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Acute Perforation

by Parswa Ansari, MD

Any part of the GI tract may become perforated, releasing gastric or intestinal contents into the peritoneal space. Causes vary. Symptoms develop suddenly, with severe pain followed shortly by signs of shock. Diagnosis is usually made by the presence of free air in the abdomen on imaging studies. Treatment is with fluid resuscitation, antibiotics, and surgery. Mortality is high, varying with the underlying disorder and the patient’s general health.

Etiology

Both blunt and penetrating trauma can result in perforation of any part of the GI tract (see Some Causes of GI Tract Perforation). Swallowed foreign bodies, even sharp ones, rarely cause perforation unless they become impacted, causing ischemia and necrosis from local pressure (see Foreign Bodies in the GI Tract). Foreign bodies inserted via the anus may perforate the rectum or sigmoid colon.

Some Causes of GI Tract Perforation

Perforation Site

Cause

Comments

All sites

Trauma

Foreign bodies

Esophagus

Forceful vomiting

Termed Boerhaave syndrome

Iatrogenic causes

Typically perforation with an esophagoscope, balloon dilator, or bougie

Ingestion of corrosive material

Stomach or duodenum

Peptic ulcer disease

In about one third of patients, no previous history of ulcer symptoms

In about 20%, no free air visible on x-ray

Ingestion of corrosive material

Typically stomach

Intestine

Strangulating obstruction

Possibly acute appendicitis and Meckel diverticulitis

Free air rarely visible on x-rays

Colon

Obstruction

Typically perforates at cecum

High risk: Colon > 13 cm diameter, patients receiving prednisone or other immunosuppressants (symptoms and signs may be minimal in this group)

Diverticulitis

Inflammatory bowel disease (ulcerative colitis, Crohn disease)

Toxic megacolon

Sometimes spontaneous

Gallbladder

Iatrogenic injury during cholecystectomy or liver biopsy

Usually the biliary tree or duodenum is injured

Rarely, acute cholecystitis

Usually walled off by omentum

Symptoms and Signs

Esophageal, gastric, and duodenal perforation tends to manifest suddenly and catastrophically, with abrupt onset of acute abdomen with severe generalized abdominal pain, tenderness, and peritoneal signs (see Peritonitis). Pain may radiate to the shoulder.

Perforation at other GI sites often occurs in the setting of other painful, inflammatory conditions. Because such perforations are often small initially and frequently walled off by the omentum, pain often develops gradually and may be localized. Tenderness also is more focal. Such findings can make it difficult to distinguish perforation from worsening of the underlying disorder or lack of response to treatment.

In all types of perforation, nausea, vomiting, and anorexia are common. Bowel sounds are quiet to absent.

Diagnosis

  • Abdominal series

  • If nondiagnostic, abdominal CT

An abdominal series (supine and upright abdominal x-rays and chest x-rays) may be diagnostic, showing free air under the diaphragm in 50 to 75% of cases. As time passes, this sign becomes more common. A lateral chest x-ray is more sensitive for free air than a posteroanterior x-ray. If the abdominal series is nondiagnostic, abdominal CT usually with oral and IV and/or rectal contrast may be helpful. Barium should not be used if perforation is suspected.

Treatment

  • Surgery

  • IV fluids and antibiotics

If a perforation is noted, immediate surgery is necessary because mortality caused by peritonitis increases rapidly the longer treatment is delayed. If an abscess or an inflammatory mass has formed, the procedure may be limited to drainage of the abscess.

An NGT is sometimes inserted before operation. Patients with signs of volume depletion should have urine output monitored with a catheter. Fluid status is maintained by adequate IV fluid and electrolyte replacement. IV antibiotics effective against intestinal flora should be given (eg, cefotetan 1 to 2 g bid, or amikacin 5 mg/kg tid plus clindamycin 600 to 900 mg qid).

Key Points

  • Pain is sudden and followed quickly by signs of peritonitis and shock.

  • Imaging with plain x-rays and/or CT is done.

  • Surgical repair is necessary in conjunction with IV fluid resuscitation and antibiotics.

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Drugs Mentioned In This Article

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  • RAYOS
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  • CLEOCIN

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