Any part of the gastrointestinal tract may become perforated, releasing gastric or intestinal contents into the peritoneal space. Causes vary. Symptoms develop suddenly, with severe pain followed shortly by signs of shock. Diagnosis is usually made by the presence of free air in the abdomen on imaging studies. Treatment is with fluid resuscitation, antibiotics, and surgery. Mortality is high, varying with the underlying disorder and the patient’s general health.
(See also Acute Abdominal Pain.)
Etiology of Acute Perforation of the GI Tract
Both blunt and penetrating trauma can result in perforation of any part of the gastrointestinal tract (see table Some Causes of Gastrointestinal Tract Perforation).
Swallowed foreign bodies, even sharp ones, rarely cause perforation unless they become impacted, causing ischemia and necrosis from local pressure (see Foreign Bodies in the Gastrointestinal Tract).
Foreign bodies inserted via the anus may perforate the rectum or sigmoid colon (see Rectal Foreign Bodies).
Some Causes of Gastrointestinal Tract Perforation
Perforation Site | Cause | Comments |
|---|---|---|
All sites | Trauma | ― |
― | ||
Esophagus | Forceful vomiting | Termed Boerhaave syndrome |
Iatrogenic causes | Typically perforation with an esophagoscope, balloon dilator, or bougie | |
Ingestion of corrosive material | ― | |
Stomach or duodenum | Can occur in patients with no previous history of ulcer symptoms Sometimes no free air is visible on radiograph | |
Ingestion of corrosive material | Typically stomach | |
Intestine | ― | |
Possibly acute appendicitis and Meckel diverticulitis | Free air rarely visible on radiographs | |
Colon | Obstruction | Typically perforates at cecum High risk: Colon ≥ 13 cm diameter, patients receiving prednisone or other immunosuppressants (symptoms and signs may be minimal in this group) |
― | ||
Inflammatory bowel disease (ulcerative colitis, Crohn disease) | ― | |
― | ||
Sometimes spontaneous | ― | |
Gallbladder | Iatrogenic injury during cholecystectomy or liver biopsy | Usually the biliary tree or duodenum is injured |
Rarely, acute cholecystitis | Usually walled off by omentum |
Symptoms and Signs of Acute Perforation of the GI Tract
Esophageal, gastric, or duodenal perforation tends to manifest suddenly and catastrophically, with abrupt onset of acute abdomen with severe generalized abdominal pain, tenderness, and peritoneal signs. Pain may radiate to the shoulder.
Perforation at other gastrointestinal sites often occurs in the setting of other painful, inflammatory conditions. Because such perforations are often small initially and frequently walled off by the omentum, pain often develops gradually and may be localized. Tenderness also is more focal. Such findings can make it difficult to distinguish perforation from worsening of the underlying disorder or lack of response to treatment.
In all types of perforation, nausea, vomiting, and anorexia are common. Bowel sounds are quiet to absent.
Diagnosis of Acute Perforation of the GI Tract
Abdominal series
If nondiagnostic, abdominal CT
An abdominal series (supine and upright abdominal radiographs and chest radiographs) may be diagnostic, showing free air under the diaphragm in 50 to 75% of cases (1, 2). As time passes, this sign becomes more common. A lateral chest radiograph is more sensitive for free air than a posteroanterior radiograph.
If the abdominal series is nondiagnostic, abdominal CT usually with oral and IV and/or rectal contrast may be helpful. Barium should not be used if perforation is suspected.
Diagnosis references
1. Chen CH, Yang CC, Yeh YH. Role of upright chest radiography and ultrasonography in demonstrating free air of perforated peptic ulcers. Hepatogastroenterology. 2001;48(40):1082-1084.
2. Winek TG, Mosely HS, Grout G, Luallin D. Pneumoperitoneum and its association with ruptured abdominal viscus. Arch Surg. 1988;123(6):709-712. doi:10.1001/archsurg.1988.01400300051008
Treatment of Acute Perforation of the GI Tract
Surgery
IV fluids and antibiotics
If a perforation is noted, immediate surgery is necessary because mortality caused by peritonitis increases rapidly the longer treatment is delayed. If an abscess or an inflammatory mass has formed, the procedure may be limited to drainage of the abscess.
A nasogastric tube is sometimes inserted before operation. Patients with signs of volume depletion should have urine output monitored with a catheter. Fluid status is maintained by adequate IV fluid and electrolyte replacement. Broad-spectrum IV antibiotics effective against intestinal flora should be given.
Key Points
Pain is sudden and followed quickly by signs of peritonitis and shock.
Imaging with plain radiographs and/or CT is done.
Surgical repair is necessary in conjunction with IV fluid resuscitation and antibiotics.
