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Overview of gastrointestinal tract perforation

Author
Michael J Cahalane, MD
Section Editors
Martin Weiser, MD
Hilary Sanfey, MD
Lillian S Kao, MD, MS
Deputy Editor
Wenliang Chen, MD, PhD

INTRODUCTION

Perforation of the gastrointestinal tract may be suspected based upon the patient’s clinical presentation, or the diagnosis becomes obvious through a report of extraluminal “free” air on diagnostic imaging performed to evaluate abdominal pain or another symptom. Clinical manifestations depend somewhat on the organ affected and the nature of the contents released (air, succus entericus, stool), as well as the ability of the surrounding tissues to contain those contents.

Intestinal perforation can present acutely, or in an indolent manner (eg, abscess or intestinal fistula formation). A confirmatory diagnosis is made primarily using abdominal imaging studies, but on occasion, exploration of the abdomen (open or laparoscopic) may be needed to make a diagnosis. Specific treatment depends upon the nature of the disease process that caused the perforation. Some etiologies are amenable to a more conservative approach, while others will require emergent surgery.

An overview of the clinical features, diagnosis, and management of the patient with alimentary tract perforation is reviewed here. Specific etiologies are briefly reviewed below and discussed in the linked topic reviews in more detail. (See 'Risk factors' below and 'Specific organs' below.)

GENERAL PRINCIPLES

Pathophysiology — Perforation requires full-thickness injury of the bowel wall; however, partial-thickness bowel injury (eg, electrocautery, blunt trauma) can progress over time to become a full-thickness injury or perforation, subsequently releasing gastrointestinal contents. Full-thickness injury and subsequent perforation of the gastrointestinal tract can be due to a variety of etiologies, commonly instrumentation (particularly with cautery) or surgery, blunt or penetrating injury, and bowel obstruction. In addition to causing obstruction, neoplasms (particularly colon carcinoma) can also cause perforation by direct penetration of the tumor through the bowel wall. Other etiologies are less common [1-4]. Spontaneous perforation can be related to inflammatory changes or tissues weakened by medications or connective tissue disorders. Esophageal, gastric, or duodenal perforations may also be associated with peptic ulcer disease, corrosive agents, or particular medications. (See 'Risk factors' below.)

With bowel obstruction, perforation occurs proximal to the obstruction as pressure builds up within the bowel, exceeding intestinal perfusion pressure, and leading to ischemia and subsequently necrosis. When perforation is proximal to a colon obstruction, it usually occurs in the cecum in the presence of a competent ileocecal valve. Enteroliths and gallstones can also cause perforation by direct pressure or indirectly by leading to obstruction resulting in a proximal perforation [5,6].

                                             

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