Definition

Perforation refers to a hole or injury in the wall of an internal organ. This condition can occur in various parts of the digestive system, including the esophagus, stomach, small intestine, large intestine, anus, or gallbladder. Perforation can arise from several causes, such as appendicitis, diverticulitis, or traumatic injuries like stab wounds or gunshot wounds.

Intestinal perforation, or enteric perforation, refers to a hole, gap, or discontinuity in the intestinal wall. This disorder can be described as a hole in the intestinal wall, allowing intestinal contents to leak into the abdominal cavity, leading to peritonitis, an inflammation of the peritoneum. Peritonitis can result in sepsis, leading to organ failure and potentially death.

Intestinal perforation is a serious complication caused by many disease processes and is a medical emergency that necessitates prompt treatment. Recovery from this condition depends on prompt diagnosis and early intervention.

Causes

Intestinal perforation can result from a variety of causes, such as:

• Appendicitis or inflammation of the appendix
• Gastrointestinal cancer
• Diverticulitis
• Crohn's disease
• Ulcerative colitis
• Ischemic colitis
• Inflammatory bowel disease
• Colorectal cancer
• Meckel's diverticulum inflammation is a congenital disease of the small intestine that resembles appendicitis.
• Intestinal volvulus or obstruction.

The following are additional potential causes of intestinal perforation:

• Acute blunt trauma to the intestines
• Abdominal or pelvic injuries, such as those caused by an accident, a gunshot, or a puncture wound
• Elective abdominal or pelvic surgery
• Surgical procedures, including upper gastrointestinal endoscopy and colonoscopy
• Ingestion of foreign objects or corrosive substances, injuries to the gastrointestinal tract resulting from the use of aspirin, non-steroidal anti-inflammatory medications (NSAIDs), and steroids, chemotherapy.

Risk factor

Various factors can increase the risk of developing a perforation, specifically:

• Aged over 75 years
• Suffer from multiple diseases or medical conditions
• Using monoclonal antibody immunotherapy medicines, including ipilimumab
• Experiencing adhesions in the pelvic organs
• Female

Perforated tissue may sometimes fail wound healing. Risk factors include malnutrition, smoking, excessive alcohol use, drug abuse, poor hygiene, type 2 diabetes, obesity, sepsis, hematomas, and the use of corticosteroid medicines.

Symptoms

Intestinal perforation symptoms may include:

• Chronic abdominal pain. This sensation can manifest abruptly or develop slowly.
• Sudden pain may result from a perforation or trauma to the small intestine, while pain that develops slowly may be caused by the formation of a hole or wound in the large intestine.
• The pain intensifies when the individual changes body position or inadvertently applies pressure to the stomach. Lying down could help this problem.
• The abdomen may bulge and become rigid to the touch
• Perspiration caused by fear or nervousness
• Fever
• Nausea and vomiting
• Shock

Diagnosis

Intestinal perforation is diagnosed based on digestive symptoms, including abdominal pain, nausea, vomiting, and often fever. The pain's location is determined by the perforation site; for instance, in appendicitis, the pain is felt in the lower right abdomen. Understanding the initial pain and past complaints, including the moment of onset, duration, location, and pain triggers. Evaluating the earliest symptoms will offer insights into the underlying etiology of the perforation. Anamnesis is conducted to identify potential reasons for perforation, such as:

• Nausea or vomiting typically precede lower right abdomen pain by 3-4 hours in patients with appendicitis.
• Elderly patients experiencing intense pain in the lower abdomen may be suspected of having acute appendicitis.
• Previous experiences of severe or acute trauma to the lower chest or abdomen
• Historical usage of pharmaceuticals like anti-inflammatory medications or steroids
• Consistent episodes of fever, along with abdominal pain, gas, diarrhea, and constipation, may indicate a diagnosis of typhoid fever.
• Historical background of endoscopy and colonoscopy procedures

During a physical examination, signs of peritonitis may include fever, flatulence, reduced bowel sounds, and pain in the abdominal area. As a result of the pain, you may observe elevated blood pressure and tachycardia (increased heart rate) when assessing vital signs. Symptoms of sepsis and septic shock may arise from a high fever and decreased consciousness.

Additional examinations such as X-rays, CT scans, and abdominal ultrasound (USG) are necessary to confirm a diagnosis of intestinal perforation and laboratory tests.

• A CT scan is conducted to identify the perforation's location, the surrounding inflammatory condition, free air, and potential organ abscesses.
• An ultrasound examination (USG) is performed to evaluate the existence of gas accumulation resulting from intestinal perforation. This ultrasound examination can identify further abnormalities, such as intestinal thickness and the perforation's location. Ultrasound examination can evaluate the liver, spleen, pancreas, kidneys, ovaries, and uterus to help make an accurate diagnosis.
• An abdominal x-ray is performed in two positions, lying down and standing up, to detect the presence of fluid or air in the stomach.

A complete blood laboratory test will show elevated white blood cells, indicating an infection. A blood culture investigation is conducted to determine the appropriate antibiotic treatment. Liver and kidney function tests could show abnormalities in the presence of sepsis complications.

Management

Treatment of perforation involves prompt surgical intervention. If the perforation is fully recovered, antibiotics can be administered promptly. Exploratory laparotomy is typically the procedure used in situations of perforation. The doctor will perform surgery on the patient's stomach to mend the developed hole. The operation's success rate hinges on the perforation's severity, promptness of treatment, and the patient's health status. Antibiotics are administered to prevent infections that may lead to sepsis.

Complications

Complications resulting from perforation differ as it is a medical emergency requiring prompt treatment. Without treatment, this condition can lead to complications such as abdominal bleeding, peritonitis, sepsis, abdominal abscesses, intestinal damage, necrosis, and potentially death.

Prevention

Intestinal perforation is not preventable, although risk factors can be managed to reduce the risk of occurrence. Individuals over 75 should get routine health assessments, particularly if they encounter abdominal pain and a high fever. If you experience abdominal pain in the lower right, be evaluated promptly since it could indicate appendicitis. Properly treating appendicitis can prevent it from perforating.

When to see a doctor?

It is advisable to promptly consult a doctor if you exhibit the symptoms mentioned or have risk factors that may elevate the risk of perforation. Early treatment of perforations can prevent complications and enhance the patient's quality of life.

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