Gastrointestinal perforation

Medical quality assurance by Dr. Albrecht Nonnenmacher, MD at April 14, 2016
StartDiseasesGastrointestinal perforation

Gastrointestinal perforation is one of the most common causes of emergency surgeries. This condition occurs when a hole develops through the wall of the stomach, rectum, large intestine, small intestine, or gallbladder. Despite the latest advancements in healthcare, mortality rates are as high as 50 percent. Early diagnosis is the key to successful treatment.

Contents

Definition & Facts

Perforation of the intestines may cause the bowel contents to leak into the abdomen, leading to infection. This condition requires emergency surgery, antibiotics, and fluid replacement. Gastrointestinal perforation has non-specific symptoms, which makes diagnosis difficult. Every year, millions of people die from peritonitis, medical shock, and other complications caused by this disorder. The main types of gastrointestinal perforation include:

  • Lower bowel perforation
  • Upper bowel perforation
  • Contained upper bowel perforation
  • Free upper bowel perforation (gastric or duodenal perforation)

Any of these conditions may cause sudden death. Perforation can occur anywhere in the gastrointestinal tract, affecting the small and large intestine, jejunum, duodenum, sigmoid colon, and other internal organs. This disorder occurs in people of all ages, including children.

Symptoms & Complaints

Perforation of the intestines may cause severe abdominal pain, nausea, vomiting, fever, chills, sweating, rapid heart rate, and bloating. Most patients experience sudden pain in the epigastrium, ingestion, flatulence, and bloody bowel movements.

Symptoms depend on where the perforation is located. Pain usually develops gradually, causing a burning sensation. In general, it starts from the site of perforation and spreads across the abdominal region. Sometimes it may radiate to the shoulder. Gastrointestinal perforation allows digestive juices and food to leak into the abdomen or the chest, causing peritonitis and severe inflammation. Often the abdomen becomes distended and rigid.

Complications tend to occur when the inflammation is widespread and extends beyond the inner lining of the intestines. However, not everyone will experience these symptoms. If left untreated, this condition can lead to abdominal abscess, sepsis, and multi-system organ failure.

Causes

Gastrointestinal perforation can have various causes such as inflammatory bowel disease, peptic ulcers, blunt or penetrating trauma, and gallbladder disease. A large number of people who develop this condition suffer from diverticulitis, ulcerative colitis, Crohn's disease, or appendicitis. Endoscopy and abdominal surgery can increase the risk of gastrointestinal tract perforations. Other possible causes include:

Perforation of the intestines can also be triggered by infection with cytomegalovirus, clorstridium difficile, and salmonella typhosa as well as fish bones, chicken bones, and tooth picks. Gastrointestinal tract perforation can occur after colonoscopy, laparotomy, laparoscopy, nasogastric tube insertion, upper endoscopy, and other medical procedures. The risk increases with diagnostic procedures that involve tissue sampling. Other common causes of gastrointestinal perforation include gastric and duodenal ulcers, ascariasis, and nonsteroidal anti-inflammatory drugs.

Gastrointestinal perforation occurs in about 15 percent of patients with acute diverticulitis. Duodenal ulcer perforations are three times more common than those caused by gastric ulcers. Recent studies indicate that gastrointestinal tract perforation occurs more frequently in men than women. Other risk factors include tumors, stab wounds to the abdomen, and use of corticosteroids.

Diagnosis & Tests

When a GI perforation is suspected, the doctor may recommend a CT scan of the abdomen, X-rays, or ultrasonography. Compared to other imaging tests, CT scans can accurately depict the site of perforation in over 86 percent of cases. Conventional radiography may not detect small amounts of free intraperitoneal gas, a common sign of gastrointestinal tract perforations.

Ultrasonography is typically recommended to patients with undiagnosed abdominal pain. It's one of the few tests that can detect primary ascaridial perforation, lymph node metastasis, hypoechoic irregular lesions, thickened bowel loops, and other common signs of gastrointestinal perforation.

Treatment & Therapy

Treatment options depend on the nature of the underlying disease or injury that caused the perforation. After diagnosis, immediate surgery is needed. Patients usually require laparotomy, nasogastric aspiration, antibiotics, and intravenous fluids. Antibiotic treatment aims to eliminate infection and destroy aerobic and anaerobic organisms. It also helps lower the risk of sepsis and postoperative wound infection.

The goal of surgery is to remove bile, food, and gastric secretions in the abdominal cavity, and correct the cause of perforation. A temporary ileostomy or colostomy may be needed. In severe cases, the surgeon will remove a small part of the intestine. If the hole closes on its own, the doctor will only prescribe antibiotics and forgo surgery.

Factors that can affect treatment include drug abuse or alcohol abuse, smoking, poor nutrition, bleeding complications, existing bowel diseases, emphysema, and kidney disease or liver disease. Certain medical conditions that require steroids, such as rheumatoid arthritis and lupus, can slow down healing.

Prevention & Prophylaxis

This condition has many causes such as diverticulosis and duodenal ulcers. The only way to prevent it is to eliminate the risk factors associated with these disorders. Simple lifestyle changes, such as eating healthy and quitting smoking, can lower the risk of gastrointestinal perforation.

Patients with a history of diverticulitis or diverticulosis should stick to a high fiber diet based on whole grains, fruits, beans, and vegetables. At the same time, it's essential to avoid hard-to-digest foods like popcorn, nuts, and seeds. People suffering from peptic ulcers, which are a common cause of gastrointestinal perforation, should quit alcohol and increase their fiber intake. A diet rich in fiber can lower the risk of peptic ulcers by as much ad 60 percent.

It's recommended to chew food slowly and manage stress. Cocoa, soft drinks, red or hot peppers, tomatoes, fries, fatty meat, and other foods that cause gastric discomfort should be avoided. Aspirin and non-steroidal anti-inflammatory drugs can worsen peptic ulcer symptoms, leading to gastrointestinal perforation.