Gastrointestinal perforation

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.

• Ulcerative/erosive disease ^[1]
  • Peptic ulcer disease:
    • Most common cause of stomach and duodenal perforation ^[2]
    • Duodenal ulcers of the anterior wall are more likely to perforate.
  • Malignancy
  • Inflammatory bowel disease: ulcerative colitis, Crohn disease
• Infections
  • Diverticulitis (colonic diverticula, Meckel diverticulum)
  • Acute appendicitis
  • Typhoid
  • Gastrointestinal tuberculosis
  • Toxic megacolon
• Bowel ischemia
  • Bowel obstruction (i.e., adhesions, volvulus, malignancy)
  • Acute mesenteric ischemia
• Trauma
  • Penetrating trauma (e.g., stab injury, iatrogenic perforations)
  • Blunt abdominal trauma
• Miscellaneous
  • Foreign body ingestion
  • Drug-induced; (e.g., NSAIDs, glucocorticoids, cocaine)
  • Radiation therapy to the abdominopelvic or lower thoracic region
  • Post renal transplant ^[3]

• General signs and symptoms
  • Sudden onset of abdominal pain and abdominal distention
  • Nausea, vomiting, obstipation
  • Fever, tachycardia, tachypnea, hypotension
  • Signs of peritonitis or shock
  • Decreased or absent bowel sounds
  • Loss of liver dullness on RUQ percussion
• History suggestive of specific locations
  • Perforated PUD:
    • Sudden onset of intense, stabbing pain, followed by diffuse abdominal pain and distention (beginning peritonitis)
    • Referred pain to the shoulder due to irritation of the diaphragm, which is innervated by the phrenic nerve (C3-C5); the shoulder skin is innervated by supraclavicular nerves (C3-C4) (see referred pain)
    • History of recurrent epigastric pain, chronic use of NSAIDs
    • Perforation of chronic ulcers may only cause mild symptoms.
  • Perforated diverticulitis: constipation, previous LLQ pain
  • Perforated appendicitis: progressively worsening RLQ pain, migratory pain
  • Perforated malignancy or IBD: anorexia, weight loss, melena, change in bowel habits
• Localization of pain
  • Diffuse: in patients with free intraperitoneal perforation
  • Localized RLQ pain: contained perforated appendicitis
  • Localized LLQ pain: contained perforated diverticulitis

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

Laboratory analysis

• CBC: neutrophilic leukocytosis
• BMP: ↑ BUN, ↑ creatinine
• Blood gas analysis: lactic acidosis (in ischemic perforation) ^[4]

Imaging ^[5][6]

• First line: CT abdomen and pelvis with IV contrast (most sensitive)
  • Indications: acute non-localized abdominal pain
  • Findings
    • Pneumoperitoneum
    • Signs of perforated bowel: loss of bowel wall continuity, localized mesenteric fat stranding
• Alternative imaging modalities
  • X-ray of the abdomen ; (upright and supine) and chest (upright)
    • Indications: Consider in patients with contraindications to IV contrast.
    • Findings: free intraperitoneal air (pneumoperitoneum) under the diaphragm; and/or between liver and lateral abdominal wall :
  • 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.

• Bowel rest (NPO)
• IV access with two large-bore peripheral IVs
• Start broad-spectrum IV antibiotics: See “severe infection” in empiric antibiotic therapy for intra-abdominal infection.
• Aggressive IV fluid resuscitation
• Determine whether indications for surgery are present (i.e., generalized peritonitis, sepsis) or whether the patient can be managed conservatively with IV antibiotics.
• Provide supportive care (e.g., analgesics, antiemetics).

Supportive care

• NG tube with continuous or intermittent suction
• Consider IV PPI.
• Parenteral analgesics
  • Opioid analgesics ^[7]
    • Morphine
    • Meperidine
    • Hydromorphone
    • Tramadol
  • NSAIDs: Diclofenac
• Parenteral antiemetics (see antiemetics)
  • Ondansetron
  • Promethazine

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.

• Indications:
  • Signs of generalized peritonitis
  • Signs of sepsis
• Procedure: Exploratory laparotomy with midline incision is usually preferred.
  • Obtain peritoneal fluid for cultures.
  • Thorough peritoneal lavage with saline ^[9]
  • Closure of the perforation, if feasible
    • Primary closure with/without an omental pedicle
    • Resection of the perforated segment of bowel with primary anastomosis or temporary stoma creation
  • If perforated appendix identified: Perform an appendectomy.
  • If malignancy is identified (e.g., perforated colon cancer):
    • Consider curative resection.
    • Obtain intraoperative biopsies of the mass if resection is not possible.
  • Place peritoneal drains and close the abdomen.
• Postoperative care
  • Continue bowel rest, IV fluids, and NG tube with suction until normal bowel function returns (see “conservative management” below).
  • Identify and treat the underlying condition. ^[10]

Conservative management ^[10][11]

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

• NPO, maintenance IV fluids, and IV PPI (see supportive care above)
• IV broad-spectrum antibiotics: See “severe infection” in empiric antibiotic therapy for intra-abdominal infection
• If imaging shows evidence of an abscess: Consider image-guided percutaneous drainage of abscess. ^[12]
• Serial abdominal examination
• Further management:
  • If there are clinical signs of improvement : Obtain an abdominal x-ray with water-soluble contrast to confirm that the perforation has sealed.
    • No leakage of contrast: Initiate enteral feeds and switch to oral antibiotics.
  • If there are clinical signs of deterioration : exploratory laparotomy

• Urgent general surgery consult for emergency exploratory laparotomy
• NPO
• IV access with two large-bore peripheral IVs
• Aggressive IV fluid resuscitation
• Nasogastric tube insertion (continuous or intermittent suction)
• IV broad-spectrum antibiotics: See “severe infection” in empiric antibiotic therapy for intra-abdominal infection.
• Electrolyte repletion
• Supplemental oxygen, if necessary
• Parenteral analgesics
• Parenteral antiemetics
• Admit to surgical ICU.
• Serial abdominal exams

• Peritonitis
• Bacteremia
• Sepsis
• Multiorgan dysfunction
• Intra-abdominal abscess
• Intra-abdominal adhesions
• Subhepatic abscess
• Pyogenic liver abscess
• Pelvic abscess
• Postoperative complications

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