Gastrointestinal perforation

An Overview

A perforation may also occur in the gallbladder. This can have symptoms that are similar to the symptoms of a gastrointestinal perforation. A hole in your gastrointestinal system or gallbladder can lead to peritonitis. Peritonitis is inflammation of the membrane that lines the abdominal cavity.
Gastrointestinal perforation is a hole in the wall of the gastrointestinal tract. Other names for the condition include:

• ruptured bowel
• intestinal perforation
• perforation of the intestines

Most people who have gastrointestinal perforation will have a hole in their stomach or small intestine.
A hole in the large bowel, also known as the lower intestine, occurs less frequently. Researchers estimate that perforations of the lower intestine only affect 4 in every 100,000 people in the European population.
A small intestine leak is the common term for a perforation (hole) in the small intestine. The term is sometimes confused with leaky gut syndrome, a condition that supposedly increases the permeability of the intestinal wall. With a perforation an actual hole develops thereby allowing the contents of the small intestine to leak out into the abdominal cavity. Due to the concentration of different types of bacteria in the small intestine, leakage of the small intestinal contents will allow for infection to develop within the abdominal cavity. Activated digestive enzymes may also cause inflammation of the surrounding abdominal structures. If left untreated, perforation of the small intestine can quickly progress to life threatening complications.

Gut Wall

The gut wall is continuous throughout its length ensuring that the contents within it are kept separate from other organs as it passes through the thoracic (chest) and then the abdominal cavity. The strength and flexibility of the gut walls allows for parts of the gut to run close to vital organs like the heart without running the risk of digestive enzymes, bacteria and substances within it from making contact with the various organs. The gut itself is capable of contending with the various potential irritants within it – food, fluid, strong enzymes and disease-causing (pathogenic) microbes. Even when diseased, the structure of the gut allows for the pathology to be restricted to within the gut in most instances. However, the surrounding organs and structures in the abdomen are easily injured.

A perforation can cause the contents of the stomach, small intestine, or large bowel to seep into the abdominal cavity. Bacteria will also be able to enter, potentially leading to a condition called peritonitis, which is life-threatening and requires immediate treatment.

Symptoms for gastrointestinal perforation

The primary symptoms of gastrointestinal perforation are severe abdominal pain and tenderness. The abdomen may also protrude or feel hard to the touch.
If the hole is in a person’s stomach or small intestine, the onset of pain is usually sudden, but if the hole is in the large bowel, the pain may come on gradually. In either case, once the pain starts, it is likely to be constant.
Symptoms of GP may include:
• severe stomach pain
• chills
• fever
• nausea
• vomiting
When you’ve had a gastrointestinal perforation and peritonitis occurs, the abdomen feels very tender. Pain often worsens when someone touches or palpates the area or when the patient moves. Pain is generally better when lying still. The abdomen may stick outward farther than normal and feel hard.

Causes of gastrointestinal perforation

Illnesses can cause GP, including:
• appendicitis, which is more common among older persons
• diverticulitis, which is a digestive disease
• a stomach ulcer
• gallstones
• gallbladder infection
• inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis, which is less common
• inflamed Meckel’s diverticulum, which is a congenital abnormality of the small intestine that’s similar to the appendix
• cancer in the gastrointestinal tract
• volvulus — a bowel obstruction that happens when the large bowel becomes twisted
• colon cancer
• diverticulitis — an inflammatory condition that affects the large bowel
• peptic ulcers in the stomach or small intestine
• ischemic colitis — inflammation of the large bowel due to an inadequate supply of blood
• gallstones
• gallbladder infection
• inflammatory bowel disease
• reactions to nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen
• injury or trauma to the abdomen, such as a knife wound or swallowing something sharp

Abdominal injury

With the abdominal cavity lacking of skeletal protection and the small intestine occupying most of the space, it is the more likely organ to be injured in the following situations :
 Motor vehicle collisions
 Bicycle handlebar injuries
 Falls
 Blows including assault
 Stab injuries
Depending on the nature of the injury and force, the small intestine wall may be perforated.

Ulcers

Peptic ulcer disease (PUD) is the formation of open sores in the lining of the stomach and duodenum (first part of the small intestine). In severe cases the ulcer may extend through the entire thickness of the gut wall. Since duodenal ulcers are more common, a perforation is more likely to be seen in the duodenum. Helicobacter pylori (H.pylori) infection and prolonged use of NSAIDs (non-steroidal anti-inflammatory drugs) are the leading causes of peptic ulcers.

Diagnosis

To diagnose the condition, the doctor may carry out one or more of the following tests:
• X-ray of the chest and abdomen. This is to check for air in the abdominal cavity, a sign of gastrointestinal perforation.
• CT scan. This helps the doctor to locate any possible holes.
• Blood test. This is to check for signs of infection and possible blood loss.
• People with gastrointestinal perforation often require emergency surgery.
• This will usually involve an exploratory laparotomy. The surgeon will open up the person’s abdomen and repair any holes in the gastrointestinal tract.
• They will also remove any substances from the person’s stomach, small intestine, or large bowel that are now in the abdomen. This helps to treat the peritonitis and prevent sepsis.
• For some people, it may be necessary to remove part of the intestine. This can lead to a person needing a colostomy or ileostomy. These procedures allow the contents of the person’s intestine to collect in a bag that attaches to their abdomen.

Treatment

In most cases, surgery is necessary to close the hole and treat the condition. The goals of the surgery are to:
• fix the anatomical problem
• fix the cause of peritonitis
• remove any foreign material in the abdominal cavity that might cause problems, such as feces, bile, and food
In rare cases, your doctor may forgo surgery and prescribe antibiotics alone if the hole closed on its own.

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