute abdomen". The Medical Clinics of North America. 92 (3): 599–625, viii–ix. doi:10.1016/j.mcna.2007.12.004. PMID   18387378.
  3. ↑ Langell, JT; Mulvihill, SJ (May 2008). "Gastrointestinal perforation and the acute abdomen". The Medical Clinics of North America. 92 (3): 599–625, viii–ix. doi:10.1016/j.mcna.2007.12.004. PMID   18387378.
  4. ↑ Yeo, Charles J.; McFadden, David W.; Pemberton, John H.; Peters, Jeffrey H.; Matthews, Jeffrey B. (2012). Shackelford's Surgery of the Alimentary Tract (7 ed.). Elsevier Health Sciences. p. 701. ISBN   978-1455738076. Archived from the original on 2016-08-17.
  5. 1 2 3 Mayumi, Toshihiko; Yoshida, Masahiro; Tazuma, Susumu; Furukawa, Akira; Nishii, Osamu; Shigematsu, Kunihiro; Azuhata, Takeo; Itakura, Atsuo; Kamei, Seiji; Kondo, Hiroshi; Maeda, Shigenobu; Mihara, Hiroshi; Mizooka, Masafumi; Nishidate, Toshihiko; Obara, Hideaki (January 2016). "Practice Guidelines for Primary Care of Acute Abdomen 2015". Journal of Hepato-Biliary-Pancreatic Sciences. 23 (1): 3–36. doi: 10.1002/jhbp.303 . ISSN   1868-6974.
  6. ↑ Ansari, Parswa. "Acute Perforation". Merck Manuals. Archived from the original on July 10, 2016. Retrieved June 30, 2016.
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  8. ↑ Lohsiriwat, Varut (2010). "Colonoscopic perforation: Incidence, risk factors, management and outcome". World Journal of Gastroenterology. 16 (4): 425. doi: 10.3748/wjg.v16.i4.425 . ISSN   1007-9327.
  9. ↑ "Definition & Facts for Appendicitis - NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 2023-11-15.
  10. ↑ Langell, JT; Mulvihill, SJ (May 2008). "Gastrointestinal perforation and the acute abdomen". The Medical Clinics of North America. 92 (3): 599–625, viii–ix. doi:10.1016/j.mcna.2007.12.004. PMID   18387378.
  11. ↑ Fitzgerald, J. Edward F. (2010-01-31), Brooks, Adam; Cotton, Bryan A.; Tai, Nigel; Mahoney, Peter F. (eds.), "Small Bowel Obstruction", Emergency Surgery (1 ed.), Wiley, pp. 74–79, doi:10.1002/9781444315172.ch14, ISBN   978-1-4051-7025-3 , retrieved 2023-11-15
  12. ↑ Lima, Mario (2016). Pediatric Digestive Surgery. Springer. p. 239. ISBN   9783319405254.
  13. ↑ Langell, John T.; Mulvihill, Sean J. (2008-05-01). "Gastrointestinal Perforation and the Acute Abdomen". Medical Clinics of North America. Common Gastrointestinal Emergencies. 92 (3): 599–625. doi:10.1016/j.mcna.2007.12.004. ISSN   0025-7125.
  14. ↑ Sigmon, David F.; Tuma, Faiz; Kamel, Bishoy G.; Cassaro, Sebastiano (2023), "Gastric Perforation", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   30137838 , retrieved 2023-11-15
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  16. ↑ Carlos Sostres; Carla J Gargallo; Angel Lanas (2013). "Nonsteroidal anti-inflammatory drugs and upper and lower gastrointestinal mucosal damage". Arthritis Res. Ther. 15 (Suppl 3): S3. doi: 10.1186/ar4175 . PMC   3890944 . PMID   24267289.
  17. ↑ Ramasamy, Kovil; Gumaste, Vivek V. (2003). "Corrosive Ingestion in Adults". Journal of Clinical Gastroenterology. 37 (2): 119–124. doi:10.1097/00004836-200308000-00005. PMID   12869880.
  18. ↑ Poitras, Renée; Warren, Daun’Lee; Oyogoa, Sylvanus (2018-01-01). "Opioid drugs and stercoral perforation of the colon: Case report and review of literature". International Journal of Surgery Case Reports. 42: 94–97. doi: 10.1016/j.ijscr.2017.11.060 . ISSN   2210-2612.
  19. ↑ Mayumi, Toshihiko; Yoshida, Masahiro; Tazuma, Susumu; Furukawa, Akira; Nishii, Osamu; Shigematsu, Kunihiro; Azuhata, Takeo; Itakura, Atsuo; Kamei, Seiji; Kondo, Hiroshi; Maeda, Shigenobu; Mihara, Hiroshi; Mizooka, Masafumi; Nishidate, Toshihiko; Obara, Hideaki (January 2016). "Practice Guidelines for Primary Care of Acute Abdomen 2015". Journal of Hepato-Biliary-Pancreatic Sciences. 23 (1): 3–36. doi: 10.1002/jhbp.303 . ISSN   1868-6974.
  20. ↑ Kruse, Ole; Grunnet, Niels; Barfod, Charlotte (December 2011). "Blood lactate as a predictor for in-hospital mortality in patients admitted acutely to hospital: a systematic review". Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 19 (1). doi: 10.1186/1757-7241-19-74 . ISSN   1757-7241.
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  22. ↑ Rustagi, T; McCarty, TR; Aslanian, HR (2015). "Endoscopic Treatment of Gastrointestinal Perforations, Leaks, and Fistulae". Journal of Clinical Gastroenterology. 49 (10): 804–9. doi:10.1097/mcg.0000000000000409. PMID   26325190. S2CID   38323381.
  23. ↑ "Gastrointestinal perforation Information | Mount Sinai - New York". Mount Sinai Health System. Retrieved 2023-11-03.
  24. ↑ Wong, PF; Gilliam, AD; Kumar, S; Shenfine, J; O'Dair, GN; Leaper, DJ (18 April 2005). "Antibiotic regimens for secondary peritonitis of gastrointestinal origin in adults". The Cochrane Database of Systematic Reviews (2): CD004539. doi:10.1002/14651858.CD004539.pub2. PMID   15846719.
  25. ↑ Wilson, William C.; Grande, Christopher M.; Hoyt, David B. (2007). Trauma: Resuscitation, Perioperative Management, and Critical Care. CRC Press. p. 882. ISBN   9781420015263. Archived from the original on 2016-08-17.
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