Gastrointestinal perforation

Gastrointestinal perforation results in sudden, severe abdominal pain at the site of perforation, which then spreads across the abdomen. The pain is intensified by movement. Nausea, vomiting, hematemesis, and increased heart rate are common early symptoms. Later symptoms include fever and or chills. On examination, the abdomen is rigid and tender. The death rate in this case is 20%. ==Causes==

Gastrointestinal perforation is defined by a full-thickness injury to all layers of the gastrointestinal wall, resulting in a hole in the hollow GI tract (esophagus, stomach, small intestine, or large intestine). A hole can occur due to direct mechanical injury or progressive damage to the bowel wall due to various disease states. Trauma or accidental perforations during medical procedures Penetrating trauma such as from a knife or gunshot wound can puncture the bowel wall. Additionally, blunt trauma, such as in a motor vehicle accident may abruptly increase the pressure within the bowel, resulting in bowel rupture. Perforation can also be a very rare complication of certain medical procedures such as upper gastrointestinal endoscopy and colonoscopy. Infection or inflammatory disease Appendicitis and diverticulitis are conditions in which a small, tubular area in bowel becomes inflamed and may burst. A number of infections including C. difficile It may occur due to scar tissue after surgery, twisting of the bowel around itself, hernias, or gastrointestinal tumors. Reduced forward movement of bowel contents results in a build up of pressure within the part of the bowel just before the site of obstruction. This increased pressure may prevent blood flow from reaching the bowel wall, resulting in bowel ischemia (lack of blood flow), necrosis, and eventually perforation. Erosion A peptic ulcer is a defect in the inner lining of the stomach or duodenum typically due to excessive stomach acid. Extension of the ulcer through the lining of the digestive tract results in spillage of the stomach or intestinal contents into the abdominal cavity, leading to an acute chemical peritonitis. Helicobacter pylori infection and overuse of non-steroidal anti-inflammatory drugs may contribute to formation of peptic ulcers. Ingestion of corrosives can lead to esophageal perforation. Indirect causes An often overlooked indirect cause of obstruction leading to perforation is the chronic use of opioids, which can create severe constipation and damage to the colon, often termed stercoral perforation. ==Diagnosis==

A hole in the gastrointestinal tract causes leakage of gas into the abdominal cavity. In intestinal perforation, gas may be visible under the diaphragm on chest x-ray while the patient is in an upright position. While x-ray is a fast and inexpensive to screen for perforation, an abdominal CT scan with contrast is more sensitive and specific for establishing a diagnosis as well as determining the underlying cause. Both CT and x-ray may initially appear normal, in which case diagnosis can be made by open or laparoscopic exploration of the abdomen. White blood cells and blood lactate levels may also be elevated, particularly in the case of advanced disease including peritonitis and sepsis. Differential diagnoses of gastrointestinal perforation includes other causes of an acute abdomen, including appendicitis, diverticulitis, ruptured ovarian cyst, or pancreatitis. ==Treatment==

Surgical intervention is nearly always required in the form of open or laparoscopic exploration. The goals of surgery are to remove any dead tissue and close the hole in the gastrointestinal wall. Peritoneal wash is performed and a drain may be placed to control any fluid collections that may form. A Graham patch may be used for duodenal perforations. Conservative treatment (avoiding surgery) may be sufficient in the case of a contained perforation. It is indicated only if the person has normal vital signs and is clinically stable. == References ==