Bowel perforation (summary)

Bowel perforation is an acute surgical emergency where there is release of gastric or intestinal contents into the peritoneal space.

Summary

• presentation
  • history
    • may depend on location of perforation
      • severe and generalised abdominal pain occurs with gastric(upper)
      • gradual and duodenal perforations. It is often associated with a history of dyspepsia and burninglocalised pain in the epigastrium. In intestinal perforation the pain may develop more gradually and become localised. Anorexia(lower)
    • anorexia, nausea and vomiting are often associated symptoms.

      On

  • examination findings of an acute
    • rigid abdomen such as a board like rigid abdomen,and generalised tenderness,
    • guarding and rebound tenderness are usually present. Bowels
    • bowel sounds may range from quiet to absent.

      Pathology

      Causes of bowel perforation can include both

• pathology
  • gastric and duodenal ulceration
  • infection (diverticulitis, appendicitis), ischaemia and cancer
  • blunt and penetrating trauma to the abdomen, gastric ulcers,
  • ingestion of corrosive materials, appendicitis, diverticulitis and ischaemia. Iatrogenic
  • iatrogenic causes such as(ERCP, colonoscopy, ERCP or via laparotomy can also causelaparotomy, biopsy)
• radiology
  • an erect plain radiograph is sensitive for small volumes of free gas
  • supine abdominal radiograph may show signs of free gas
  • CT with IV contrast is the gold standard investigation
    • free gas and fluid within the peritoneal cavity
• treatment
  • fluid resuscitation and IV antibiotics
  • surgical intervention is often required to close the perforation.
    • bowel resection may be required
  • mortality increases the longer surgical treatment is delayed

Radiographic features

Plain filmradiograph

Supine andAn erect abdominal and chest x rays areradiograph is often obtained if there is clinical suspicion of bowel perforation, with free. Chest radiographs are very sensitive for even small amounts of gas underwithin the diaphragm usually seenperitoneal cavity.

Abdominal radiographs are often also performed. Lateral chest x ray Several signs of pneumoperitoneum may be more sensitive to free gas compared toseen on a PA viewsupine abdominal radiograph including Riglers sign. However, they rarely add information because pneumoperitoneum on an erect CXR will prompt surgery or a CT.

CT

The site of perforationAbdominal CT with IV contrast can be visualised on abdominalused to confirm hollow viscus perforation. CT is very sensitive for even the smallest amount of free gas within the abdomen. Contrast via oralIt is seen rising to the top of the supine abdomen as triangles or rectal ingestionbubbles or gas outwith the bowel.

CT is also useful to detect fluid within the peritoneal cavity which may be considered, however barium contrast shouldalso leak from an intestinal perforation. Peritoneal fluid does not be used ifalways mean perforation.

Finding the cause

CT is also useful to determine the cause of the perforation and is therefore very helpful before surgical intervention.

Where there is more gas than fluid, think upper GI perforation (e.g. duodenal ulcer). Where there is more fluid than gas, lower GI perforation is suspectedmore likely.