Gastro intestinal perforation

cause, symptom and clinical cases

1. PREPARED BY:- SONALI HARSH RAJ gastrointestinal PERFORATION

2. What are the 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

3. The condition may also be due to: blunt trauma to the abdomen a knife or gunshot wound to the abdomen abdominal surgery stomach ulcers due to taking aspirin, nonsteroidal anti-inflammatory drugs, and steroids (more common in older adults) ingestion of foreign objects or caustic substances Smoking and excessive use of  alcohol increase your risk of GP. Rarely, the condition may occur due to bowel injuries from an endoscopy or colonoscopy.

4. Symptoms of an Intestinal Perforation Severe abdominal pain. Fever. Chills. Nausea. Rectal bleeding, sometimes heavy. Vomiting.

5. How is gastrointestinal perforation diagnosed? To diagnose GP, your doctor will likely take  X-rays of your chest  or  abdomen  to check for air in the abdominal cavity. They may also perform a  CT scan to get a better idea where the perforation might be. They’ll also order lab work to: look for signs of infection, such as a high  white blood cell count evaluate your hemoglobin level, which can indicate if you have blood loss evaluate  electrolytes evaluate acid level in the blood assess  kidney function assess  liver function

6. What are the treatment options for gastrointestinal perforation ? 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 for go surgery and prescribe antibiotics alone if the hole closed on its own. Sometimes, a piece of the intestine will need removal. The removal of a portion of either the small or large intestine may result in a  colostomy  or  ileostomy , which allows intestinal contents to drain or empty into a bag attached to your abdominal wall.

7. What are the complications associated with gastrointestinal perforation? Complications associated with GP include: bleeding sepsis , which is a life-threatening bacterial infection abscesses in the belly a  wound infection a bowel infarction, which is the death of part of the bowel a permanent ileostomy or colostomy Wound failure may occur in some cases. “Wound failure” means the wound can’t or doesn’t heal. Factors that increase the risk of this include:

8. malnutrition , or poor diet smoking excessive alcohol use drug abuse poor hygiene sepsis uremia , which is an illness caused by kidney failure obesity hematoma, which occurs when blood collects outside the blood vessels type 2 diabetes steroid therapy or the use of corticosteroids, which are anti-inflammatory drugs that suppress the immune system and can mask an ongoing infection and delay diagnosis the use of biologic agents for conditions such as Crohn’s disease, ulcerative colitis,  rheumatoid arthritis

9. What is the long-term outlook? The success of surgery to repair a perforation depends on the size of the perforation or hole and the length of time before treatment. The chances of recovery improve with early diagnosis and treatment. Factors that can hinder treatment include: advanced age existing bowel disease bleeding complications malnutrition the nature of the original cause of the condition smoking alcohol or drug abuse

10. active treatment for cancer conditions requiring steroids or biologic agents including  lupus , rheumatoid arthritis, and similar conditions. other medical conditions such as  heart diseases , kidney or liver problems, and  emphysema If you experience pain or fever and you’re at risk of having a GP, you should see your doctor. The sooner you see your doctor, the better your outlook will be.

11. How can I prevent gastrointestinal perforation? There are many causes of GP. For example, an underlying gastrointestinal disease can increase your risk for perforation. Get to know your medical history and seek information on the current conditions that might increase your risk. Speak to a doctor if you experience any significant change from your normal state, especially if you have abdominal pain and fever.

12. CLINICAL CASE Male patient, 31 years old, admitted on April 15, 2016, with complaint of abdominal pain and vomiting for 3 consecutive days. The patient had a history of alcohol abuse and reported he might have accidentally ingested a toothpick while drinking, 10 days prior to symptom presentation. Physical examination: vital signs were stable, with mild upper abdominal tenderness and no rebound tenderness. WBC: 11.8×10 9 /L NEUT%: 82%, CRP: 54.4 mg/L. Abdominal contrast-enhanced computed tomography (CT) scans demonstrated: a 62 mm long opaque foreign body at the third part of the duodenum, piercing the transverse mesocolon and forming an abscess (4×3 cm), considered possibly to be a toothpick( Fig. 2 A). Emergency laparoscopy was conducted. Intraoperative exploration revealed upper abdominal adhesions. Underneath the transverse colon, a mesentery encapsulated abscess was exposed with fibrin and pus on the surface ( Fig. 2 B), where the penetrating wooden foreign body was identified as a toothpick (6 cm) ( Fig. 2 C). The toothpick was extracted and the wound was left open. An indwelling drainage tube was placed during the surgical procedure. Five days post surgery the patient fully recovered and was discharged with no further complications .

13. CLINICAL CASE A forty-seven year old man presented with abdominal pain and intermittent fever of one month duration. The pain became more severe in the last 2 days and was associated with nausea and vomiting. The temperature of the patient was 37 µC, pulse 113 per minute and blood pressure 105/70 mmHg. The abdomen was slightly distended, soft with generalized tenderness. Bowel sounds were audible. White blood cell count was 8x10 9 /L. Lymphocytes were increased (40%). Serum electrolytes, blood sugar, and serum bilirubin were all normal. Serum amylase was mildly raised (231 U/L). Chest X-ray has shown air under diaphragm. A laparotomy has shown a punched-out perforation of the ileum at midpoint ( Fig 1 ) with free fluid in the peritoneal cavity.

14. The ulcer was excised; the defect was closed in two layers. Histopathological examination has shown few scattered aggregated epithelioid cells poorly forming granulomas, without obvious caseation. Special stains have failed to reveal any organism. Blood cultures were negative. Clinically, the patient was diagnosed as typhoid fever and was treated with intravenous broad spectrum antibiotic (Meronem 1 gm 8 hourly for one week followed by Ciprobay 400 mg 12 hourly for four weeks). The patient was discharged home in the 8 th  postoperative day in a good condition.