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Free air under the right hemidiaphragm from a bowel perforated.
|Classification and external resources|
|Specialty||gastroenterology, emergency medicine|
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 entering 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 pain in the epigastrium to the right of the midline indicates perforation of a duodenal ulcer. In a gastric ulcer performation creates a history of burning pain in epigastrium, with flatulence and dyspepsia. A history of drug intake with insufficient food intake may be present.
In intestinal perforation pain starts from the site of perforation and spreads across the abdomen.
In any case the abdomen becomes rigid with tenderness and rebound tenderness. After some time the abdomen becomes silent and heart sounds can be heard all over. Patient stops passing flatus and motion, abdomen is distended.
Underlying causes include gastric ulcers, duodenal ulcers, appendicitis, gastrointestinal cancer, diverticulitis, inflammatory bowel disease, superior mesenteric artery syndrome, trauma and ascariasis. Typhoid fever, non-steroidal anti-inflammatory drugs, ingestion of corrosives may also be responsible.
On x-rays, gas may be visible in the abdominal cavity. Gas is easily visualized on x-ray while the patient is in an upright position. The perforation can often be visualised using computed tomography. White blood cells are often elevated.
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 including intravenous fluids, antibiotics, nasogastric aspiration and bowel rest is indicated if the patient is nontoxic and clinically stable. Consultation with a specialist is often needed.