1. The patient presented with persistent fever and abdominal pain and was diagnosed with infectious enterocolitis, likely caused by rotavirus. Imaging showed colitis of the ascending colon with suspected perforation and abscess formation. 2. Gastrointestinal perforation requires full-thickness injury to the bowel wall and can result from various medical and surgical causes. Clinical features depend on the location and contents released. 3. Management involves IV fluids, antibiotics, and surgery to repair the perforation site for patients with signs of peritonitis or worsening symptoms. Some perforations can be managed non-operatively with antibiotics if the perforation is contained.

1. 高雄市醫師公會
病例報告及討論
高雄市立小港醫院
吳晃維醫師

2. Patient Information
• Name: 崔O慈
• Sex: Female
• Age: 16 year old
• Patient number: 04143721
• Admission date: 2023/06/10
• Nutritional Status:
– Height 155cm ( 15-50th)
– Weight 42kg (3-15th)

3. Chief Complaint
• Persistent fever up to 39.3'C since three days ago

4. Present illness
According to her family, she suffered from fever up to 39.3℃ for 3 days.
Associated symptoms: mild dysuria, odorus urine, nausea, mild to moderate
abdominal pain, muddy stool passage, mild headache and mild dizziness.
she was brought to our pediatric emergency department on three days ago.
Suspected UTI and unifradine was prescribed. (06/07 Influenza Ag rapid
test: negative; U/A: cloudy; PRO: 100; Leu: -;NIT: -; WBC: 11-25 HPF)
After three days of treatment, persisted fever was still noted and she came
to our pediatric emergency department again.

5. Denied
• Vomiting
• chest tightness
• chest pain
• Hematuria
• blood-tinged in stool content
• tarry stool passage
• skin rash

6. Past history
• Vaccination: up to date
• Congenital heart disease/Type 1 Diabetes mellitus∕Glucose 6-phosphate dehydrogenase
deficiency: denied
• Asthma∕Allergic rhinitis∕Atopic dermatitis：denied
• Other systemic disease: denied
• Growth and development: appropriate for age
• Prior hospitalization: denied
• Operation history: denied

7. Physical examinations
• Consciousness: alert Conjunctiva: not pale
• Sclera/Conjunctiva: anicteric
• Neck: supple。
• Chest: symmetric movement with respiration。
• Breath sound: clear
• Heart sound: regular，normal S1, S2, no murmur
• Abdomen: hyperactive bowel sound, soft。 tenderness(+/-, right lower quadrate) , no rebound pain
• Percussion: ﹝tympanic﹞
• Flank knocking pain: present on the bilateral sides
• Murphy's sign(-), Mcburney's sign(-)
• General appearance: grossly normal，no skin rash

8. Family history
• No hereditary disease
• No family members have similar symptoms

9. Lab

10. KUB on 6/7
Impression：
Scoliosis of thoracolumbar spine.

11. CXR on 6/10
Impression：
Scoliosis at thoracolumbar spine.

12. Tentative diagnosis
• Infectious enterocolitis, cause to be determined
• Pyuria, suspect APN, bilateral
• Hypokalemia
• Dehydration
• Scoliosis of thoracolumbar spine

13. Plan
• # Respiratory: room air
• # Nutrition: Bland diet, KCl 0.298% ST (at once (=stat)) and Taita No.1 fluid maintain
• # Medication:
• Antibiotics: Ceftriaxone 50mg/kg/dose Q12H (every 12 hours) since 06/10
• Kascoal, Miyarisan
• # Examination:
• Stool: Routine, Rotavirus, Enteric ADV, Clostrisium difficle
• Arrange abdominal echo
• Pending on urine culture and blood culture

14. Hospital course
6/11
• Persistent fever
• Abdominal pain got worse
• Arrange abdominal CT 06/11 night

15. 6/11 Abdominal CT

16. 6/11 Abdominal CT
• Impression：
• 1) Suspect colitis of the ascending colon, suspect superimposed perforation and
abscess formation at the right paracolic gutter. -- Air dissecting along the
retroperitoneal space.
• 2) Suspicious a right ovarian cyst. Differential diagnosis includes: hemorrhagic cyst
or cystic tumor.
• 3) Suspect functional cyst in bilateral adnexae.
• 4) Mild hydrometra.

17. 6/12
. intermittent abdominal cramping pain
. much yellowish watery diarrhea ,blood tinged(-), mucous coating(-)
. RLQ (right lower quadrant) pain sometimes
-> add metronidazole + consult Colorectal Surgery

19. Lab

20. Diagnosis when transferred to Colorectal Surgery
on 6/13
. colitis of the ascending colon, suspect superimposed perforation and abscess formation
at the right paracolic gutter.
. Infectious enterocolitis, rotavirus related
. Pyuria, suspect UTI (urinary tract infection)
. Hypokalemia
. Dehydration

21. - pre-op survey on 6/13
- Improved abdominal pain on 6/13, 6/14 and no fever from 6/12.
- 6/15 follow lab data
- Keep antibiotic treatment
- Discharge on 6/20

22. 6/15 lab data

23. TPR

24. Final diagnosis
• Infectious enterocolitis, rotavirus related
• Pyuria, suspect UTI
• colitis of the ascending colon, suspect superimposed perforation and
abscess formation at the right paracolic gutter
• Dehydration
• Scoliosis of thoracolumbar spine

25. OPD follow up
• 病歷號:04143721
姓 名:崔O慈
大腸鏡檢查過程記錄暨報告 (2023/08/29)
Colonoscopic Findings :
Up to terminal ileum, mucosa scarring with whitish mucosa noted over A-colon.
Bx1-2. Mixed hemorrhoid was also noted.
Endoscopic diagnosis :
Non-specific colitis
Mixed hemorrhoids
Complication :
NIL
Suggestion :
normal A-colon mucosa.

26. • 高 雄 市 立 小 港 醫 院 病理科 病理組織檢查報告
• 病理編號： HKH-12-08363 病歷號碼： 0414372-1
• 病人姓名： 崔O慈 出生日期： 2006/10/29 年齡： 17 Yrs. 性別： 女
• 採檢日： 2023/08/29 收到日： 2023/08/30 10:05:16 報告日： 2023/08/31 09:10:04
• 組織名稱： Ascending colon
• 臨床診斷： non-specific colitis
• Pathologic Diagnosis:
• Intestine, large, colon, ascending, colonofiberoscopic biopsy, erosion and inflammation.
• Gross Examination:
• The specimen submitted consists of 2 tissue fragments in 1 bottle, measuring up to 0.8 x 0.2 x 0.1 cm in
size, fixed in formalin. Grossly, they are grayish and elastic.
• Entire specimen is embedded.
• Microscopic Examination:
• Section shows eroded epithelium with intense mixed inflammation. Many eosinophils are found,
up to 75 per high power filed.

27. Discussion
GI perforation

28. Introduction
• suspected based upon
• the patient's clinical presentation
• becomes obvious through a report of extraluminal "free" gas or fluid
• Clinical manifestations depend on
• the organ affected
• the nature of the contents released (gas, succus entericus, stool)
• the ability of the surrounding tissues to contain those contents.

29. • Intestinal perforation can present acutely or in an indolent manner (eg, abscess or
intestinal fistula formation).
• A confirmatory diagnosis is made primarily using abdominal imaging studies, but on
occasion, exploration of the abdomen (open or laparoscopic) may be needed to
make a diagnosis.
• Specific treatment depends upon the nature of the disease process that caused the
perforation.
• Some etiologies are amenable to a nonoperative approach, while others will require
surgery.

30. Pathophysiology
• Perforation requires full-thickness injury of the bowel wall
• partial-thickness bowel injury (eg, electrocautery, blunt trauma) can progress over
time to become a full-thickness injury or perforation
• Instrumentation (eg, endoscopy, instillation of contrast, cautery application during surgery)
• Trauma (blunt or penetrating)
• Bowel ischemia
• Bowel obstruction
• Neoplasms (particularly colon carcinoma), besides by causing bowel obstruction, can also
cause perforation by direct penetration of the tumor

31. Anatomic considerations
• gastrointestinal perforation leads to free fluid and diffuse peritonitis or is
contained, resulting in an abscess or fistula formation
• depends upon location along the gastrointestinal tract and the patient's ability
to mount an inflammatory response to the specific pathologic process.
• retroperitoneal perforations are more likely to be contained.

32. Risk Factors
• Instrumentation/surgery
• iatrogenic perforation : upper endoscopy (especially rigid endoscopy), sigmoidoscopy,
colonoscopy, stent placement, endoscopic sclerotherapy , nasogastric intubation , esophageal
dilation, and surgery.
• Penetrating or blunt trauma
• Medications, other ingestions, foreign body
• Violent retching/vomiting: Boerhaave syndrome
• Hernia/intestinal volvulus/obstruction
• Inflammatory bowel disease

33. • Appendicitis
• Peptic ulcer disease
• Diverticular disease
• Cardiovascular disease – Any process that reduces the blood flow to the intestines
(occlusive or nonocclusive mesenteric ischemia
• Infectious disease
• Neoplasms
• Connective tissue disease
• Spontaneous intestinal perforation

34. Clinical Features
• Presentations
• Sudden, severe chest or abdominal pain following instrumentation or surgery is very
concerning for perforation.
• Acute pain: Inflammation of the gastrointestinal tract, as a result of perforation by
a variety of etiologies
• Abdominal/pelvic mass
• It is not uncommon for perforation to lead to abscess or phlegmon formation that can be
appreciated on examination as an abdominal mass or with abdominal exploration.
• A pelvic abscess caused by a perforation can sometimes be felt on digital rectal examination.
Diverticulitis is the most common etiology leading to intra-abdominal abscess formation.

35. Diagnosis
• General approach
• history and physical examination
• diagnosis relies upon imaging that demonstrates gas outside the gastrointestinal tract in
the abdomen (ie, pneumoperitoneum) or mediastinum (ie, pneumomediastinum), or
complications associated with perforation, such as an intra-abdominal or mediastinal
abscess, or gastrointestinal fistula formation

36. Imaging Signs of Perforation
Chest Imaging
• Pneumomediastinum
-The "V" sign of Naclerio is free gas in the mediastinum outlining the diaphragm and is seen in
approximately 20 percent of cases.
-Ring-around-the-artery
-Widening of the mediastinum is sometimes seen with esophageal perforation.
• Free gas
• Pleural effusion
• Pneumothorax is a rare finding

37. Imaging signs of perforation
Abdominal imaging
• Plain abdominal films
• The Cupola sign (inverted cup) is an arcuate (bow-
shaped) lucency over the lower thoracic spine
• The Rigler sign (double-wall sign) is seen as gas outlining
the inner and outer surfaces of the intestine
• The Psoas sign is gas in the retroperitoneal space
• The Urachus sign is gas in the preperitoneal space
outlining the urachus or umbilical ligaments.

38. Imaging Signs of Perforation
Abdominal Imaging
Abdominal CT
• Signs of perforation on abdominal CT scanning include extraluminal gas

39. Differential Diagnosis
• Pneumoperitoneum
• Pneumomediastinum

40. Initial Management
• intravenous (IV) fluid therapy
• cessation of oral intake
• broad-spectrum antibiotics.
• Monitoring should initially take place in an intensive care unit.
• PPI for upper GI perforation
• Patients with intestinal perforation can have severe volume depletion.

41. Conservative Care
• A subset of patients may not require immediate surgery to manage
gastrointestinal perforation.
• Traditionally, conservative management of gastrointestinal perforation
(including esophagus) was used only for patients who were deemed so ill that
they would not likely survive surgery.

42. • Patients chosen for nonoperative management are those with
• contained perforation
• gastrointestinal fistula formation
• limited contamination as judged by imaging
• in those who have no signs of systemic sepsis
• Patients chosen for conservative management in contemporary series are
generally less ill, conservative management is often associated with lower
rates of morbidity and mortality compared with surgical management.

43. Indications for Abdominal Exploration
• Many patients will require urgent surgical intervention to
• limit ongoing abdominal contamination
• manage the perforated site.
• Patients with evidence of perforation and the following clinical signs benefit from
immediate surgery:
1. Abdominal sepsis, worsening or continuing abdominal pain, and/or signs of
diffuse peritonitis.
2. Bowel ischemia.
3. Complete or closed-loop bowel obstruction.

44. Specific Organs
-Esophagus
• Perforation of the esophagus is more often iatrogenic
• As an element of conservative care, covered stents are increasingly being
used to manage some patients with esophageal perforation.
• open surgery remains the mainstay of treatment.
• primary repair, repair over a drain, and, in the case of severe stricture or
tumor, esophagectomy and esophageal exclusion
• may involve a neck incision and/or thoracotomy

45. Stomach and Duodenum
• Peptic ulcer disease is the most common cause of stomach and duodenal
perforation.
• Marginal ulcers may complicate procedures involving a gastrojejunostomy (eg,
partial gastrectomy, bariatric surgery)
• Perforated duodenal ulcers are located on the anterior or superior portions of the
duodenum and typically rupture freely, causing severe acute abdominal pain.
• Perforated gastric ulcer is associated with a higher mortality, possibly related to
delays in diagnosis
• Most perforations of the stomach and duodenum require surgical repair

46. Small Intestine
• Perforation of the small intestine can be related to bowel obstruction, acute
mesenteric ischemia, inflammatory bowel disease, or due to iatrogenic or
non-iatrogenic trauma
• Treatment of small intestinal perforation is performed by closing the
perforation in one or two layers.
• If it has been long-standing, producing significant induration, a small bowel
resection with primary anastomosis is performed.

47. Appendix
• Approximately 30 percent of those with acute appendicitis present with
perforation.
• Younger children often have atypical or vague symptoms and are more likely
to present after perforation has occurred

48. 1. Unstable patients or patients with free perforation — A free perforation of
the appendix can cause intraperitoneal dissemination of pus and fecal material
and generalized peritonitis. These patients are typically quite ill and may be septic
or hemodynamically unstable, thus requiring emergency appendectomy
2. Stable patients — Stable patients with perforated appendicitis who have
symptoms localized to the right lower quadrant can be treated with immediate
appendectomy or initial nonoperative management. Both approaches are safe.
the decision ultimately rests with the treating surgeon.

49. • Initial nonoperative management — Stable patients with perforated
appendicitis who have symptoms localized to the right lower quadrant (ie, no
free perforation or generalized peritonitis) may be treated initially with
antibiotics, intravenous fluids, and bowel rest, rather than immediate surgery.
• These patients will often have a palpable mass on physical examination; a
computed tomography (CT) scan may reveal a phlegmon or abscess.
• Treatment failure, as evidenced by bowel obstruction, sepsis, or persistent
pain, fever, or leukocytosis, requires immediate rescue appendectomy.

50. Colon and Rectum
• Colon and rectal perforation is more commonly due to diverticulitis, neoplasm, and
iatrogenic and noniatrogenic traumatic mechanisms
• Colonic diverticulosis is common in the developed world, affecting up to 50 percent
of adults, most with left-sided disease. In Asian countries, by contrast, the most
common cause of right-sided colonic perforation is diverticulitis
• Most cases of diverticulitis with contained perforation or small abscess can be
treated nonoperatively with antibiotics with or without percutaneous drainage.
Resection is usually required for more severe diverticular complications

51. • Colon perforations can be treated by simple suture if the perforation is small,
often using a laparoscopic approach
• If the perforation is larger and devascularizing the colonic wall, colon
resection will be necessary
• Primary anastomosis may be combined with proximal "protective" ostomy in
those with complicated diverticulitis or malignancy.

52. Thank you