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Acute Perforation of the Gastrointestinal Tract

By

Parswa Ansari

, MD, Hofstra Northwell-Lenox Hill Hospital, New York

Last full review/revision Apr 2020| Content last modified Apr 2020
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Any part of the gastrointestinal 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 of Acute Perforation of the GI Tract

Symptoms and Signs of Acute Perforation of the GI Tract

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 Peritonitis Abdominal pain is common and often inconsequential. Acute and severe abdominal pain, however, is almost always a symptom of intra-abdominal disease. It may be the sole indicator of the need... read more . Pain may radiate to the shoulder.

Perforation at other gastrointestinal 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 of Acute Perforation of the GI Tract

  • 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 of Acute Perforation of the GI Tract

  • 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.

A nasogastric tube 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. Broad-spectrum IV antibiotics effective against intestinal flora should be given.

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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