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Acute perforation
Last reviewed: 23.04.2024
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Acute perforation can occur in any part of the gastrointestinal tract from various causes with the ingestion of gastric or intestinal contents into the abdominal cavity. Symptoms of acute perforation develop suddenly, with severe pain accompanied by rapidly developing signs of shock. Diagnosis is usually established by instrumental examination based on the presence of free air in the abdominal cavity. Treatment of acute perforation includes infusion intensive therapy, antibiotics and surgical treatment. Mortality is high, depends on the cause of the perforation and the general condition of the patient.
[What causes acute perforation?
Perforation of any part of the gastrointestinal tract can result in a closed and penetrating injury. Swallowed foreign bodies, even acute, rarely cause perforation, until they cause local pressure on the wall, leading to ischemia and necrosis.
Perforation of the esophagus usually occurs above the diaphragm (Burhave syndrome), but it can occur in the intra-abdominal part of it with severe vomiting or iatrogenic damage (eg, esophagoscope perforation, balloon dilatation or bougie). The intake of a large amount of caustic substance can cause perforation of the esophagus or stomach.
Perforation of the stomach or duodenum is usually a consequence of peptic ulcers, but in about 1/3 of the patients, symptoms of a history of ulcers are not noted.
Perforation of the intestine can be the result of strangulation obstruction. Acute appendicitis and inflammation of Meckel's diverticulum can also complicate perforation.
Perforation of the colon is usually caused by obturation, diverticulitis, ulcerative colitis, Crohn's disease and toxic megacolon. Sometimes perforation arises spontaneously. In the presence of colonic obturation, perforation usually occurs in the caecum; This catastrophe is unavoidable if the cecum is> 13 cm in diameter. Perforation is predisposed to patients receiving prednisolone or other immunosuppressants, with perforation occurring without vivid symptomatology.
Perforation of the gallbladder, associated with acute cholecystitis, occurs rarely. Perforation of the biliary tree can occur with cholecystectomy with iatrogenic damage. Perforation of the gallbladder usually leads to the formation of a local abscess, delimited by the omentum, and rarely leads to a general peritonitis.
Symptoms of acute perforation
Perforation of the esophagus, stomach and duodenum usually occurs suddenly and catastrophically, with a sharp onset of acute abdominal syndrome, severe generalized abdominal pain, tenderness and abdominal symptoms. Pain can radiate to the shoulder.
Perforation of other parts of the gastrointestinal tract often occurs against the background of other inflammatory processes accompanied by pain syndrome. Since the perforations are often initially small and mostly delimited by the omentum, the pain often develops gradually or can be localized. Soreness is also more local.
For all types of perforation, nausea, vomiting and anorexia are common. Intestinal noises are weakened or absent.
Diagnostics of acute perforation
The diagnosis can be made by radiography of the abdominal cavity and chest organs (on the back and vertically) in 50-75% of patients in the case of visualization of free air under the diaphragm. With the passage of time, this symptom becomes more obvious. Lateral chest X-ray is more informative for detecting free air than anteroposterior radiography. If this examination does not allow a diagnosis, CT with oral or intravenous contrast may be used.
Treatment of acute perforation
If perforation is verified, surgical intervention is indicated, since the mortality from peritonitis is rapidly increased in the event of delayed treatment. If an abscess or inflammatory infiltrate is formed, the operation may be limited to the drainage of the abscess.
Nasogastric drainage is performed before the operation . Patients with signs of dehydration need control of diuresis by catheterization of the bladder. Water-electrolyte balance is corrected by adequate intravenous infusion of liquids and electrolytes. Against intestinal flora, intravenous administration of antibiotics is effective (eg, cefotetan 1-2 g 2 times a day or amikacin 5 mg / kg 3 times a day plus clindamycin 600-900 mg 4 times a day).