Gastro-intestinal perforation

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Referral

Definition

Gastrointestinal (GI) perforation is a life-threatening condition where a hole develops in the wall of the stomach, small intestine, or large intestine, leading to leakage of intestinal contents into the peritoneal cavity, causing peritonitis and sepsis.

Aetiology

Common causes include:

  • Peptic ulcer disease: perforation of the stomach or duodenum due to long-standing ulcers.
  • Diverticulitis: inflamed diverticula in the colon can rupture.
  • Appendicitis: ruptured appendix leading to localised or generalised peritonitis.
  • Trauma: blunt or penetrating abdominal injury.
  • Malignancy: advanced gastrointestinal cancers can erode through the bowel wall.
  • Ischaemic bowel disease: bowel infarction due to mesenteric ischaemia.
  • Inflammatory bowel disease (IBD): severe Crohn’s disease or ulcerative colitis.
  • Foreign body ingestion: perforation due to sharp objects.
  • Iatrogenic causes: perforation following endoscopy, colonoscopy, or surgery.

Pathophysiology

  • Loss of gastrointestinal integrity leads to spillage of gastric or faecal contents into the peritoneal cavity.
  • This results in an inflammatory response, leading to peritonitis.
  • If untreated, the condition progresses to sepsis and multi-organ failure.

Risk factors

  • Long-term NSAID or steroid use (increases ulcer risk).
  • Smoking and alcohol consumption.
  • Advanced age.
  • Previous abdominal surgery.
  • Gastrointestinal malignancy.
  • Severe infections (e.g., typhoid, tuberculosis affecting the bowel).

Signs and symptoms

Symptoms:

  • Sudden severe abdominal pain (often diffuse, sometimes localised initially).
  • Nausea and vomiting.
  • Fever and chills.
  • Reduced or absent bowel movements (paralytic ileus).

Signs:

  • Rigid abdomen with involuntary guarding (suggests peritonitis).
  • Absent bowel sounds (indicating paralytic ileus).
  • Tachycardia and hypotension (suggesting shock).
  • Rebound tenderness on palpation.

Investigations

  • Blood tests:
    • Raised white cell count and CRP (indicating infection).
    • Elevated lactate (suggesting tissue hypoxia and sepsis).
    • Urea and electrolytes (assess dehydration and renal function).
  • Imaging:
    • Plain abdominal X-ray: may show free air under the diaphragm (pneumoperitoneum).
    • CT abdomen (gold standard): confirms perforation site, detects extraluminal air and fluid collections.
    • Ultrasound: may detect free fluid but is less sensitive for perforation.

Management

1. Immediate Resuscitation:

  • IV fluids: aggressive fluid resuscitation with crystalloid solutions.
  • Oxygen therapy: if hypoxic.
  • Broad-spectrum IV antibiotics.
  • Analgesia: IV paracetamol ± opiates.
  • Nil by mouth: to prevent further bowel contents leaking.
  • Nasogastric tube: to decompress the stomach if needed.
  • Urinary catheter: to monitor urine output in critically ill patients.

2. Surgical Intervention:

  • Emergency laparotomy: most cases require surgical repair.
  • Primary closure: if a small perforation with minimal contamination.
  • Bowel resection: if extensive bowel damage or malignancy is present.
  • Laparoscopic approach: considered in selected stable patients.

3. Conservative Management (Selected Cases Only):

  • Only considered in stable patients with sealed perforations (e.g., contained diverticular perforation).
  • IV antibiotics and close monitoring.
  • Repeat imaging to assess progress.

Referral

  • Urgent surgical referral for suspected GI perforation.
  • Critical care referral if haemodynamic instability is present.
GastroenterologymypanotesGastro-intestinal perforation