A perforation is a hole or several holes in a structure. A perforation in the gastrointestinal tract can have serious consequences. The contents of the perforated organs, i.e. air, food, digestive juices, stool or pus, empty into the abdominal cavity. Here you will find further information and selected intestinal perforation specialists and centers.
Possible causes of a perforation in the gastrointestinal tract can be
Air in the abdominal cavity outside the stomach or intestine, so-called free air as a sign of perforation of a hollow organ (white arrow), air in the intestine as a normal finding (black arrow)
The symptoms of an intestinal perforation can be varied and depend on the respective cause.
For example, appendicitis will initially cause increasing pain in the right lower abdomen. At the moment of the appendix rupture, there is a certain amount of relief. However, the pain increases again as peritonitis then develops.
As a rule, however, the perforation leads to severe pain.
An injury to the oesophagus often causes few symptoms at first. This causes the so-called mediastinal cavity in the center of the chest to become inflamed, which can have fatal consequences. The chest cavities are often also involved in the inflammation.
Because of the delayed progression and the involvement of the central structures, these perforations are extremely dangerous.
Perforation at the gastric outlet, clear fibrin deposits as an expression of chemical irritation and peritonitis
Even before a perforation, the underlying diseases can cause pain. When the intestine perforates, stool or chyme escapes and suddenly causes severe pain.
The cause is the irritation of the peritoneum by the leaked substances, simply because of the chemical stimulus, for example the stomach acid. The pain is transmitted by the nerves of the thin envelope layer (peritoneum) that surrounds the inner wall of the abdomen and the organs. This event can lead to a state of shock .
In the second phase, stomach acid causes severe, painful inflammation. If stool passes from the colon into the abdominal cavity, this leads to a massive bacterial infection with corresponding inflammation.
In addition to pain, perforation is accompanied by other signs of inflammation such as fever and increasing intestinal paralysis with vomiting . Blood tests show an increase in the so-called inflammation values (leukocytes, CRP or procalcitonin).
If no therapeutic intervention has been taken by then, a generalized sepsis develops. The entire body is now affected by the infection. The result is the increasing failure of other organ systems:
This can be fatal. Elderly patients in particular, or those weakened by other illnesses, e.g. tumors, often have little to offer against such a general infection.
Peritonitis is a clinical diagnosis and requires first and foremost an experienced doctor who will use further diagnostics in a targeted manner.
Gastroscopies(colonoscopy or gastroscopy) are rarely helpful in the acute phase.
Laboratory tests provide information, including
Sonography (ultrasound) is very helpful, less stressful and can be checked at almost any time. Conventional X-rays only help by detecting or excluding free air, possibly also to prove or exclude an intestinal obstruction(ileus).
In most cases, CT (computed tomography) with swallowed contrast medium administered via the vein is the most informative. It is completed quickly using modern spiral techniques.
In most cases, the decision on the treatment to be taken can be made quickly. The clinical course during a possible observation period of the patient is a further aid to the decision.
Not every perforation requires surgery. In rare exceptional situations, a wait-and-see approach or a targeted two-stage approach can be adopted. An incidental finding of "free air" in the X-ray, i.e. a clear indication that a perforation may have occurred, can be treated with a wait-and-see approach. However, only if the patient has no complaints and is in a good state of health.
Appendicitis can lead to regional abscess formation. Here too
stabilization of the conditions with removal of the appendix is possible in about 6 weeks.
An interventional puncture of the abscess under sonographic or CT control may be necessary as a supportive measure.
A similar approach can be taken if a so-called covered perforation has occurred, e.g. due to sigmoid diverticulitis. In this case, the perforation has occurred but is covered by neighboring structures, the diverticula. In the absence of peritonitis, it is also possible to wait and see.
Illustration of an intestinal perforation © Henrie | AdobeStock
If surgery is necessary, the aim of all therapeutic measures is to quickly eliminate the perforation and its consequences. This must be seen in the context of the underlying disease causing the perforation. Different procedures are therefore required depending on the cause. There are a few exceptions, which are explained above.
Part of every operation in the context of a perforation is
In most cases, drainage tubes are inserted to drain any excess secretions to the outside. They may also have a certain indicator function for leaking sutures or newly occurring problems.
However, peritonitis also requires time and support of the general condition in order to heal. This peritonitis can be limited to a small area, as in the case of appendicitis, but can also affect the entire abdomen in an extreme form. This is the case, for example, with intestinal perforations as part of a toxic megacolon in ulcerative colitis.
The principle of every perforation operation is to close the hole. This is only possible in exceptional cases as a pure closure by sutures or with the help of so-called staple sutures (steel).
This type of closure is recommended for
are useful and possible. Perforations in the course of diagnostic gastroscopies or colonoscopies can also often be sutured over. In these cases, the bowel is clean due to laxative measures and the event is often detected early and operated on accordingly.
The possibility of suturing becomes less likely the more time passes after the intestinal perforation and the further the inflammation develops.
The tissue loses its solidity due to the inflammation and can therefore no longer be sutured.
It is necessary to freshen the tissue, i.e. to cut out parts of the tissue in order to achieve stable, sutureable conditions. This has its anatomical limits and often necessitates the removal of entire organ parts. The resulting operations are correspondingly complex.
In the simplest case, only the inflamed appendix is removed. The secure closure of the separation plane at the base (transition into the colon) is the problem here. However, if the inflammation has not caused too much involvement of the beginning of the colon, this should be quite possible.
It may be necessary to temporarily insert an artificial anus. This will divert the stool around the problematic section and allow it to stabilize. The passage can be restored weeks later in another operation under stabilized conditions.
Extremely poor circulatory conditions or extreme infection situations can also make such a two-stage procedure necessary.
In the case of inflammation of the colon or inflammation ofdiverticula of the colon, the inflamed section of the colon must be removed.
Here too, the type of underlying disease and inflammation plays a decisive role. In Europe, diverticula and their complications usually occur in the left-sided colon, particularly in the sigmoid colon. In the event of a perforation, it is therefore advisable to remove the affected part, usually the sigmoid colon, along with the perforation.
Ulcerative colitis tends to cause inflammatory changes in the entire colon and can also degenerate into malignancy over the years. In extreme cases, it may be necessary to remove the entire colon.
In the case of the other specific inflammatory bowel disease, Crohn's disease, however, only sparing removal of parts of the bowel is indicated.
If there is a perforation in a tumor, even in a malignant tumor, suturing is ruled out. Removal of the tumor must be attempted if at all possible. This applies to both the stomach and the intestine. However, the spread of tumor cells through the perforation has an extremely negative influence on the further course of the disease.
Gastric ulcers that perforate in the region of the transition to the duodenum are usually inflammatory in nature. They are very often caused by colonization with the germ Helicobacter pylori.
Cross-section of the stomach and illustration of a gastric ulcer © bilderzwerg | AdobeStock
In the upper parts of the stomach, on the other hand, it is often a previously unknown perforated carcinoma. In these cases, the findings should be excised and then closed. Simple over-sewing is not recommended here.
In the case of clear or proven tumor findings, partial removal of the stomach (B-I or B-II resection) may be necessary. In unfavorable cases, even complete removal of the stomach(gastrectomy) is indicated.
The effects of violence , such as in accidents, can cause very complex injuries. Organ ruptures such as in the area of the spleen or liver can lead to extreme bleeding. The shock situation caused by the loss of blood is then the primary concern.
In cases of severe inflammation, it may be necessary to perform multiple operations to clean the abdominal cavity and check any sutures for leaks.
In these cases, temporary and provisional abdominal wall closure using films and sponges has proven effective. These so-called VAC dressings (vacuum assisted closure) drain the inflammatory secretions from the abdominal cavity using negative pressure.
The dressing can be changed under anesthesia in the intensive care unit or in the operating theatre and is changed every 3-4 days.
After stabilization of the conditions, the abdomen can then be closed. It may also be necessary to apply a VAC bandage to the abdominal wall for a certain period of time. This can often be changed without anesthesia.
Perforations in the gastrointestinal tract can have serious consequences and usually need to be treated quickly © ag visuell | AdobeStock
In addition to treating the cause of the perforation and the peritonitis, it is usually necessary to combat the infection with antibiotics. The choice of the appropriate substance depends on the type and extent of the perforation, but also on the patient's additional illnesses.
During the operation, material is taken to detect the respective germs and to test the appropriate antibiotic. This testing takes 2-3 days, during which time the antibiotic treatment must be based on the empirical values for the relevant situation. Severe courses or additional infections such as pneumonia require the medication to be adjusted accordingly.
The technique of the surgical approach depends on whether the cause of the perforation can be remedied using this technique.
The only difference between a laparoscopic or conventional approach to the problem is the access route. The requirements for the procedure in the abdominal cavity are otherwise the same: stitching over a gastric perforation or removing an appendix is safely possible using the laparoscopic technique, including the necessary irrigation of the abdominal cavity.
A conventional large incision is also possible for laparoscopy-experienced teams in cases such as
is necessary.
It is a matter of reliable focal decontamination and handling of the organs in the abdominal cavity, taking into account the special situation of peritonitis. The possibilities of laparoscopy may be limited here.
The range of surgical options for intestinal perforation is broad:
Significant risk factors are
Peritonitis, which is usually caused by a perforation, is a potentially life-threatening disease.
Treatment is based on the principle of treating the focus. However, it otherwise proceeds in stages depending on the extent of the disease and the resulting organ damage. The effort involved ranges from a two-day inpatient stay to weeks of struggle with
The early and late consequences can vary accordingly. Typical consequences are
All suturing procedures - whether manual or stapling technique - are performed in the special situation of perforation and the inflammatory involvement of the tissue that is usually present. The risk of leakage is higher than with non-emergency operations.
The tightness of the sutures can be checked by administering an aqueous contrast medium as a sip or via a probe from above or as an enema from the rectum in the X-ray. Leaks may require a second operation.
The underlying inflammatory diseases in the gastrointestinal tract listed above should be treated consistently as far as possible.
The following applies to the stomach: treat ulcers and have healing checked by gastroscopy. Limit the intake of non-steroidal anti-inflammatory drugs (many so-called rheumatism and painkillers) as far as possible to short periods and low doses.
Treat underlying intestinal diseases consistently, even in the case of alternating episodes. In the case of sigmoid diverticulitis in conjunction with
decide in good time whether an elective, preventive resection is advisable.
If in doubt, it is better to visit the doctor or outpatient clinic "for nothing"! They are familiar with the picture of perforation peritonitis. At the same time, however, other causes for the pain must also be considered:
can show similar symptoms. The course of the disease gives the experienced doctor further clues as to the causes of the symptoms. However, repeated examination or observation in hospital is quite common for cases that are not initially so dramatic.
The Leading Medicine Guide's quality assurance is ensured by the following acceptance prerequisites.
