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Free air under the right hemidiaphragm from a bowel perforated.
Gastrointestinal perforation is a complete penetration of any part of the wall of the gastrointestinal tract, which lines the stomach, small intestine or large bowel, resulting in intestinal contents flowing into the abdominal cavity. Perforation of the intestines results in the potential for bacterial contamination of the abdominal cavity (a condition known as peritonitis). Perforation of the stomach can lead to a chemical peritonitis due to leaked gastric acid. Perforation anywhere along the gastrointestinal tract is a surgical emergency.
Signs and symptoms
Sudden attack of pain in epigastrium to the right of midline in case of perforation of duodenal ulcer. In case of gastric ulcer the pain is in epigastrium. There is history of burning pain in epigastrium, flatulence and dyspepsia. History of drug intake without sufficient food intake may be present. In case of intestinal perforation pain starts from the site of perforation, visceral, and then spreads all over the abdomen. In any case there is board-like rigidity of abdomen, tenderness, and rebound tenderness. After some time the abdomen becomes silent, heart sounds can be heard all over. Patient stops passing flatus and motion, abdomen is distended. Gastrointestinal perforation results in severe abdominal pain intensified by movement, nausea and vomiting. Later symptoms include fever and or chills.
Underlying causes include gastric ulcer, appendicitis, gastrointestinal cancer, diverticulitis, Inflammatory Bowel Disease, superior mesenteric artery syndrome, trauma, ascariasis. Typhoid fever, non-steroidal anti-inflammatory drugs, ingestion of corrosives may also be responsible.
In some extreme cases, certain forms of physical trauma may be responsible.
On x-rays, free gas/air may be visible in the abdominal cavity. The perforation can often be visualised using computed tomography. White blood cells are often elevated. Visible signs can occasionally include a ridged abdomen on palpation.
Treatment depends on the underlying cause. Surgical intervention is nearly always required in form of exploratory laparotomy and closure of perforation with peritoneal wash. Conservative treatment is indicated in case patient is nontoxic and clinically stable, these patients are to be treated with intravenous fluids, antibiotics, nasogastric aspiration and bowel rest. Consultation with a specialist is often needed.