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Stomach Perforation

Stomach perforation is considered to be a medical emergency and may be seen after peptic ulcer, use of non-steroidal anti-inflammatory drugs, complications from surgery or malignant diseases, and foreign body injury. Abdominal pain and an epigastric sensation are notable symptoms, while some individuals have a completely asymptomatic course. The diagnosis rests on findings obtained during history taking and imaging studies, with computed tomography being the gold standard.


Presentation

Stomach perforation can be life-threatening if not recognized on time, and various causes have been described in the literature [1]. Peptic ulcer disease (PUD) and perforation, long-term administration of non-steroidal anti-inflammatory drugs (NSAIDs), malignancies involving the gastrointestinal system (GI), medical procedures (eg. intubation, GI surgery), and ingestion of foreign bodies (toothpicks, metal coins, etc.), either incidental or intentional, are notable etiologies of stomach perforation [1] [2] [3] [4] [5] [6] [7]. In addition, incarcerated hiatal hernia is also reported as a condition that may lead to perforation [8]. The clinical presentation is often nonspecific, with most common symptoms being abdominal distension and pain accompanied by an abnormal sensation in the epigastric area and reduced appetite [3]. Signs of peritonitis might be seen as well [9]. Perforation caused by foreign bodies tend to have a chronic course, and days or weeks often pass before the diagnosis is made [3] [9]. On the other hand, severe forms have an abrupt onset, in which case a prompt diagnosis is imperative. Unfortunately, some patients may have an asymptomatic presentation, thus the diagnosis might be delayed for a significant period of time [9].

Fever
  • After a period of seven days the patient was readmitted to the PICU, with signs and symptoms of acute abdomen: severe epigastric pain whose intensity increased with the change of position, nausea, vomiting, fever and chills.[cejpaediatrics.com]
  • A 41-year-old man presented weight loss, low grade fever, and vomiting. Upper gastrointestinal endoscopy showed a large ulcer on the antrum of the stomach.[jstage.jst.go.jp]
  • The patient may feel pain in the upper abdomen or fever ( 101.5 F) or a low-grade temperature. The surgeon or staff will order blood work and possibly an x-ray or CT scan.[obesityhelp.com]
  • Speak to a doctor if you experience any significant change from your normal state, especially if you have abdominal pain and fever.[healthline.com]
  • A perforation may also occur in the gallbladder, and symptoms include severe stomach pain, vomiting, and fever.[sheknows.com]
Sepsis
  • Sepsis If left untreated (hours or days), perforation can lead to Sepsis . Sepsis is a life-threatening complication of the infection process.[cuthbertlaw.com]
  • (enterale Motilitätsstörung) Ursachen: Mensenterialinfarkt, Infektiöse Enteritis, Toxische Enteritis, Ulkus, Meteorismus, Darmperforation, feline Dysautonomie, Pylorusstenose, Peritionitis, Urämie, Sepsis, Pankreatitis, Hypokaliämie, Hypothyreose, DKA[card2brain.ch]
  • […] entire body If either peritonitis or sepsis is suspected, then immediate medical attention must be sought.[dovemed.com]
  • Body-wide infection is called sepsis . Sepsis can be very serious and can lead to death.[medlineplus.gov]
Weight Loss
  • She underwent a 2-hour, elective, LAP-band insertion operation to achieve weight loss; 27 hours after band insertion, following the conduction of all FDA-mandated Lap-Band postoperative protocol (including a radiologic Gastrogrografin swallow), the patient[ncbi.nlm.nih.gov]
  • All the benefits of weight loss are clearly evident to everyone. How do we wrap our head around the risks vs. the benefits? Every time a surgeon evaluates someone for treatment, that’s what we do.[obesityhelp.com]
  • A 41-year-old man presented weight loss, low grade fever, and vomiting. Upper gastrointestinal endoscopy showed a large ulcer on the antrum of the stomach.[jstage.jst.go.jp]
  • You should see a doctor if you have any of the following: Blood when you have a bowel movement Severe abdominal pain Heartburn not relieved by antacids Unintended weight loss Ongoing vomiting or diarrhea NIH: National Institute of Diabetes and Digestive[icdlist.com]
Weakness
  • […] the all the warning signs of peritonitis- her stomach was severely painful to the touch, she was complaining of 10/10 pain, she had not had a bowel movement for 5 days (despite being given 4 different constipation medications), her urine output was weak[cuthbertlaw.com]
Fishing
  • FISHing for the Miracle of Eicosapentaenoic Acid J.J.P. Kastelein et al. The SUPPORT for Patients and Communities Act — What Will It Mean for the Opioid-Overdose Crisis? C.S. Davis Medicare Advantage Checkup P. Neuman et al.[nejm.org]
Vomiting
  • After a period of seven days the patient was readmitted to the PICU, with signs and symptoms of acute abdomen: severe epigastric pain whose intensity increased with the change of position, nausea, vomiting, fever and chills.[cejpaediatrics.com]
  • A 41-year-old man presented weight loss, low grade fever, and vomiting. Upper gastrointestinal endoscopy showed a large ulcer on the antrum of the stomach.[jstage.jst.go.jp]
  • Symptoms can include: repeated episodes of vomiting, with large amounts of vomit that contain undigested food a persistent feeling of bloating or fullness feeling very full after eating less food than usual unexplained weight loss An endoscopy can be[nhs.uk]
  • A perforation may also occur in the gallbladder, and symptoms include severe stomach pain, vomiting, and fever.[sheknows.com]
  • Symptoms may include: Severe abdominal pain Chills Fever Nausea Vomiting 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]
Nausea
  • After a period of seven days the patient was readmitted to the PICU, with signs and symptoms of acute abdomen: severe epigastric pain whose intensity increased with the change of position, nausea, vomiting, fever and chills.[cejpaediatrics.com]
  • Symptoms may include: Severe abdominal pain Chills Fever Nausea Vomiting 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]
  • You have frequent episodes of nausea and vomiting. Care Agreement You have the right to help plan your care. Learn about your health condition and how it may be treated.[drugs.com]
  • Symptoms Signs and symptoms of peritonitis include: Abdominal pain or tenderness Bloating or a feeling of fullness (distention) in your abdomen Fever Nausea and vomiting Loss of appetite Diarrhea Low urine output Thirst Inability to pass stool or gas[mayoclinic.org]
Acute Abdomen
  • After a period of seven days the patient was readmitted to the PICU, with signs and symptoms of acute abdomen: severe epigastric pain whose intensity increased with the change of position, nausea, vomiting, fever and chills.[cejpaediatrics.com]
  • Diagnosis of an acute abdomen can often be made on clinical grounds and an emergency operation performed.[pdfs.semanticscholar.org]
  • Investigations Laboratory Tests Any patient with an acute abdomen will require routine baseline blood tests , including G&S.[teachmesurgery.com]
  • abdomen with severe generalized abdominal pain, tenderness, and peritoneal signs .[merckmanuals.com]
  • "Gastrointestinal perforation and the acute abdomen". The Medical clinics of North America . 92 (3): 599–625, viii–ix. doi : 10.1016/j.mcna.2007.12.004 . PMID 18387378 .[en.wikipedia.org]
Abdominal Distension
  • The clinical presentation is often nonspecific, with most common symptoms being abdominal distension and pain accompanied by an abnormal sensation in the epigastric area and reduced appetite. Signs of peritonitis might be seen as well.[symptoma.com]
  • Abdominal distension can be striking and infants may also develop rapidly progressive pneumoperitoneum with associated cardiopulmonary compromise.[ijcasereportsandimages.com]
  • Sudden abdominal distension and respiratory distress have been reported as predominant symptoms (1,5).[ispub.com]
  • distension, feeding intolerance, respiratory distress, or poor activity. 3 The most common radiographic finding in gastric perforation is pneumoperitoneum, which in this case is obvious on the KUB, and significant enough to cause elevation of the diaphragms[nature.com]
Loss of Appetite
  • You might notice other symptoms instead, such as: loss of appetite feeling and being sick burping or bloating after eating losing weight without trying When it's something else These symptoms don't always mean you have a stomach ulcer.[beta.nhs.uk]
  • Symptoms Signs and symptoms of peritonitis include: Abdominal pain or tenderness Bloating or a feeling of fullness (distention) in your abdomen Fever Nausea and vomiting Loss of appetite Diarrhea Low urine output Thirst Inability to pass stool or gas[mayoclinic.org]
Chest Pain
  • The symptoms of esophageal rupture may include sudden onset of chest pain.[en.wikipedia.org]
  • Thoracic Any thoracic region perforation will present with pain, ranging from chest pain or neck pain to pain radiating to the back or pain on inspiration.[teachmesurgery.com]

Workup

Because of the nonspecific presentation of gastric perforation, many studies have stressed the importance of a proper physical examination and a detailed patient history [3] [7]. Patients should be asked about the duration of symptoms and the nature of their onset, whereas assessment of risk factors (underlying malignant disease or peptic ulcer, use of NSAIDs, recent upper gastrointestinal tract instrumentation or ingestion of foreign bodies) is also vital during clinical assessment. Once a presumptive diagnosis of an upper GI pathology is made, imaging studies are the next step of the diagnostic workup. Barium studies are not recommended in the setting of gastrointestinal perforation, but plain radiography of the chest and abdomen (lateral images are superior to posteroanterior) can be a useful initial method that is able to detect free air under the diaphragm in up to 75% of cases [6] [10]. However, contrast-enhanced CT, considered as the gold standard [10], is employed in the presence of inconclusive findings on abdominal X-rays. Typical signs are defects in the stomach wall and the presence of gas in the supramesocolic compartment (the space over the transverse mesocolon in the peritoneum) [10]. Abdominal ultrasonography has also been described as a useful tool in the evaluation of gastric perforation [6]. Finally, a biopsy of the lesion at the site of perforation, especially if suspicion toward a malignancy exists, might be performed [11], primarily through endoscopic techniques.

Treatment

  • Despite the best available treatments, leaks can be hard to treat and frequently multiple modalities are necessary.[obesityhelp.com]
  • It pays special attention to emerging procedures and technologies, including the use of robotics and the treatment of carcinoma. Of particular importance is the section on complications, which shows you how to recognize and avoid potential pitfalls.[books.google.com]
  • Abstract We report a rare case of gastric perforation due to cytomegalovirus infection that required surgical treatment. A 41-year-old man presented weight loss, low grade fever, and vomiting.[jstage.jst.go.jp]
  • And, delaying treatment can increase the risk of serious complications and even death.[stomachbloating.net]

Prognosis

  • The prognosis of DLBCL patients with GI involvement was retrospectively investigated regarding treatments.[bloodjournal.org]
  • DISCUSSION Neonatal gastric perforation is extremely rare and associated with poor prognosis [1] [2] [4] . Various theories have been proposed describing the etiology and prognosis but it still remains obscure [1] [2] [3] [5] .[ijcasereportsandimages.com]
  • Prognosis A GI perforation is a medical emergency and requires quick recognition of the signs and symptoms, and rapid medical response. When this occurs, recovery should be complete.[sepsis.org]
  • Prognosis of gastric cancer stays dependent on tumour stage and seems not to be worsened by the perforation itself. Postoperative pain and rate of wound infections are lower after laparoscopic operation for perforated peptic ulcer.[thieme-connect.com]

Etiology

  • .), either incidental or intentional, are notable etiologies of stomach perforation. In addition, incarcerated hiatal hernia is also reported as a condition that may lead to perforation.[symptoma.com]
  • ABSTRACT Introduction : Gastric perforation in neonates is a rare surgical emergency of uncertain etiology.[ijcasereportsandimages.com]
  • Etiologies include gastrogastric fistula, excessively large gastric pouch containing antral mucosa, H pylori infection, non-steroidal anti-inflammatory drugs use, and smoking [1, 2].[websurg.com]
  • Kneiszi F: Some data on the etiology of gastric rupture in the newborn, Biol Neonate; 1962; 4: 201-222. 11. Lloyd JR: The etiology of gastrointestinal perforations in the newborn. J Pediatr Surg; 1969; 4: 77-84. 12.[ispub.com]

Epidemiology

  • An Atlas of Operative Laparoscopy and Hysteroscopy, Second Edition is not just a how-to-do-the-surgery book, but also a guide to the pathogenesis, pathophysiology, and epidemiology of the urogynecological area.[books.google.com]
  • Time-trends in the epidemiology of peptic ulcer bleeding. Scand J Gastroenterol . 2005; 40 :914–20. 3. Sharma SS, Mamtani MR, Sharma MS, Kulkarni H.[tropicalgastro.com]
  • Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion 2011; 84:102-113. 4. Williams N, Bullstrode C, Connell RO.[ejs.eg.net]
  • The Zidovudine Epidemiology Study Group. J Infect Dis. 1992, 166: 1223-1227.[bmcinfectdis.biomedcentral.com]
Sex distribution
Age distribution

Pathophysiology

  • An Atlas of Operative Laparoscopy and Hysteroscopy, Second Edition is not just a how-to-do-the-surgery book, but also a guide to the pathogenesis, pathophysiology, and epidemiology of the urogynecological area.[books.google.com]
  • 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]
  • Neonatalogy: Pathophysiology and Management of the Newborn. Philadelphia, PA: Lippincott Williams and Wilkins ; 1999. p. 1022–1023. 3. Chung MT , Kuo CY , Wang JW , Hsieh WS , Huang CB , Lin JN .[nature.com]

Prevention

  • Prevent Risks of a Leak/Perforation In the first few weeks after surgery, don’t gulp, don’t overeat, and follow the rules your surgical team has set out for you. Prevention of a leak may, at best, be minimizing risky or unpredictable behaviors.[obesityhelp.com]
  • Prevention Often, peritonitis associated with peritoneal dialysis is caused by germs around the catheter.[mayoclinic.org]
  • Onset of symptoms that are characteristic of a perforated gastric ulcer should therefore be addressed immediately to prevent the situation from becoming increasingly dangerous.[stomachbloating.net]
  • Preventing stomach ulcers To help prevent stomach ulcers or stop them coming back: Do regularly wash your hands with soap and water - to reduce the chance of bacterial infections only take ibuprofen, aspirin and other NSAIDs when you need them follow[beta.nhs.uk]

References

Article

  1. Daliya P, White T, Makhdoomi K. Gastric perforation in an adult male following nasogastric intubation. Ann R Coll Surg Engl. 2012;94(7):e210-e212.
  2. Mahar AL, Brar SS, Coburn NG, Law C, Helyer LK. Surgical management of gastric perforation in the setting of gastric cancer. Gastric Cancer. 2012;15 (1):S146-152.
  3. Avila Alvarez AA, Parra JF, Buitrago DA, Rodriguez F, Moreno A. Gastric Perforation and Phlegmon Formation by Foreign BodyIngestion. Emerg (Tehran). 2014;2(3):141-143.
  4. Rao VSR, Sarkar R, Turner R, Wedgwood KR. Unusual Presentation of Gastric Perforation by Foreign Body: A Case Report. Case Rep Surg. 2011;2011:509806.
  5. Steenvoorde P, Moues CM, Viersma JH. Gastric perforation due to the ingestion of a hollow toothpick: report of a case. Surg Today. 2002;32(8):731–733
  6. Coppolino F, Gatta G, Di Grezia G, et al. Gastrointestinal perforation: ultrasonographic diagnosis. Crit Ultrasound J. 2013;5(1):S4.
  7. Di Saverio S, Bassi M, Smerieri N, et al. Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper. World J Emerg Surg. 2014;9:45.
  8. Trainor D, Duffy M, Kennedy A, Glover P, Mullan B. Gastric perforation secondary to incarcerated hiatus hernia: an important differential in the diagnosis of central crushing chest pain. Emerg Med J. 2007;24(8):603-604.
  9. Mehran A, Podkameni D, Rosenthal R, Szomstein S. Gastric Perforation Secondary to Ingestion of a Sharp Foreign Body. JSLS. 2005;9(1):91-93.
  10. Singh J, Steward M, Booth T, Mukhtar H, Murray D. Evolution of imaging for abdominal perforation. Ann R Coll Surg Engl. 2010;92(3):182-188.
  11. Roviello F, Rossi S, Marrelli D, et al. Perforated gastric carcinoma: a report of 10 cases and review of the literature. World J Surg Oncol. 2006;4:19.

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Last updated: 2017-08-09 15:03