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Gastrointestinal perforation

Last updated: July 27, 2021

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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. 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 intraabdominal contamination, and other comorbidities.

See also esophageal perforation.

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

Laboratory analysis

Imaging [5][6]

Immediate studies

Before an upright x-ray, patients must be sitting up for at least 10 minutes in order to allow free air to move upward and collect under the diaphragm. [7]

Confirmatory studies

  • First line: CT abdomen and pelvis with IV contrast (most sensitive)
  • Alternative: formal 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.

See “Differential diagnoses” in “Acute abdomen”.

The differential diagnoses listed here are not exhaustive.

Initial management

Supportive care

Ketorolac is contraindicated in patients with suspected bowel perforation.

Opioids are contraindicated in patients with suspected bowel obstruction.

Surgical management [12]

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

Conservative management [10][14]

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

See “Primary survey” for the general approach to trauma patients; see also “Blunt abdominal trauma” (BAT) and “Penetrating abdominal trauma.”

Diagnosis [16][17]

  • Emergency surgery consult (prior to imaging) in patients with :
  • Maintain high index of suspicion: Clinical features may be subtle.
    • Patients with BAT are at elevated risk, especially if they also have : [17]
      • High-energy injury: e.g., resulting from high-speed motor vehicle collision
      • Seat belt sign with pain and guarding
      • Other injuries associated with hollow viscus injury: e.g., abdominal aortic injury, L-spine transverse fracture
    • Iatrogenic injury: Suspect in patients with clinical features of GI perforation following recent liver biopsy, paracentesis, peritoneal dialysis or lavage, or GI endoscopy.
  • CT abdomen: test of choice for all stable patients
    • In patients with BAT, evidence of hollow viscus injury may be absent on the initial CT abdomen.
    • Consider repeat imaging in at-risk patients with BAT, especially if they have:

Maintain a high index of suspicion for hollow viscus injury in patients with blunt abdominal trauma as clinical features may initially be very subtle. [17]

Management

  • All patients: Administer broad-spectrum IV antibiotics and provide supportive care and monitoring identical to that for nontraumatic GI perforation.
  • Patients with sepsis, peritonitis, or hemodynamic instability: Operative management is indicated.
  • Stable patients with penetrating abdominal trauma: Operative management is typically indicated. [18][19]
  • Stable patients with any other traumatic etiologies: Consult surgery to determine if operative or nonoperative management is most appropriate. [17][20][21][22]

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

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