Gastrointestinal perforation

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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.

• Ulcerative/erosive disease ^[2]
  • Peptic ulcer disease:
    • Most common cause of stomach and duodenal perforation ^[3]
    • 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): e.g., post-ERCP duodenal perforation
  • Penetrating trauma (e.g., stab injury)
  • Iatrogenic perforations (e.g, during colonoscopy, laparoscopic surgery): e.g., post-ERCP duodenal perforation
  • 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 ^[4]

• 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) ^[5]

Imaging ^[6][7]

Immediate studies

• Indications: Consider only for patients too unstable to safely undergo CT scanning.
• X-ray abdomen (upright or lateral decubitus) ^[8]
  • Combine lateral decubitus with upright CXR to increase sensitivity.
  • Findings: free intraperitoneal air (pneumoperitoneum) under the diaphragm and/or between liver and lateral abdominal wall
• Point of care ultrasound (POCUS) for which characteristic findings include: ^[9][10]
  • Enhanced peritoneal stripe sign: a hyperechogenic focal thickening of the peritoneum
  • Horizontal reverberation artifacts: horizontal stripes resulting from the interface of free air and fascia

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. ^[8]

Confirmatory studies

• First line: CT abdomen and pelvis with IV contrast (most sensitive)
  • Indications: acute nonlocalized abdominal pain
  • Findings
    • Pneumoperitoneum: the presence of air in the peritoneal cavity
      • An abdominal x-ray showing radiolucent air under the diaphragm and/or the delineation of the bowel wall by radiolucent air is diagnostic.
      • Can occur after perforation of a hollow abdominal viscus (e.g., perforated peptic ulcer) or after surgery in which air is introduced into the abdominal cavity.
    • Signs of perforated bowel: loss of bowel wall continuity, localized mesenteric fat stranding
• 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

• Bowel rest (NPO)
• IV access with two large-bore peripheral IVs
• Start broad-spectrum IV antibiotics: See “Severe infection” in “Empiric antibiotic therapy for intraabdominal infection.”
• Obtain an urgent surgical consult to determine whether surgery or conservative management is appropriate.
• Patients with signs of sepsis and/or shock additionally require:
  • Immediate hemodynamic support, e.g., aggressive IV fluid resuscitation
  • Urgent critical care consult
• Begin supportive care (e.g., analgesics, antiemetics).
• Reevaluate frequently (serial abdominal examination, vital signs), as the patient's condition may rapidly deteriorate.

Supportive care

• NG tube with continuous or intermittent suction
• Consider IV PPI, e.g., pantoprazole for patients with suspected perforated peptic ulcer. ^[11]
• Parenteral analgesics
  • Opioid analgesics ^[12]
    • 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 ^[13]

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 ^[14]
  • 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. ^[15]

Conservative management ^[11][15]

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 intraabdominal infection”
• If imaging shows evidence of an abscess: Consider image-guided percutaneous drainage of abscess. ^[16]
• 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

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

Diagnosis ^[17][18]

• Emergency surgery consult (prior to imaging) in patients with :
  • Suspected GI perforation due to penetrating abdominal trauma
  • Suspected traumatic GI perforation with hemodynamic instability
• Maintain high index of suspicion: Clinical features may be subtle.
  • Patients with BAT are at elevated risk, especially if they also have : ^[18]
    • High-energy injury: e.g., resulting from high-speed motor vehicle collision
    • Seat belt sign (typical injury after a vehicle collision with ecchymoses on the neck or on the flank caused by the seat belt strap) 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:
    • Persistent pain
    • Pain out of proportion
    • Delayed peritoneal signs

Maintain a high index of suspicion for hollow viscus injury in patients with blunt abdominal trauma as clinical features may initially be very subtle. ^[18]

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. ^[19][20]
• Stable patients with any other traumatic etiologies: Consult surgery to determine if operative or nonoperative management is most appropriate. ^{[18][21][22][23]}

• 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 intraabdominal infection”.
• Electrolyte repletion
• Supplemental oxygen, if necessary
• Parenteral analgesics
• Parenteral antiemetics
• Admit to surgical ICU.
• Serial abdominal examination

• Peritonitis
• Bacteremia
• Sepsis
• Multiorgan dysfunction
• Intraabdominal abscess
• Intraabdominal adhesions
• Subhepatic abscess
• Pyogenic liver abscess
• Pelvic abscess
• Postoperative complications

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