(See also Acute Abdominal Pain.)
Etiology
Both blunt and penetrating trauma can result in perforation of any part of the gastrointestinal tract (see table Some Causes of Gastrointestinal Tract Perforation). Swallowed foreign bodies, even sharp ones, rarely cause perforation unless they become impacted, causing ischemia and necrosis from local pressure (see Overview of Foreign Bodies in the Gastrointestinal Tract). Foreign bodies inserted via the anus may perforate the rectum or sigmoid colon (see Rectal Foreign Bodies).
Some Causes of Gastrointestinal Tract Perforation
Perforation Site |
Cause |
Comments |
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All sites |
Trauma |
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Esophagus |
Forceful vomiting |
Termed Boerhaave syndrome |
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Iatrogenic causes |
Typically perforation with an esophagoscope, balloon dilator, or bougie |
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Ingestion of corrosive material |
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Stomach or duodenum |
In about one third of patients, no previous history of ulcer symptoms In about 20%, no free air visible on x-ray |
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Ingestion of corrosive material |
Typically stomach |
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Intestine |
― |
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Possibly acute appendicitis and Meckel diverticulitis |
Free air rarely visible on x-rays |
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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) |
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Sometimes spontaneous |
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Gallbladder |
Iatrogenic injury during cholecystectomy or liver biopsy |
Usually the biliary tree or duodenum is injured |
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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 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
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
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
Drugs Mentioned In This Article
| Drug Name | Select Trade |
|---|---|
prednisone |
RAYOS |
