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.

• Camping

  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. Abdominal examination suggested acute peritonitis. [ncbi.nlm.nih.gov]

• Abdominal Pain

  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]

  abdominal pain and abdominal hardness, bloody stools, and many other conditions. [dovemed.com]

  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. [nlm.nih.gov]

• 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]

  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]

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• 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]

  vomiting) History of endoscopic procedures, such as colonoscopy [5, 6, 7, 8] History of chronic disease, such as ulcerative colitis With regard to abdominal pain, it is important to ask patients about the time of onset of pain, the duration and location [emedicine.medscape.com]

• Tachycardia

  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]

  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]

  Tachycardia, fever, and generalized abdominal tenderness may suggest peritonitis. Abdominal fullness and doughy consistency may indicate intra-abdominal hemorrhage. Tenderness on percussion may suggest peritoneal inflammation. [emedicine.medscape.com]

  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]

• Neck Pain

  In order to evaluate the patient's complaint of severe focal neck pain, MRI of the neck was performed. [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]

• Denial

  The autopsy and histological examination revealed a perforated crevasse, confirming the cause of peritonitis while excluding other probabilities despite the doctor's denial. [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]

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]

  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]

• Hepatic Necrosis

  Portal hypertension secondary to hepatic necrosis may be responsible for the exacerbation with the resumption of EN. [ncbi.nlm.nih.gov]

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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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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.