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 Table 4: Acute Abdomen and Surgical Gastroenterology: 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. Foreign bodies inserted via the anus may perforate the rectum.

Table 4
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Some Causes of GI Tract Perforation Perforation Site Cause Comments All sites Trauma ― Foreign bodies ― Esophagus Forceful vomiting Termed Boerhaave's 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's diverticulitis Free air rarely visible on x-rays Colon Obstruction Typically perforates at cecum High risk: Colon > 13 cm diameter, patients receiving prednisoneSome Trade Names DELTASONE Click for Drug Monograph or other immunosuppressants (symptoms and signs may be minimal in this group) Diverticulitis ― Inflammatory bowel disease (ulcerative colitis, Crohn's disease) ― Toxic megacolon ― Sometimes spontaneous ― Gallbladder Iatrogenic injury during cholecystectomy or liver biopsy Usually biliary tree Rarely, acute cholecystitis Usually walled off by omentum Some Causes of GI Tract Perforation Perforation Site Cause Comments All sites Trauma ― Foreign bodies ― Esophagus Forceful vomiting Termed Boerhaave's 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's diverticulitis Free air rarely visible on x-rays Colon Obstruction Typically perforates at cecum High risk: Colon > 13 cm diameter, patients receiving prednisoneSome Trade Names DELTASONE Click for Drug Monograph or other immunosuppressants (symptoms and signs may be minimal in this group) Diverticulitis ― Inflammatory bowel disease (ulcerative colitis, Crohn's disease) ― Toxic megacolon ― Sometimes spontaneous ― Gallbladder Iatrogenic injury during cholecystectomy or liver biopsy Usually biliary tree 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. 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.

Free Air

CT With Free Peritoneal Air

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, cefotetanSome Trade Names
CEFOTAN
Click for Drug Monograph
1 to 2 g bid, or amikacinSome Trade Names
AMIKIN
Click for Drug Monograph
5 mg/kg tid plus clindamycinSome Trade Names
CLEOCIN
Click for Drug Monograph
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.

Last full review/revision August 2012 by Parswa Ansari, MD

Content last modified November 2012