gastrointestinal perforation

Gastrointestinal perforation results in sudden, severe abdominal pain at the site of perforation, which then spreads across the abdomen.{{Cite journal |last1=Mayumi |first1=Toshihiko |last2=Yoshida |first2=Masahiro |last3=Tazuma |first3=Susumu |last4=Furukawa |first4=Akira |last5=Nishii |first5=Osamu |last6=Shigematsu |first6=Kunihiro |last7=Azuhata |first7=Takeo |last8=Itakura |first8=Atsuo |last9=Kamei |first9=Seiji |last10=Kondo |first10=Hiroshi |last11=Maeda |first11=Shigenobu |last12=Mihara |first12=Hiroshi |last13=Mizooka |first13=Masafumi |last14=Nishidate |first14=Toshihiko |last15=Obara |first15=Hideaki |date=January 2016 |title=Practice Guidelines for Primary Care of Acute Abdomen 2015 |journal=Journal of Hepato-Biliary-Pancreatic Sciences |language=en |volume=23 |issue=1 |pages=3–36 |doi=10.1002/jhbp.303 |issn=1868-6974|doi-access=free |pmid=26692573 }} The pain is intensified by movement. Nausea, vomiting, hematemesis, and increased heart rate are common early symptoms. Later symptoms include fever and or chills.{{cite web | url=http://www.merckmanuals.com/professional/gastrointestinal-disorders/acute-abdomen-and-surgical-gastroenterology/acute-perforation | title=Acute Perforation | work=Merck Manuals | access-date=June 30, 2016 | author=Ansari, Parswa | url-status=live | archive-url=https://web.archive.org/web/20160710102237/http://www.merckmanuals.com/professional/gastrointestinal-disorders/acute-abdomen-and-surgical-gastroenterology/acute-perforation | archive-date=July 10, 2016 }} On examination, the abdomen is rigid and tender. After some time, the bowel stops moving, and the abdomen becomes silent and distended.

The symptoms of esophageal rupture may include sudden onset of chest pain.

A hole in the intestinal tracts allows intestinal contents to enter the abdominal cavity. The entry of bacteria from the gastrointestinal tract into the abdomen results in peritonitis or in the formation of an abscess.

Patients may develop sepsis, a life-threatening response to infection, which may appear as an increased heart rate, increased breathing rate, fever, and confusion. This may progress to multi-level organ dysfunction, including acute respiratory and kidney failure.

Posterior gastric wall perforation may lead to bleeding due to the involvement of gastroduodenal artery that lies behind the first part of the duodenum.{{cite journal |vauthors=Lanas A, Chan FK |date=August 2017 |title=Peptic ulcer disease |journal=Lancet |volume=390 |issue=10094 |pages=613–624 |doi=10.1016/S0140-6736(16)32404-7 |pmid=28242110 |s2cid=4547048}} The death rate in this case is 20%.

File:2402 Layers of the Gastrointestinal Tract.jpg

Gastrointestinal perforation is defined by a full-thickness injury to all layers of the gastrointestinal wall, resulting in a hole in the hollow GI tract (esophagus, stomach, small intestine, or large 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 gastrointestinal endoscopy and colonoscopy.{{Cite journal |last=Lohsiriwat |first=Varut |date=2010 |title=Colonoscopic perforation: Incidence, risk factors, management and outcome |journal=World Journal of Gastroenterology |language=en |volume=16 |issue=4 |pages=425–430 |doi=10.3748/wjg.v16.i4.425 |issn=1007-9327|doi-access=free |pmid=20101766 |pmc=2811793 }}

Appendicitis and diverticulitis are conditions in which a small, tubular area in bowel becomes inflamed and may burst.{{Cite web |title=Definition & Facts for Appendicitis - NIDDK |url=https://www.niddk.nih.gov/health-information/digestive-diseases/appendicitis/definition-facts |access-date=2023-11-15 |website=National Institute of Diabetes and Digestive and Kidney Diseases |language=en-US}} A number of infections including C. difficile{{cite journal |last1=Langell |first1=JT |last2=Mulvihill |first2=SJ |date=May 2008 |title=Gastrointestinal perforation and the acute abdomen. |journal=The Medical Clinics of North America |volume=92 |issue=3 |pages=599–625, viii–ix |doi=10.1016/j.mcna.2007.12.004 |pmid=18387378}} infection can lead to full-thickness disruption of the bowel wall. In patients with inflammatory 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 of digestion.{{Citation |last=Fitzgerald |first=J. Edward F. |title=Small Bowel Obstruction |date=2010-01-31 |url=https://onlinelibrary.wiley.com/doi/10.1002/9781444315172.ch14 |work=Emergency Surgery |pages=74–79 |editor-last=Brooks |editor-first=Adam |access-date=2023-11-15 |edition=1 |publisher=Wiley |language=en |doi=10.1002/9781444315172.ch14 |isbn=978-1-4051-7025-3 |editor2-last=Cotton |editor2-first=Bryan A. |editor3-last=Tai |editor3-first=Nigel |editor4-last=Mahoney |editor4-first=Peter F.|url-access=subscription }} It may occur due to scar tissue after surgery, twisting of the bowel around itself, hernias, or gastrointestinal 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 bowel ischemia (lack of blood flow), necrosis, and eventually perforation.

Eating multiple magnets can also lead to perforation if the magnets attract and stick to one another through different loops of the intestine.{{cite book |last1=Lima |first1=Mario |url=https://books.google.com/books?id=6_mqDQAAQBAJ&pg=PA239 |title=Pediatric Digestive Surgery |date=2016 |publisher=Springer |isbn=9783319405254 |page=239 |language=en}}

A peptic ulcer is a defect in the inner lining of the stomach or duodenum typically due to excessive stomach 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 acute chemical peritonitis.{{Cite journal |last1=Langell |first1=John T. |last2=Mulvihill |first2=Sean J. |date=2008-05-01 |title=Gastrointestinal Perforation and the Acute Abdomen |url=https://www.sciencedirect.com/science/article/pii/S0025712507001812 |journal=Medical Clinics of North America |series=Common Gastrointestinal Emergencies |volume=92 |issue=3 |pages=599–625 |doi=10.1016/j.mcna.2007.12.004 |pmid=18387378 |issn=0025-7125|url-access=subscription }}{{Citation |last1=Sigmon |first1=David F. |title=Gastric Perforation |date=2023 |url=http://www.ncbi.nlm.nih.gov/books/NBK519554/ |work=StatPearls |access-date=2023-11-15 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=30137838 |last2=Tuma |first2=Faiz |last3=Kamel |first3=Bishoy G. |last4=Cassaro |first4=Sebastiano}} Helicobacter pylori infection and overuse of non-steroidal anti-inflammatory drugs{{cite journal |author=R I Russell |year=2001 |title=Non-steroidal anti-inflammatory drugs and gastrointestinal damage—problems and solutions |journal=Postgrad Med J |volume=77 |issue=904 |pages=82–88 |doi=10.1136/pmj.77.904.82 |pmc=1741894 |pmid=11161072}}{{cite journal |author=Carlos Sostres |author2=Carla J Gargallo |author3=Angel Lanas |year=2013 |title=Nonsteroidal anti-inflammatory drugs and upper and lower gastrointestinal mucosal damage |journal=Arthritis Res. Ther. |volume=15 |issue=Suppl 3 |pages=S3 |doi=10.1186/ar4175 |pmc=3890944 |pmid=24267289 |doi-access=free }} may contribute to formation of peptic ulcers. Ingestion of corrosives{{cite journal |author=Ramasamy, Kovil |author2=Gumaste, Vivek V. |year=2003 |title=Corrosive Ingestion in Adults |journal=Journal of Clinical Gastroenterology |volume=37 |issue=2 |pages=119–124 |doi=10.1097/00004836-200308000-00005 |pmid=12869880}} can lead to esophageal perforation.

An often overlooked indirect cause of obstruction leading to perforation is the chronic use of opioids, which can create severe constipation and damage to the colon, often termed stercoral perforation.{{Cite journal |last1=Poitras |first1=Renée |last2=Warren |first2=Daun'Lee |last3=Oyogoa |first3=Sylvanus |date=2018-01-01 |title=Opioid drugs and stercoral perforation of the colon: Case report and review of literature |journal=International Journal of Surgery Case Reports |volume=42 |pages=94–97 |doi=10.1016/j.ijscr.2017.11.060 |issn=2210-2612|doi-access=free |pmid=29232630 |pmc=5730425 }}

A hole in the gastrointestinal tract causes leakage of gas into the abdominal cavity. In intestinal perforation, gas may be visible under the diaphragm on chest x-ray while the patient is in an upright position. While x-ray is a fast and inexpensive to screen for perforation, an abdominal CT scan with contrast is more sensitive and specific for establishing a diagnosis as well as determining the underlying cause.{{Cite journal |last1=Mayumi |first1=Toshihiko |last2=Yoshida |first2=Masahiro |last3=Tazuma |first3=Susumu |last4=Furukawa |first4=Akira |last5=Nishii |first5=Osamu |last6=Shigematsu |first6=Kunihiro |last7=Azuhata |first7=Takeo |last8=Itakura |first8=Atsuo |last9=Kamei |first9=Seiji |last10=Kondo |first10=Hiroshi |last11=Maeda |first11=Shigenobu |last12=Mihara |first12=Hiroshi |last13=Mizooka |first13=Masafumi |last14=Nishidate |first14=Toshihiko |last15=Obara |first15=Hideaki |date=January 2016 |title=Practice Guidelines for Primary Care of Acute Abdomen 2015 |journal=Journal of Hepato-Biliary-Pancreatic Sciences |language=en |volume=23 |issue=1 |pages=3–36 |doi=10.1002/jhbp.303 |issn=1868-6974|doi-access=free |pmid=26692573 }} Both CT and x-ray may initially appear normal, in which case diagnosis can be made by open or laparoscopic exploration of the abdomen.

White blood cells and blood lactate levels may also be elevated, particularly in the case of advanced disease including peritonitis and sepsis.{{Cite journal |last1=Kruse |first1=Ole |last2=Grunnet |first2=Niels |last3=Barfod |first3=Charlotte |date=December 2011 |title=Blood lactate as a predictor for in-hospital mortality in patients admitted acutely to hospital: a systematic review |journal=Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine |volume=19 |issue=1 |page=74 |doi=10.1186/1757-7241-19-74 |issn=1757-7241|doi-access=free |pmid=22202128 |pmc=3292838 }}

Differential diagnoses of gastrointestinal perforation includes other causes of an acute abdomen, including appendicitis, diverticulitis, ruptured ovarian cyst, or pancreatitis.{{Cite journal |last1=Falch |first1=C. |last2=Vicente |first2=D. |last3=Häberle |first3=H. |last4=Kirschniak |first4=A. |last5=Müller |first5=S. |last6=Nissan |first6=A. |last7=Brücher |first7=B.L.D.M. |date=August 2014 |title=Treatment of acute abdominal pain in the emergency room: A systematic review of the literature |journal=European Journal of Pain |language=en |volume=18 |issue=7 |pages=902–913 |doi=10.1002/j.1532-2149.2014.00456.x |issn=1090-3801|doi-access=free |pmid=24449533 }}

Surgical intervention is nearly always required in the form of open or laparoscopic 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.{{cite journal |last1=Rustagi |first1=T |last2=McCarty |first2=TR |last3=Aslanian |first3=HR |date=2015 |title=Endoscopic Treatment of Gastrointestinal Perforations, Leaks, and Fistulae. |journal=Journal of Clinical Gastroenterology |volume=49 |issue=10 |pages=804–9 |doi=10.1097/mcg.0000000000000409 |pmid=26325190 |s2cid=38323381}} A Graham patch may be used for duodenal perforations.{{Cite web |title=Gastrointestinal perforation Information {{!}} Mount Sinai - New York |url=https://www.mountsinai.org/health-library/diseases-conditions/gastrointestinal-perforation |access-date=2023-11-03 |website=Mount Sinai Health System |language=en-US}}

Conservative treatment (avoiding surgery) may be sufficient in the case of a contained perforation. It is indicated only if the person has normal vital signs and is clinically stable.

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, and antibiotics. A number of different antibiotics may be used such as piperacillin/tazobactam or the combination of ciprofloxacin and metronidazole.{{cite journal |last1=Wong |first1=PF |last2=Gilliam |first2=AD |last3=Kumar |first3=S |last4=Shenfine |first4=J |last5=O'Dair |first5=GN |last6=Leaper |first6=DJ |date=18 April 2005 |title=Antibiotic regimens for secondary peritonitis of gastrointestinal origin in adults. |journal=The Cochrane Database of Systematic Reviews |volume=2012 |issue=2 |pages=CD004539 |doi=10.1002/14651858.CD004539.pub2 |pmid=15846719|pmc=11297476 }}{{cite book |last1=Wilson |first1=William C. |url=https://books.google.com/books?id=6FPvBQAAQBAJ&pg=PA882 |title=Trauma: Resuscitation, Perioperative Management, and Critical Care |last2=Grande |first2=Christopher M. |last3=Hoyt |first3=David B. |date=2007 |publisher=CRC Press |isbn=9781420015263 |page=882 |language=en |archive-url=https://web.archive.org/web/20160817092456/https://books.google.ca/books?id=6FPvBQAAQBAJ&pg=PA882 |archive-date=2016-08-17 |url-status=live}}

{{Reflist}}

{{Medical resources |DiseasesDB=34042 |ICD10=K63.1, S36.9 |ICD9={{ICD9|569.83}}, {{ICD9|863.9}} |MedlinePlus=000235 |eMedicineSubj=med |eMedicineTopic=2822}}

• [https://www.nlm.nih.gov/medlineplus/ency/article/000235.htm Gastrointestinal perforation]—MedlinePlus

{{Digestive system diseases}}

{{Nonmusculoskeletal injuries of abdomen and pelvis}}

{{Authority control}}

Category:Medical emergencies

Category:Diseases of intestines

Category:Injuries of abdomen, lower back, lumbar spine and pelvis

Category:Acute pain

Category:Wikipedia medicine articles ready to translate

Category:Wikipedia emergency medicine articles ready to translate