| Gastrointestinal perforation | |
|---|---|
| Other names | Ruptured bowel,[1] gastrointestinal rupture |
 | |
| Free air under the rightdiaphragm from a perforated bowel. | |
| Specialty | Gastroenterology,emergency medicine |
| Symptoms | Abdominal pain, tenderness[2] |
| Complications | Sepsis,abscess[2] |
| Usual onset | Sudden or more gradual[2] |
| Causes | Trauma, followingcolonoscopy,bowel obstruction,colon cancer,diverticulitis,stomach ulcers,ischemic bowel,C. difficile infection[2] |
| Diagnostic method | CT scan,plain X-ray[2] |
| Treatment | Emergency surgery in the form of anexploratory laparotomy[2] |
| Medication | Intravenous fluids,antibiotics[2] |
Gastrointestinal perforation, also known asgastrointestinal rupture,[1] is a hole in thewall of the gastrointestinal tract. The gastrointestinal tract is composed of hollow digestive organs leading from themouth to theanus.[3] Symptoms of gastrointestinal perforation commonly include severeabdominal pain,nausea, andvomiting.[2] Complications include a painfulinflammation of the inner lining of the abdominal wall andsepsis.
Perforation may be caused bytrauma,bowel obstruction,diverticulitis,stomach ulcers, cancer, or infection.[2] ACT scan is the preferred method of diagnosis; however, free air from a perforation can often be seen onplain X-ray.[2]
Perforation anywhere along the gastrointestinal tract typically requiresemergency surgery in the form of anexploratory laparotomy.[2] This is usually carried out along withintravenous fluids andantibiotics.[2] Occasionally the hole can besewn closed while other times abowel resection is required.[2] Even with maximum treatment the risk of death can be as high as 50%.[2] A hole from astomach ulcer occurs in about 1 per 10,000 people per year, while one from diverticulitis occurs in about 0.4 per 10,000 people per year.[1][4]
Gastrointestinal perforation results in sudden, severeabdominal pain at the site of perforation, which then spreads across the abdomen.[5] The pain is intensified by movement.Nausea,vomiting,hematemesis, and increased heart rate are common early symptoms. Later symptoms includefever and or chills.[6] On examination, the abdomen is rigid and tender.[1] After some time, the bowel stops moving, and the abdomen becomes silent and distended.
The symptoms ofesophageal rupture may include sudden onset of chest pain.
A hole in the intestinal tracts allows intestinal contents to enter theabdominal cavity.[2] The entry ofbacteria from the gastrointestinal tract into the abdomen results inperitonitis or in the formation of anabscess.[2]
Patients may developsepsis, a life-threatening response to infection, which may appear as anincreased heart rate, increased breathing rate, fever, andconfusion.[2] This may progress to multi-level organ dysfunction, including acuterespiratory andkidney failure.[5]
Posterior gastric wall perforation may lead to bleeding due to the involvement ofgastroduodenal artery that lies behind the first part of the duodenum.[7] The death rate in this case is 20%.[7]
Gastrointestinal perforation is defined by a full-thickness injury to all layers of thegastrointestinal wall, resulting in a hole in the hollowGI tract (esophagus,stomach,small intestine, orlarge intestine). A hole can occur due to direct mechanical injury or progressive damage to the bowel wall due to various disease states.
Penetrating trauma such as from a knife or gunshot wound can puncture the bowel wall. Additionally,blunt trauma, such as in a motor vehicle accident may abruptly increase the pressure within the bowel, resulting in bowel rupture. Perforation can also be a very rare complication of certain medical procedures such as upper gastrointestinalendoscopy andcolonoscopy.[8]
Appendicitis anddiverticulitis are conditions in which a small, tubular area in bowel becomes inflamed and may burst.[9] A number of infections includingC. difficile[10] infection can lead to full-thickness disruption of the bowel wall. In patients withinflammatory bowel disease, prolonged inflammation of the bowel wall can eventually result in perforation.
Bowel obstruction is a blockage of the small or large intestine which prevents the normal movement of the products ofdigestion.[11] It may occur due toscar tissue after surgery,twisting of the bowel around itself,hernias, orgastrointestinal tumors. Reduced forward movement of bowel contents results in a build up of pressure within the part of the bowel just before the site of obstruction. This increased pressure may prevent blood flow from reaching the bowel wall, resulting in bowelischemia (lack of blood flow),necrosis, and eventually perforation.[5]
Eating multiplemagnets can also lead to perforation if the magnets attract and stick to one another through different loops of the intestine.[12]
Apeptic ulcer is a defect in the inner lining of thestomach orduodenum typically due to excessivestomach acid. Extension of the ulcer through the lining of the digestive tract results in spillage of the stomach or intestinal contents into the abdominal cavity, leading to an acutechemical peritonitis.[13][14]Helicobacter pylori infection and overuse ofnon-steroidal anti-inflammatory drugs[15][16] may contribute to formation of peptic ulcers.Ingestion ofcorrosives[17] can lead to esophageal perforation.
An often overlooked indirect cause of obstruction leading to perforation is the chronic use ofopioids, which can create severe constipation and damage to the colon, often termedstercoral perforation.[18]
A hole in the gastrointestinal tract causes leakage of gas into the abdominal cavity. In intestinal perforation, gas may be visible under thediaphragm on chestx-ray while the patient is in an upright position. While x-ray is a fast and inexpensive to screen for perforation, an abdominalCT scan with contrast is moresensitive and specific for establishing a diagnosis as well as determining the underlying cause.[19] Both CT and x-ray may initially appear normal, in which case diagnosis can be made byopen orlaparoscopic exploration of the abdomen.
White blood cells and blood lactate levels may also be elevated, particularly in the case of advanced disease includingperitonitis andsepsis.[20]
Differential diagnoses of gastrointestinal perforation includes other causes of anacute abdomen, including appendicitis,diverticulitis,ruptured ovarian cyst, orpancreatitis.[21]
Surgical intervention is nearly always required in the form ofopen orlaparoscopic exploration. The goals of surgery are to remove any dead tissue and close the hole in the gastrointestinal wall.Peritoneal wash is performed and a drain may be placed to control any fluid collections that may form.[22] AGraham patch may be used for duodenal perforations.[23]
Conservative treatment (avoiding surgery) may be sufficient in the case of a contained perforation. It is indicated only if the person has normalvital signs and is clinically stable.[21]
Regardless of whether surgery is performed, all patients are offered pain therapy and placed on bowel rest (avoiding all food and fluids by mouth),intravenous fluids, andantibiotics.[21] A number of different antibiotics may be used such aspiperacillin/tazobactam or the combination ofciprofloxacin andmetronidazole.[24][25]
Authority control databases: National |
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