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Gastrointestinal perforation

Last updated: April 2, 2020

Summary

Gastrointestinal perforation is a full-thickness loss of bowel wall integrity that results in perforation peritonitis. Perforation of a duodenal ulcer is the most common cause of perforation peritonitis. Patients typically present with an acute onset of severe abdominal pain associated with nausea, vomiting, and fever. Signs of peritoneal irritation are evident on examination and include decreased bowel sounds and diffuse or localized abdominal guarding and rebound tenderness. Abdominal CT abdomen with IV contrast is the preferred imaging modality to confirm the presence of free air within the peritoneal cavity (pneumoperitoneum) and localize the site of the perforated viscus. Most patients will require an emergency exploratory laparotomy. Patients with evidence of a well-contained perforation (e.g., a small localized appendicular or diverticular perforation) and no signs of sepsis may be given a trial of conservative management with antibiotics, bowel rest, close monitoring of vital signs, and serial abdominal examination. The prognosis depends on the etiology, degree of intra-abdominal contamination, and other comorbidities.

See also esophageal perforation.

Etiology

Clinical features

Bowel perforation is a surgical emergency. In some cases, clinical features alone are sufficient to warrant emergency explorative laparotomy.

Diagnostics

Laboratory analysis

Imaging [5][6]

  • First line: CT abdomen and pelvis with IV contrast (most sensitive)
    • Indications: acute non-localized abdominal pain
    • Findings
  • Alternative imaging modalities
    • X-ray of the abdomen ; (upright and supine) and chest (upright)
    • Ultrasound abdomen
      • Indication: preferred in patients with contraindications to radiation exposure (e.g., pregnancy)
      • Findings: pneumoperitoneum, localized fluid collection, localized thickening of a bowel segment

IV contrast is preferred if bowel perforation is suspected. If oral contrast must be used, a water-soluble contrast agent is preferred.

Differential diagnoses

See “Differential diagnoses” in acute abdomen.

The differential diagnoses listed here are not exhaustive.

Treatment

General principles

Supportive care

Ketorolac is contraindicated in patients with suspected bowel perforation.

Opioids are contraindicated in patients with suspected bowel obstruction.

Surgical management [8]

Most patients with GI tract perforation should be managed with urgent explorative laparotomy.

Conservative management [10][11]

Patients with only localized peritonitis and no signs of sepsis may be candidates for conservative (nonsurgical) management.

Acute management checklist

Complications

We list the most important complications. The selection is not exhaustive.

References

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  5. American College of Radiology ACR Appropriateness Criteria® Acute Nonlocalized Abdominal Pain. https://acsearch.acr.org/docs/69467/Narrative/. Updated: January 1, 2018. Accessed: March 30, 2018.
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