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Intestinal Perforation

Intestinal perforation can occur as a result of iatrogenic or accidental injuries or can be secondary to inflammation or malignancies. It can progress rapidly to life-threatening shock and should be diagnosed early to prevent morbidity and mortality.


Presentation

Intestinal perforation is an acute or subacute condition prevalent in all age groups. In adults, it presents with sudden onset of acute pain in the abdomen. It should be differentiated from other causes of abdominal pain as the manifestations of the different etiologies can be diverse with abdominal rigidity being common to all [1] [2]. The disastrous onset of diffuse abdominal pain may be associated with nausea, vomiting, hiccups, inability to pass flatus, constipation and referred pain to the shoulder. Abdominal pain may be minimal in elderly patients. The condition can deteriorate rapidly to tachycardia, diaphoresis, dyspnea and shock. Intestinal perforation secondary to inflammation is often small in the beginning with the omentum walling it off. This leads to localized pain and a slow progression of the symptoms.

Intestinal perforation in infants is associated with difficulty feeding, bilious vomiting typically after feeds, abdominal distension, hematochezia and features of sepsis such as apneic episodes, respiratory distress, thermo-instability, listlessness, and excessive crying. Premature infants are more susceptible to necrotizing enterocolitis with intestinal perforation than full-term neonates.

Cerebral Palsy
  • During the long-term follow-up period (median 6 years), six (five males) (26%) infants developed moderate to severe disabilities in combination with cerebral palsy. No surgical complications were observed.[ncbi.nlm.nih.gov]
Unable to Stand
  • However, the patients are often too sick and unable to stand erect for a radiogram.[symptoma.com]
Abdominal Pain
  • The disastrous onset of diffuse abdominal pain may be associated with nausea, vomiting, hiccups, inability to pass flatus, constipation and referred pain to the shoulder. Abdominal pain may be minimal in elderly patients.[symptoma.com]
  • A 14-year-old Nepalese girl presented with fever, abdominal pain and vomiting. She was living with her family in a temporary settlement camp following the earthquake in Nepal in 2015. She had had abdominal pain for 2 months and fever for 1 month.[ncbi.nlm.nih.gov]
  • Immunosuppression not only places the patient at risk for intestinal perforation but also masks classic clinical symptoms and signs of acute abdominal pain, leading to delayed diagnosis and proper treatment.[ncbi.nlm.nih.gov]
  • He initially responded to antibiotic treatment; however, his abdominal pain was rapidly worsened after resumption of oral intake.[ncbi.nlm.nih.gov]
  • A 34-year-old man with an 8-year history of outbreaks of oral and genital ulcers presented with high fever and skin lesions that had developed 21 days earlier, without abdominal pain.[ncbi.nlm.nih.gov]
Severe Abdominal Pain
  • In addition, sudden severe abdominal pain and tenderness developed 10 days after lung biopsy. He was diagnosed with gastrointestinal perforation, and he underwent surgery. However, he died 2 weeks after the surgery.[ncbi.nlm.nih.gov]
  • Symptoms may include: Severe abdominal pain Chills Fever Nausea Vomiting Shock X-rays of the chest or abdomen may show air in the abdominal cavity. This is called free air. It is a sign of a tear.[medlineplus.gov]
  • Snap Shot A 41-year-old male with history of Crohns disease presents to the emergency departmentwith severe abdominal pain. The patient reports that he has not had a bowel movement in 24 hours. His pain continues to worsen.[step2.medbullets.com]
Acute Abdomen
  • Phytobezoars are uncommon causes of acute abdomen. We report a patient who presented with acute abdomen and who was intra-operatively diagnosed as having a small intestinal perforation due to an intestinal phytobezoar.[ncbi.nlm.nih.gov]
  • However, in some cases, the ingested foreign body can cause complications such as acute abdomen due to intestinal perforation and even death.[ncbi.nlm.nih.gov]
  • He presented with acute abdomen, and an emergency laparotomy revealed a plug-related bowel perforation. The plug had migrated and penetrated the peritoneum, presenting with bowel perforation and adhesions.[ncbi.nlm.nih.gov]
  • Small intestinal perforation secondary to foreign body ingestion is usually manifested as an acute abdomen without a history of trauma.[ncbi.nlm.nih.gov]
  • Some Causes of GI Tract Perforation Symptoms and Signs Esophageal, gastric, and duodenal perforation tends to manifest suddenly and catastrophically, with abrupt onset of acute abdomen with severe generalized abdominal pain, tenderness, and peritoneal[msdmanuals.com]
Intestinal Disease
  • The intestinal diseases included necrotizing enteritis in two and meconium-related ileus with focal intestinal perforation in one. The duration of total PN without EN in the three cases was 17, 24 and 24 days, respectively.[ncbi.nlm.nih.gov]
  • […] cw ヒト, ヒト, human(primates), 012150, human, 男性, ダンセイ(オトコ), man, 017125, ダンセイ, 成人, セイジン, adult(person), 017082, adult, 症例報告, ショウレイホウコク, case report, 054676, 外傷, ガイショウ, injury, 023276, 穿孔, センコウ(アナ), piercing, 051349, センコウ, *, 腸疾患, チョウシッカン, intestinal[togodb.biosciencedbc.jp]
  • Typhoid intestinal disease: 32 perforations in 1 patient. Niger Postgrad Med J. 2008; 15 :55–7. [ PubMed ] 7. Connolly DP, Ugwu BT, Eke BA. Single-layer closure for typhoid perforations of the small intestine: Case report.[ncbi.nlm.nih.gov]
Oral Ulcers
  • The report of histology in conjunction with the clinical history and the presence of oral ulcers, uveitis and suspected cutaneous lesions suggests the diagnosis. The optimal medical treatment of Behçet syndrome has not yet been well established.[ncbi.nlm.nih.gov]
Tachycardia
  • The condition can deteriorate rapidly to tachycardia, diaphoresis, dyspnea and shock. Intestinal perforation secondary to inflammation is often small in the beginning with the omentum walling it off.[symptoma.com]
  • Nausea and vomiting, tachycardia, hypotension, fevers, chills, sweats, confusion, and decreased urinary output are common. Treatment Surgical treatment is necessary.[medical-dictionary.thefreedictionary.com]
  • Presenting signs and symptoms of bowel perforation in 24 patients treated with bevacizumab. 12 *Specific signs included mental status changes, fever, tachycardia ( 120 beats per minute), and leukocytosis.[jaoa.org]
  • After approximately 20 minutes the patient developed pain, abdominal distension, cyanosis, and hypoperfusion of the lower limbs which were followed by sweating, tachycardia (120 bpm), arterial hypotension (70 x 50 mmHg), and moderate dyspnea and reduction[scielo.br]
  • If a patient is experiencing pain, tachycardia, and fever following surgery, bowel injury should be suspected, warranting immediate consultation with a general surgeon.[theexpertinstitute.com]
Skin Lesion
  • A 34-year-old man with an 8-year history of outbreaks of oral and genital ulcers presented with high fever and skin lesions that had developed 21 days earlier, without abdominal pain.[ncbi.nlm.nih.gov]
  • During a follow-up, although a radiological improvement was observed in the chest X-ray, cardiac failure, peripheral neuropathy and skin lesions developed and high-dose intravenous immunoglobulin and anti-TNF therapy (adalimumab) were applied.[ncbi.nlm.nih.gov]
Palpable Purpura
  • We report a 4-year-old Thai boy who presented with palpable purpura, abdominal colicky pain, seizure, and eventually developed intestinal ischemia and perforation despite adequate treatment, including corticosteroid and intravenous immunoglobulin therapy[ncbi.nlm.nih.gov]
Vaginal Bleeding
  • Antecedents of mNEC included mother's identification as Black, consumption of aspirin during the pregnancy, and vaginal bleeding after the 12th week of gestation.[ncbi.nlm.nih.gov]
Aphasia
  • Overall, this is the first patient with MAP combined with motor aphasia and intestinal perforation and may provide insights for future studies on the treatment of this disease.[ncbi.nlm.nih.gov]

Workup

The diagnosis of intestinal perforation in the setting of an emergency can be made from a detailed history, physical examination, laboratory and radiological tests [3]. The onset, duration, location, and progression of abdominal pain provides an approximate clue about the organ involved e.g. pain in perforated appendicitis is often located in the right lower abdominal quadrant; pain in diverticulitis is in the left lower quadrant and pain secondary to duodenal perforation is typically in the epigastric region. It is important to inquire about foreign body ingestion, especially in children; chronic use of medications like steroids or aspirin; recent history of gastrointestinal endoscopy [4] [5] [6] [7]; and a history of travel to exclude salmonella gastroenteritis perforation. Physical examination may reveal abdominal guarding, rigidity, signs of injury or even shock. A rectal and vaginal examination should be a part of the workup to exclude appendicitis, diverticulitis and tubo-ovarian abscess as the cause for the symptoms.

Laboratory workup should include a complete blood count, erythrocyte sedimentation rate, packed cell volume, liver transaminases and renal function tests. In presence of leukocytosis indicative of infection, a blood culture should be performed.

Plain X-ray abdomen in the standing position is the best initial investigation in intestinal perforation [8] as the gas under the diaphragm is diagnostic of a perforated viscus. However, the patients are often too sick and unable to stand erect for a radiogram. In such patients, an abdominal ultrasound is useful as an initial tool in the workup and computed tomography (CT) scan is obtained in patients with nonspecific ultrasound results [3].

In some cases, a diagnostic peritoneal tap may be indicated to detect intra-abdominal blood or to drain pus for microbiological culture sensitivity testing. In presence of blunt trauma, peritoneal lavage is used to measure alkaline phosphatase levels and a level > 10IU/L is a strong indicator of an occult small intestinal perforation.

Pneumoperitoneum
  • After two weeks of conservative management, including bowel rest and antibiotics, his pneumoperitoneum resolved spontaneously without any complications.[ncbi.nlm.nih.gov]
  • Inclusion criteria were pneumoperitoneum on x-ray (isolated perforation or necrotising enterocolitis), birthweight RESULTS: Fifty patients met the criteria (38 PD, 12 primary laparotomy).[ncbi.nlm.nih.gov]
  • Pneumoperitoneum without peritonitis is a rare phenomenon which creates a management problem for the treating surgeon. We present two cases of pneumoperitoneum to discuss the non-surgical management of pneumoperitoneum and describe their outcomes.[afrjpaedsurg.org]
  • There were 68 infants with suspicion for SIP, 11 with pneumoperitoneum and 57 with gasless abdomen on X-rays. Ultrasound was performed in 55 of 57 infants with gasless abdomen, 10 with SIP and 45 nonperforated.[ncbi.nlm.nih.gov]
  • Occult spontaneous intestinal perforation (SIP), without pneumoperitoneum on abdominal radiograph, typically occurs in neonates 2 weeks of age and is usually diagnosed by visualization of particulate matter seen on an abdominal ultrasound.[ncbi.nlm.nih.gov]
Hepatic Necrosis
  • Portal hypertension secondary to hepatic necrosis may be responsible for the exacerbation with the resumption of EN.[ncbi.nlm.nih.gov]

Treatment

  • However, few reports compare primary anastomosis and ileostomy as IIP treatment. In our institution we favored primary anastomosis as first line treatment whenever patient's condition permitted.[ncbi.nlm.nih.gov]
  • AIM: To discuss intestinal side effects of ibuprofen in the treatment of patent ductus arteriosus, after having observed two cases of spontaneous intestinal perforation following ibuprofen treatment.[ncbi.nlm.nih.gov]
  • Despite all treatment, the patient died a week later. We summarized all the previous reports of MAP based on thorough review of previous published work.[ncbi.nlm.nih.gov]
  • Prompt diagnosis and appropriate surgical treatment are essential to avoid morbidity and mortality.[ncbi.nlm.nih.gov]
  • RESULTS: Mean norepinephrine dose was significantly reduced (0.9 0.5 μg/kg/min pre-first DHP-PMX vs 0.3 0.4 μg/kg/min post-second DHP-PMX treatment, p CONCLUSIONS: Performing two sessions of DHP-PMX treatment in a cohort of patients with abdominal sepsis[ncbi.nlm.nih.gov]

Prognosis

  • Early surgical treatment is the main treatment strategy with a good prognosis. However, delayed diagnosis may result in complications and even death.[ncbi.nlm.nih.gov]
  • Immunocompromised patients with intestinal perforation due to CMV enteritis have a poor prognosis. We report a case with along with the results of a literature review.[ncbi.nlm.nih.gov]
  • Because of the high mortality rate early diagnosis and treatment are important to improve the prognosis of bowel perforation in patients with non-Hodgkin's lymphoma.[ncbi.nlm.nih.gov]
  • Henoch-Schönlein purpura (HSP) is generally a self-limited vasculitis disease and has a good prognosis.[ncbi.nlm.nih.gov]
  • Type of study-Prognosis study. Copyright 2017 Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]

Etiology

  • Infant, Premature, Diseases/diagnosis* Infant, Premature, Diseases/etiology Infant, Premature, Diseases/mortality Infant, Premature, Diseases/surgery Intestinal Perforation/diagnosis* Intestinal Perforation/etiology Intestinal Perforation/mortality Intestinal[ncbi.nlm.nih.gov]
  • Abstract Peritonitis of viral etiology is rarely reported in the literature; a prior report described a patient undergoing continuous ambulatory peritoneal dialysis who had the disease.[ncbi.nlm.nih.gov]
  • Although the etiology was not clear, the use of nonabsorbable sutures for plug fixation may be recommended to avoid this complication.[ncbi.nlm.nih.gov]
  • The described case supports that a mechanical rather than a bacterial etiology underlies the pathogenesis of PI.[ncbi.nlm.nih.gov]
  • Wegener's granulomatosis is a necrotizing vasculitis of unknown etiology characterized mainly by inflammation of the small- and medium-sized arteries and veins that affect any viscera. It may rarely involve the gastrointestinal tract.[ncbi.nlm.nih.gov]

Epidemiology

  • Gov't MeSH terms Canada Cross Infection/epidemiology* Enterocolitis, Necrotizing/complications Enterocolitis, Necrotizing/diagnosis* Female Gestational Age Humans Infant Infant Mortality Infant, Extremely Premature* Infant, Newborn Infant, Premature,[ncbi.nlm.nih.gov]
  • Electronic address: stephanie.merhar@cchmc.org. 2 Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH. 3 Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.[ncbi.nlm.nih.gov]
  • The epidemiology and pathogenesis of necrotizing enterocolitis. Semin Neonatol 1997;2:231-8.[afrjpaedsurg.org]
  • Reference article This is a summary article ; read more in our article on bowel perforation . epidemiology depends on the cause presentation history may depend on the location of the perforation severe and generalised abdominal pain (upper) gradual and[radiopaedia.org]
  • Reference article This is a summary article ; read more in our article on bowel perforation. epidemiology depends on the cause presentation history may depend on the location of the perforation severe and generalized abdominal pain (upper) gradual and[radiopaedia.org]
Sex distribution
Age distribution

Pathophysiology

  • Their pathophysiology and molecular mechanisms remain unclear.[ncbi.nlm.nih.gov]
  • We report a case of primary herpetic peritonitis (the agent of which was typed by polymerase chain reaction as herpes simplex virus biotype 1), which caused intestinal perforation, and we review the current literature and provide possible pathophysiologic[ncbi.nlm.nih.gov]
  • ., Weening, J. and Cohen, J.W. (1994) Anti-neutrophil cytoplasmic antibodies: Current diagnostic and pathophysiological potential.[dx.doi.org]
  • Our objective was to identify dysregulated micro-RNAs (miRNAs) in small bowel tissues of NEC and SIP, and their possible roles in disease pathophysiology.[ncbi.nlm.nih.gov]
  • The possible reasons for the high mortality and morbidity rates at that time may have been related to the following factors: Knowledge in the area of bowel injuries and the pathophysiologic changes triggered by such injuries was inadequate Clinical skills[emedicine.medscape.com]

Prevention

  • Intestinal perforation is a lethal complication and continues to occur in impoverished areas despite advances in preventive and therapeutic strategies.[ncbi.nlm.nih.gov]
  • We encourage nationwide policy revision to prevent further incidents similar to the one described in this case.[ncbi.nlm.nih.gov]
  • Unique problems in diagnosis, preventive steps, and risk reduction are discussed.[ncbi.nlm.nih.gov]
  • In highly suspicious cases, exploratory laparotomy may be needed for the definite diagnosis and prevention of further complications.[ncbi.nlm.nih.gov]
  • CONCLUSION: MCZ may have preventive roles in the clinical management of IP in ELBWI by the suppression of IL-8 and HMGB-1.[ncbi.nlm.nih.gov]

References

Article

  1. Scardapane A, Rubini G, Lorusso F, et al. Role of multidetector CT in the evaluation of large bowel obstruction. Recenti Prog Med. 2012;5(11):489–92.
  2. Stabile Ianora AA, Lorusso F, Niccol Asabella A, et al. Multidetector CT for the assessment of the groin region. Recenti Prog Med. 2012;5(11):483–8.
  3. Coppolino FF, Gatta G, Di Grezia G, et al. Gastrointestinal perforation: ultrasonographic diagnosis. Crit Ultrasound J. 2013; 5 (Suppl 1): S1-S4
  4. Stapfer M, Selby RR, Stain SC, et al. Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg. 2000 Aug; 232(2):191-8.
  5. Anderson ML, Pasha TM, Leighton JA. Endoscopic perforation of the colon: lessons from a 10-year study. Am J Gastroenterol. 2000 Dec; 95(12):3418-22.
  6. Iqbal CW, Cullinane DC, Schiller HJ, et al. Surgical management and outcomes of 165 colonoscopic perforations from a single institution. Arch Surg. 2008 Jul; 143(7):701-6; discussion 706-7.
  7. Teoh AY, Poon CM, Lee JF, et al. Outcomes and predictors of mortality and stoma formation in surgical management of colonoscopic perforations: a multicenter review. Arch Surg; 2009 Jan. 144(1):9-13.
  8. Butler J, Martin B. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Detection of pneumoperitoneum on erect chest radiograph. Emerg Med J. 2002 Jan;19(1):46-7.

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Last updated: 2019-06-28 10:44