Perforated Viscus

Perforated viscus or GI perforation represents a condition in which the integrity of the GI wall is lost with subsequent leakage of enteric contents into the peritoneal cavity, resulting in peritonitis. The causes of perforated viscus include trauma, bowel ischemia, infections, or ulcerative conditions, all of which ultimately lead to a full-thickness disruption of the intestinal wall. Perforated viscus presents as sudden onset of abdominal pain, distention, nausea, vomiting, obstipation, and symptoms of peritonitis. Diagnosis relies on the medical history as well as imaging studies, including abdominal and pelvic CT scan and X-ray. Treatment includes bowel rest, the use of a nasogastric tube, antibiotics to avoid severe infections or sepsis, analgesics, and surgical repair.

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Overview

Definition

A perforated viscus, also known as intestinal or bowel perforation, is a full-thickness disruption of the intestinal wall, with subsequent leakage of enteric contents into the peritoneal cavity, resulting in a systemic inflammatory response, peritonitis, and possibly sepsis.

Epidemiology

  • A life-threatening cause of abdominal pain
  • Mortality of 30%–50%
  • 1%–7% incidence in pediatric trauma patients
  • Intestinal ulcers most common cause in adults
  • Perforated appendix most common cause in geriatric patients

Etiology

  • Peptic ulcer disease (PUD):
    • A duodenal ulcer is most common, accounting for 60% of cases (anterior ulcers perforate into the anterior abdominal cavity).
    • Antral gastric ulcers (20%)
    • Gastric body ulcers (20%)
  • Infectious causes (diverticulitis, appendicitis)
  • Bowel ischemia
  • Bowel obstruction: extrinsic and intrinsic
  • Decreased bowel-wall integrity from diverticulosis
  • Trauma
  • Foreign bodies

Clinical Presentation

History

  • Sudden onset of severe abdominal pain
  • Enquire about:
    • Prior patterns of abdominal pain
    • Prior abdominal surgeries 
    • Medications (e.g., NSAIDs)

Physical exam

Vitals:

  • Early findings: fever, tachycardia, tachypnea
  • Late findings: hypotension, sepsis, shock, overall ill appearance

Abdominal exam:

  • Early: focal tenderness on the area of perforation
  • Late: peritoneal signs
    • Patient lying still
    • Diffuse abdominal tenderness and/or rigidity
    • Rebound and guarding
    • Decreased bowel sounds
  • Lower-quadrant abdominal pain: Fluid from the stomach or biliary ducts drains down the paracolic gutters into the lower quadrants and causes localized irritation.
  • Referred pain to the shoulder due to irritation of the phrenic nerve

Atypical presentation:

  • Common in elderly and immunocompromised patients
  • Delayed presentation
  • Pain for days rather than minutes/hours
  • Pain out of proportion to physical exam
  • Insignificant vital signs (might be normal)
  • Be sure to have a low threshold for imaging in these patients.

Diagnosis

Laboratory workup

  • Lactic acid levels (indicates decreased blood flow and possible infections)
  • Urine hCG for all women of childbearing age
  • Lipase
  • Positive stool guaiac test

Imaging

  • CT scan: 
    • Test of choice when there is a concern for perforation
    • Can detect small amounts of free air in the peritoneal cavity (pneumoperitoneum)
    • Can determine the underlying problem
    • Can detect other differential diagnoses more than an X-ray
  • Upright X-ray of thorax and abdomen: 
    • Presence of air under the diaphragm
    • Poor sensitivity and specificity
  • Ultrasound: 
    • Utilized with increased frequency
    • Detects free air and enhancement of the peritoneal strip
    • Requires skilled individuals with technical knowledge

Postoperative CT scan demonstrating a large-volume pneumoperitoneum due to bronchoperitoneal fistula

Image: “Post-operative computed tomography (CT) scan” by Johns Hopkins Hospital, Department of Surgery, Baltimore, MD, USA. License: CC BY 2.0

Management

  • ABC (airway, breathing, and circulation) assessment
  • Fluid resuscitation with 2 large-bore IV lines
  • Consider the use of blood products in case of hemodynamic instability.
  • Antibiotic therapy:
    • Should cover gut flora (gram-negative bacteria and anaerobes)
    • Use of broad-spectrum antibiotics
  • Surgery:
    • Early surgical consultation (urgent exploratory laparotomy)
    • A common option for a poor operative candidate with a perforated gastric ulcer is a Graham patch (a piece of the omentum is used to cover the perforation).
    • Interventional radiology might also be used.

Differential Diagnosis

  • Peptic ulcer disease: a full-thickness ulceration of the duodenal or gastric mucosa. Perforated ulcers are the most common cause of perforated viscus. Gastric and duodenal ulcers are the 2 most common types of peptic ulcers. Peptic ulcer disease can present as chronic peptic-ulcer pain that suddenly becomes severe. Treatment is usually with surgery.
  • Diverticulitis: the inflammation of diverticula within the intestine. Diverticulitis can occur in the small and large intestine or the colon and usually presents with significant abdominal pain and elevated WBC count. Primary treatment is with antibiotics. If the diverticula are inflamed and weakened, they may rupture causing perforated viscus. 
  • Acute pancreatitis: an inflammatory process of the pancreatic tissue with cellular destruction and elevation of serum lipase. Patients present with sudden onset of severe and persistent abdominal or epigastric pain that radiates to the back, which is accompanied by nausea and/or vomiting. Continued inflammation of the surrounding intestines can cause perforation in severe cases.
  • Acute cholecystitis: an inflammation of the gallbladder that develops over hours, usually because a gallstone obstructs the cystic duct. Acute cholecystitis typically presents with right upper-quadrant epigastric abdominal pain, fever, leukocytosis, and Murphy sign (e.g., inspiratory arrest during right upper-quadrant palpation).
  • Perforated acute appendicitis: Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency. Perforation is seen in approximately 30% of presentations of acute appendicitis. Some patients may present with mild or vague pain after the appendix has already ruptured. Surgery is typically required.

References

  1. Cahalane, M.J. (2019). Overview of gastrointestinal tract perforation. In W. Chen (Ed.), UpToDate. Retrieved March 3, 2021, from https://www.uptodate.com/contents/overview-of-gastrointestinal-tract-perforation
  2. Jones, M.W., Kashyap, S., Zabbo, C.P. Bowel Perforation. (Updated February 8, 2021). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved March 3, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK537224/

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