GI perforation is a full-thickness defect in the GI tract, allowing gas / fluid / intestinal content to leak into the peritoneal cavity
Oesophageal Perforation
Aetiology
Important causes: [Ref]
- Iatrogenic (e.g. upper GI endoscopic procedures, instrumentation, surgery) – most common
- Boerhaave syndrome (spontaneous rupture following forceful vomiting / retching)
- Malignancy
- Trauma
- Foreign body
- Ingestion of button batteries
As button batteries can generate electric current in a moist environment, causing electrochemical burns
in children is an important cause of oesophageal rupture that can develop if not treated promptly
- Ingestion of button batteries
Clinical Features
Typical presentation: [Ref]
- Sudden onset of severe pain in the neck / chest / abdomen (depending on the site of perforation)
- Dysphagia, odynophagia
- Features of sepsis
Boerhaave syndrome can present with a triad (Mackler’s triad) of:
- Vomiting and/or retching
- Severe retrosternal chest pain (often radiates to the back)
- Subcutaneous / mediastinal emphysema (palpable crepitus in the neck region or crackling sound on chest auscultation)
Notably, perforations rarely manifest with signs of GI bleeding (e.g. haematemesis, melena) [Ref]
Investigation and Diagnosis
1st line: CT with oral contrast [Ref]
2nd line tests: [Ref]
- Contrast esophagography
Contrast esophagography uses fluoroscopic imaging after the patient swallows a contrast agent (usually barium) to assess the esophagus for structural or functional abnormalities.
(e.g. Gastrograffin) - Plain chest and neck radiographs – to detect subcutaneous emphysema and pneumomediastinum
Management
Initial management: [Ref1][Ref2]
- Ensure the airway is not compromised
- Make the patient NBMNil by mouth
- Fluid resuscitation
- Broad-spectrum IV antibiotics
- Gastric decompression (via NG tube)
Definitive management: [Ref1][Ref2]
- 1st line is generally endoscopic intervention (techniques include clips, metal stents, vacuum therapy)
- Surgical intervention is necessary for unstable patients / large perforation / uncontained perforation
Bowel Perforation
Aetiology
Main causes in adults, by anatomical site: [Ref]
| Anatomical site | Causes |
|---|---|
| Small intestine |
|
| Large intestine |
|
In premature infants, necrotising enterocolitis is the leading cause [Ref]
In children: [Ref]
- Appendicitis is the leading cause
- Other important causes include foreign body ingestion & Meckel diverticulum
Iatrogenic causes:
- Endoscopic procedures (while the risk is very low, it remains a serious complication, it is routinely communicated to patients while gaining consent)
- Radiological interventions
- Surgical intervention
- Feeding tube / catheter insertion
Clinical Features
This article does not cover the cause-specific clinical features of bowel perforation (covered in articles of their own); instead, it outlines the common clinical presentation shared across all types of bowel perforation
The typical disease progression of bowel perforation is as following: [Ref]
- Early localised peritonitis
- Sharp, localised abdominal pain near the site of perforation
- Localised tenderness and guarding
- Generalised peritonitis (bowel content and bacterial spread throughout the peritoneal cavity)
- Severe, diffuse abdominal pain
- Widespread guarding and abdominal rigidity
- Rebound tenderness
- Percussion tenderness
- Patients tends to lie very still (as any movement irritates the peritoneum and causes more pain)
- Patients are often very systemically unwell
- Sepsis and shock
Bowel perforation is a potentially life-threatening surgical emergency. This is because the bowel is NOT sterile; intestinal content contains a vast number of bacteria and other microorganisms. When perforation occurs, these bacteria gain direct access to the highly vascularised peritoneal cavity, leading to rapid and severe infection.
Investigation and Diagnosis
Pneumoperitoneum (free intraperitoneal air) is the diagnostic hallmark of bowel perforation.
1st line: CT with contrast [Ref1][Ref2]
- Confirmatory test for perforation (very high sensitivity) PLUS allows for assessment of complications & surgical planning
- Typical findings: extraluminal gas, extravasation of contrast, discontinuity of bowel wall
Alternative investigations (only if the patient is unstable or CT is not readily available): [Ref1][Ref2]
- Erect
Patient is asked to stand or sit upright for at least 10 minutes prior to imaging, allowing any free intraperitoneal air to rise and accumulate beneath the diaphragms (most commonly right diaphragm).
chest X-ray showing:- free air under the diaphragm (most commonly seen as a radiolucent crescent between the diaphragm and the liver on the right side)
- Abdominal X-ray showing:
- Rigler’s sign (double wall sign) – visualisation of both sides
Due to air outlining the bowel serosa and mucosa
of the bowel wall - Falciform ligament sign – air outlining the falciform ligament
- Football sign – a large oval collection of free air outlining the peritoneal cavity (most often seen in infants)
- Rigler’s sign (double wall sign) – visualisation of both sides
Colonoscopy is contraindicated if bowel perforation is suspected. Instrumentation of the bowel may worsen a perforation.
Management
Initial management: [Ref1][Ref2]
- Make patient NBMNil by mouth
- Sepsis 6 (importantly fluid resuscitation and broad-spectrum antibiotics)
- Analgesia and antiemetics
- Urgent surgical consultation
Patients with diffuse peritonitis / sepsis would generally require urgent explorative laparotomy with midline incision (or laparoscopically in stable patients) [Ref1][Ref2]
An explorative laparotomy typically involves: [Ref1][Ref2]
- Identification of the perforation site + assessment of bowel viability
- Peritoneal lavage
Involves introducing large amounts of sterile saline into the peritoneal cavity, then subsequently removed.
to clear contamination - If the perforation is small + adjacent bowel is viable → primary closure (usually via direct suturing)
- If the perforation is large / adjacent bowel is non-viable → resection of the affected bowel segment
- Stable patients → resection + primary anastomosis
A primary anastomosis refers to the immediate surgical reconnection of two ends of the intestine after a segment has been resected, restoring gastrointestinal continuity in a single operation without the creation of a stoma.
- Unstable patients / severe contamination → resection + defunctioning stoma (e.g. end ileostomy or Hartmann’s procedure) (click to see rationaleIn unstable patients or those with severe peritoneal contamination, resection with defunctioning stoma (rather than primary anastomosis) is preferred because the risk of anastomotic leak is significantly increased in these patients.
Creating a stoma diverts the faecal matter and allows the patient to recover from sepsis and physiological stress, minimising life-threatening complications before considering bowel continuity restoration at a later, safer time)
- Stable patients → resection + primary anastomosis