cause, symptom and clinical cases

1. PREPARED BY:- SONALI HARSH RAJ

3. 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

4. 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.

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

6. 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

7. 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.

8. 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:

9. •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

10. 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

11. •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.

12. 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.

13. 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: 11.8×109/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. 2A).
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. 2B), where the penetrating wooden foreign body was identified as a toothpick (6 cm) (Fig.
2C). 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.

15. 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 8x109/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.

16. 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 8th postoperative day in a
good condition.