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Perforation of the intestine

Gastrointestinal perforation or perforation of the intestine is a hole developed in the oesophagus, stomach, gall bladder, small intestine, large bowel and rectum. It is a life-threatening emergency that requires immediate medical attention. Upper bowel perforation can be contained or free. In a contained perforation an ulcer develops a full-thickness hole and in free perforation the contents of the bowel spill into the abdominal cavity.

Causes

Intraluminal acidity keeps the stomach free from any bacteria and microorganisms. Individuals who have a history of gastric problems are at a greater risk of gastric perforation.

  • Any predisposing condition such as appendicitis, peptic ulcer disease, inflamed Meckel diverticulum and acute diverticulitis can cause bowel perforation

  • Blunt trauma to the abdomen – Abdominal blunt traumas to the stomach are common with children especially handlebar injuries, seat-belt syndromes, etc.

  • NSAIDs – Aspirin and non-steroidal anti-inflammatory drugs ingested by patients with diverticulitis can increase the risk of perforation

  • Chest and lower abdomen knife injuries or any penetrating injury to the intra-abdominal viscus

  • Endoscopic bowel injuries occurring during colonoscopy and ERCP

  • Intestinal puncture as a result of laparoscopic complications

  • Dislocation of endoscopic biliary stents

  • Bacterial infections like typhoid can complicate intestinal perforation

  • Inflammatory bowel disease or Crohn’s disease

  • Intestinal ischemia or intestinal colitis

  • Intra-abdominal malignancies, metastatic renal carcinoma, desmoid tumours

  • Caustic substance ingestions

Signs and Symptoms

  • Stomach pain – severe and sudden onset of epigastric pain

  • Nausea

  • Vomiting

  • Fever

  • Chills

  • Hiccups – during a perforated peptic ulcer

  • Pain in the lower abdomen with perforated diverticulitis and a ruptured appendicitis

  • In patients with peritonitis:

    • Tender abdomen

    • Pain worsens upon palpation

    • Abdomen sticks out further than usual and feels hard

    • Dyspnea

    • Increased heart rate

    • Exhaustion

    • Decreased passage of urine, stool and gas

Diagnosis

  • CBC – complete blood count reveals infection; increased WBC levels are also suggestive of an infection

  • Blood culture to detect aerobic and anaerobic organisms

  • Liver function test

  • Renal function test

  • Abdominal CT scan reveals any localized perforation

  • Erect chest radiography can show free air in subdiaphragmatic locations, oblique structure of the falciform ligament and air fluid levels in the abdomen

  • Ultrasonography detects localized collection of gas

Treatment and Medication

Treatment for an emergency situation such as intestinal perforation is surgical intervention. Medical therapy may be inclusive of antibiotics such as metronidazole and gentamicin for post-operative wound care.

Dr. Deepak is an eminent GI surgeon based in Chennai, India.

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