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]

• 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]

  […] intestine), any congenital abnormality of the intestine, surgery involving the abdominal organs, and cancer The signs and symptoms of perforation may include fever and chills, nausea, vomiting, severe abdominal pain and abdominal hardness, bloody stools [dovemed.com]

  This causes a severe infection called peritonitis. 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]

• Acute Abdomen

  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]

  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]

  胃腸疾患, ｲﾁｮｳｼｯｶﾝ, gastrointestinal disease, 054588, 消化器疾患, ｼｮｳｶｷｼｯｶﾝ, digestive system disease, 012793, 炎症, ｴﾝｼｮｳ(ﾋﾞｮｳｷ), inflammation, 010541, ｴﾝｼｮｳ, 腹膜疾患, ﾌｸﾏｸｼｯｶﾝ, peritoneal disease, 054354, 治療法, ﾁﾘｮｳﾎｳ, therapy, 040918, 小腸, ｼｮｳﾁｮｳ, small intestine [togodb.biosciencedbc.jp]

  Perforation Gastroenteritis Gastrointestinal Diseases Digestive System Diseases Intestinal Diseases [clinicaltrials.gov]

• Bilious Vomiting

  A 4-year-old girl was admitted to our department with complaints of abdominal pain and bilious vomiting. She had been treated at another clinic with repeated abdominal X-rays because of ingestion of a magnet 5 days ago. [ncbi.nlm.nih.gov]

  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, [symptoma.com]

  This occurs, albeit uncommonly, in patients with a perforated ulcer; vomiting is, however, frequently noted in patients with acute cholecystitis; in patients with appendicitis, pain almost always precedes vomiting by 3-4 hours, whereas the converse [emedicine.medscape.com]

• 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]

  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]

  Nausea and vomiting, tachycardia, hypotension, fevers, chills, sweats, confusion, and decreased urinary output are common. Treatment Surgical treatment is necessary. [medical-dictionary.thefreedictionary.com]

  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]

  Abdominal pain (100%) and vomiting (81%) were the most common symptoms while tachycardia (50%) and tachypnea (42%) were common signs; 15-20% presented late with features of shock. [ispub.com]

• 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]

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

  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]

  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]

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]

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]

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]

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]

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]

“Epidemiology of pediatric inflammatory bowel disease: A systematic review of international trends”. Inflammatory Bowel Disease 2011; 17 (1), 423–439. Castro M., Papadatou B., Baldassare M., Balli F. et al. [ragazzicoraggiosi.it]

Their pathophysiology and molecular mechanisms remain unclear. [ncbi.nlm.nih.gov]

Seminars in Arthritis and Rheumatism, 34, 431-441. doi:10.1016/j.semarthrit.2003.12.004 [ 4 ] Kallenberg, C.G., Brouwer, E., Weening, J. and Cohen, J.W. (1994) Anti-neutrophil cytoplasmic antibodies: Current diagnostic and pathophysiological potential [dx.doi.org]

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]

We encourage nationwide policy revision to prevent further incidents similar to the one described in this case. [ncbi.nlm.nih.gov]

Experimental models involving rats have shown that concurrent use of retinoids helps prevent MTX induced reduction in crypt cell purines and pyrimidines thereby preventing perforation. [shmabstracts.com]

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3. Coppolino FF, Gatta G, Di Grezia G, et al. Gastrointestinal perforation: ultrasonographic diagnosis. Crit Ultrasound J. 2013; 5 (Suppl 1): S1-S4
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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.