Acute Perforation of the Gastrointestinal Tract

Both blunt and penetrating trauma can result in perforation of any part of the gastrointestinal tract (see table Some Causes of Gastrointestinal Tract Perforation 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 Overview of Foreign Bodies in the Gastrointestinal Tract A variety of foreign bodies may enter the gastrointestinal (GI) tract intentionally or accidentally. Many foreign bodies pass through the GI tract spontaneously, but some become impacted, causing... read more ). Foreign bodies inserted via the anus may perforate the rectum or sigmoid colon (see Rectal Foreign Bodies Rectal Foreign Bodies Rectal foreign bodies are usually objects that have been inserted into the rectum but also may have been swallowed. Sudden and excruciating pain during defecation can be caused by a foreign... read more ).

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.

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.

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.