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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock, 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 Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock.

Epidemiology

  • A life-threatening cause of abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Peptic ulcer disease Peptic ulcer disease (PUD) refers to the full-thickness ulcerations of duodenal or gastric mucosa. The ulcerations form when exposure to acid and digestive enzymes overcomes mucosal defense mechanisms. The most common etiologies include Helicobacter pylori (H. pylori) infection and prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs). Peptic Ulcer Disease ( PUD PUD Peptic ulcer disease (PUD) refers to the full-thickness ulcerations of duodenal or gastric mucosa. The ulcerations form when exposure to acid and digestive enzymes overcomes mucosal defense mechanisms. The most common etiologies include Helicobacter pylori (H. pylori) infection and prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs). Peptic Ulcer Disease):
    • 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 Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Enquire about:
    • Prior patterns of abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Prior abdominal surgeries 
    • Medications (e.g., NSAIDs)

Physical exam

Vitals:

  • Early findings: fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, tachycardia, tachypnea
  • Late findings: hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension, sepsis Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock, shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain: Fluid from the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach or biliary ducts drains down the paracolic gutters into the lower quadrants and causes localized irritation.
  • Referred pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. 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
Large volume pneumoperitoneum

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 Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology: Overview and anaerobes)
    • Use of broad-spectrum antibiotics
  • Surgery:
    • Early surgical consultation (urgent exploratory laparotomy Laparotomy Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparotomy and Laparoscopy)
    • 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 Peptic ulcer disease Peptic ulcer disease (PUD) refers to the full-thickness ulcerations of duodenal or gastric mucosa. The ulcerations form when exposure to acid and digestive enzymes overcomes mucosal defense mechanisms. The most common etiologies include Helicobacter pylori (H. pylori) infection and prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs). 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 Peptic ulcer disease Peptic ulcer disease (PUD) refers to the full-thickness ulcerations of duodenal or gastric mucosa. The ulcerations form when exposure to acid and digestive enzymes overcomes mucosal defense mechanisms. The most common etiologies include Helicobacter pylori (H. pylori) infection and prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs). Peptic Ulcer Disease can present as chronic peptic-ulcer pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain that suddenly becomes severe. Treatment is usually with surgery.
  • Diverticulitis: the inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of diverticula within the intestine. Diverticulitis can occur in the small and large intestine Large intestine The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix or the colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix and usually presents with significant abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Acute pancreatitis Acute pancreatitis is an inflammatory disease of the pancreas due to autodigestion. Common etiologies include gallstones and excessive alcohol use. Patients typically present with epigastric pain radiating to the back. 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain that radiates to the back, which is accompanied by nausea and/or vomiting. Continued inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the surrounding intestines can cause perforation in severe cases.
  • Acute cholecystitis Cholecystitis Cholecystitis is the inflammation of the gallbladder (GB) usually caused by the obstruction of the cystic duct (acute cholecystitis). Mechanical irritation by gallstones can also produce chronic GB inflammation. Cholecystitis is one of the most common complications of cholelithiasis but inflammation without gallstones can occur in a minority of patients. Cholecystitis: an inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the gallbladder Gallbladder The gallbladder is a pear-shaped sac, located directly beneath the liver, that sits on top of the superior part of the duodenum. The primary functions of the gallbladder include concentrating and storing up to 50 mL of bile. Gallbladder and Biliary Tract that develops over hours, usually because a gallstone obstructs the cystic duct. Acute cholecystitis Cholecystitis Cholecystitis is the inflammation of the gallbladder (GB) usually caused by the obstruction of the cystic duct (acute cholecystitis). Mechanical irritation by gallstones can also produce chronic GB inflammation. Cholecystitis is one of the most common complications of cholelithiasis but inflammation without gallstones can occur in a minority of patients. Cholecystitis typically presents with right upper-quadrant epigastric abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, leukocytosis, and Murphy sign (e.g., inspiratory arrest during right upper-quadrant palpation).
  • Perforated acute appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis: Appendicitis is the acute inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the vermiform appendix and the most common abdominal surgical emergency. Perforation is seen in approximately 30% of presentations of acute appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis. Some patients may present with mild or vague pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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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