Gastrointestinal perforation

Answer 1

Definition

An esophageal perforation is a hole in the esophagus, the tube through which food passes from the mouth to the stomach.

Alternative Names

Perforation of the esophagus

Causes, incidence, and risk factors

A perforation is a hole through which the contents of the esophagus can pass into the mediastinum, the surrounding area in the chest. This often results in infection of the mediastinum (mediastinitis).

The most common cause of an esophageal perforation is injury during a medical procedure such as esophagoscopy. However, because flexible instruments are now used this rarely occurs.

The esophagus may also become perforated as the result of:

• A tumor
• Gastric refluxwith ulceration
• Swallowing a foreign object or caustic chemicals
• Violent vomiting

Less common causes include injuries to the esophagus area (blunt trauma) and injury to the esophagus during an operation on another organ near the esophagus.

Symptoms

The main symptom is pain at first.

Patients with a perforation in the middle portion or lowermost portion of the esophagus may have difficulty swallowing, chest pain, and difficulty breathing.

Signs and tests

Signs include:

• Fast breathing
• Fever
• Low blood pressure
• Rapid heart rate

Patients with a perforation in the top part of the esophagus may have neck pain or stiffness and air bubbles underneath the skin.

A chest x-raymay reveal air in the soft tissues of the chest, fluid that has leaked from the esophagus into the space around the lungs, or a lung collapse.

A chest CT scanmay show an abscessin the chest or esophageal cancer. X-rays taken after you drink a non-harmful dye can help pinpoint the location of the perforation.

Treatment

Almost all patients need early surgery. Every effort should be made to have surgery within 24 hours of when the perforation occurred.

The initial treatment may include:

• Administering fluids through a vein (IV)
• Administering IV antibiotics to prevent or treat infection
• Draining fluid that has collected around the lungs with a chest tube
• Bronchoscopy to remove fluid that has collected in the area behind the breastbone and between the lungs (mediastinum)

If little or no fluid has leaked, a stent may be placed in the esophagus. This may help you avoid surgery.

Sometimes a perforation in the uppermost (neck region) part of the esophagus may heal by itself if you do not eat or drink for a period of time. In this case, you must get nutrition from another source, such as a stomach feeding tube.

Surgery is usually needed to repair a perforation in the middle or bottom portions of the esophagus. Depending on the size and location of the perforation, the leak may be treated by simple repair or by removing the esophagus.

Expectations (prognosis)

The condition can progress to shock -- even death -- if untreated.

For patients with an early diagnosis (less than 24 hours), the outlook is good. The survival rate is 90% when surgery is performed within 24 hours. However, this rate drops to about 50% when treatment is delayed.

Complications

Possible complications include:

• Permanent damage to the esophagus (narrowing or stricture)
• Abscess formation in and around the esophagus
• Infection in and around the lungs.

Calling your health care provider

Demand immediate medical attention if you are already in the hospital.

Go to the emergency room or call 911 if you have recently had surgery or a tube placed in the esophagus and you have pain, difficulty swallowing or breathing, or another reason to suspect that you may have esophageal perforation. Time is of the essence in treating this condition.

Prevention

Because of their nature, these injuries are difficult to prevent.

ReferencesKiey J, Amendola M, Bouhaider D, Sandhu BS, Zhao X, Maher J. A management algorithm for esophageal perforation.American J Surg. 2007;194:103-106.

Answer 2

Definition

Gastrointestinal perforation is a hole that develops through the entire wall of the stomach, small intestine, large bowel, or gallbladder. This condition is a medical emergency.

Alternative Names

Intestinal perforation; Perforation of the intestines

Causes, incidence, and risk factors

Gastrointestinal perforation can be caused by a variety of illnesses, including appendicitis, diverticulitis, ulcer disease, gallstones or gallbladder infection, and less commonly, inflammatory bowel disease, including Crohn's disease and ulcerative colitis.

Perforation of the intestine leads to leakage of intestinal contents into the abdominal cavity. This causes an inflammation called peritonitis.

Symptoms

Symptoms may include:

• Abdominal pain - severe
• Chills
• Fever
• Nausea
• Vomiting

Signs and tests

X-rays of the abdomen may show air in the abdominal cavity (not in the stomach or intestines), suggesting a perforation. CT scan of the abdomen often shows the location of the perforation. The person's white blood cell (WBC) count is often higher than normal.

Treatment

Treatment usually involves surgery to repair the hole (perforation). Occasionally, a small part of the intestine must be removed. A temporary colostomy or ileostomy may be needed.

In rare cases, antibiotics alone can be used to treat patients whose perforations have closed. This can be confirmed by a physical exam, blood tests, CT scan, and x-rays.

Expectations (prognosis)

Surgery is usually successful, but depends on the severity of the perforation and the length of time to treatment.

Complications

Complications include:

• Bleeding
• Infection (possible sepsis)
• Intra-abdominal abscess

Calling your health care provider

Call your doctor if you have severe abdominal pain, fever, nausea, vomiting, blood in your stool, or changes in bowel habits.

Prevention

Prevention depends on the cause. Diseases that may lead to intestinal perforation should be treated appropriately.

References

Turnage RH, Richardson KA, Li BD, McDonald JC. Abdominal wall, umbilicus, peritoneum, mesenteries, omentum, and retroperitoneum. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. St. Louis, Mo: WB Saunders; 2008:chap 43.

Answer 3

Definition

An esophageal perforation is a hole in the esophagus, the tube through which food passes from the mouth to the stomach.

Alternative Names

Perforation of the esophagus

Causes, incidence, and risk factors

A perforation is a hole through which the contents of the esophagus can pass into the mediastinum, the surrounding area in the chest. This often results in infection of the mediastinum (mediastinitis).

The most common cause of an esophageal perforation is injury during a medical procedure. However, because flexible instruments are now used this rarely occurs.

The esophagus may also become perforated as the result of:

• A tumor
• Gastric refluxwith ulceration
• Previous surgery on the esophagus
• Swallowing a foreign object or caustic chemicals, such as household cleaners, disk batteries, and battery acid
• Trauma or injury to the chest and esophagus
• Violent vomiting

Less common causes include injuries to the esophagus area (blunt trauma) and injury to the esophagus during an operation on another organ near the esophagus.

Symptoms

The main symptom is pain at first.

Patients with a perforation in the middle portion or lowermost portion of the esophagus may have difficulty swallowing, chest pain, and difficulty breathing.

Signs and tests

Signs include:

• Fast breathing
• Fever
• Low blood pressure
• Rapid heart rate

Patients with a perforation in the top part of the esophagus may have neck pain or stiffness and air bubbles underneath the skin.

A chest x-raymay reveal air in the soft tissues of the chest, fluid that has leaked from the esophagus into the space around the lungs, or a lung collapse.

A chest CT scanmay show an abscessin the chest or esophageal cancer. X-rays taken after you drink a non-harmful dye can help pinpoint the location of the perforation.

Treatment

Many patients need early surgery, depending on the location and size of the perforation. If surgery is done, it is best to have it within 24 hours of when the perforation occurred.

Treatment may include:

• Administering fluids through a vein (IV)
• Administering IV antibiotics to prevent or treat infection
• Draining fluid that has collected around the lungs with a chest tube
• Mediastinoscopyto remove fluid that has collected in the area behind the breastbone and between the lungs (mediastinum)

If little or no fluid has leaked, a stent may be placed in the esophagus. This may help you avoid surgery.

Sometimes a perforation in the uppermost (neck region) part of the esophagus may heal by itself if you do not eat or drink for a period of time. In this case, you must get nutrition from another source, such as a stomach feeding tube.

Surgery is usually needed to repair a perforation in the middle or bottom portions of the esophagus. Depending on the size and location of the perforation, the leak may be treated by simple repair or by removing the esophagus.

Expectations (prognosis)

The condition can progress to shock -- even death -- if untreated.

For patients with an early diagnosis (less than 24 hours), the outlook is good. The survival rate is 90% when surgery is performed within 24 hours. However, this rate drops to about 50% when treatment is delayed.

Complications

Possible complications include:

• Permanent damage to the esophagus (narrowing or stricture)
• Abscess formation in and around the esophagus
• Infection in and around the lungs.

Calling your health care provider

Demand immediate medical attention if you are already in the hospital.

Go to the emergency room or call 911 if you have recently had surgery or a tube placed in the esophagus and you have pain, difficulty swallowing or breathing, or another reason to suspect that you may have esophageal perforation. Time is of the essence in treating this condition.

Prevention

Because of their nature, these injuries are difficult to prevent.

References

Eckstein M, Henderson SO. Thoracic trauma. In: Marx JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa: Mosby Elsevier;2009:chap 42.

Reviewed By

Review Date: 12/13/2010

George F. Lonstreth, MD, Department of Gastroenterology, Kaiser Permanente Medical Care Program, San Diego, CA. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

Answer 4

Definition

Gastrointestinal perforation is a hole that develops through the entire wall of the stomach, small intestine, large bowel, or gallbladder. This condition is a medical emergency.

Alternative Names

Intestinal perforation; Perforation of the intestines

Causes, incidence, and risk factors

Gastrointestinal perforation can be caused by a variety of illnesses, including appendicitis, diverticulitis, ulcer disease, gallstones or gallbladder infection, and less commonly, inflammatory bowel disease, including Crohn's disease and ulcerative colitis.

It may also be caused by abdominal surgery.

Symptoms

Perforation of the intestine leads to leakage of intestinal contents into the abdominal cavity. This causes inflammation called peritonitis.

Symptoms may include:

• Abdominal pain - severe
• Chills
• Fever
• Nausea
• Vomiting

Signs and tests

X-rays of the chest or abdomen may show air in the abdominal cavity (not in the stomach or intestines), suggesting a perforation. CT scan of the abdomen often shows the location of the perforation. The white blood cell (WBC) count is often higher than normal.

Treatment

Treatment usually involves surgery to repair the hole (perforation). Occasionally, a small part of the intestine must be removed. A temporary colostomy or ileostomy may be needed.

In rare cases, antibiotics alone can be used to treat patients whose perforations have closed. This can be confirmed by a physical exam, blood tests, CT scan, and x-rays.

Expectations (prognosis)

Surgery is usually successful, but depends on the severity of the perforation and the length of time to treatment.

Complications

Complications include:

• Bleeding
• Infection (including a widespread infection called sepsis, which can lead to death)
• Intra-abdominal abscess

Calling your health care provider

Call your doctor if you have severe abdominal pain, fever, nausea, vomiting, blood in your stool, or changes in bowel habits.

Prevention

Prevention depends on the cause. Diseases that may lead to intestinal perforation should be treated appropriately.

References

Turnage RH, Richardson KA, Li BD, McDonald JC. Abdominal wall, umbilicus, peritoneum, mesenteries, omentum, and retroperitoneum. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. St. Louis, Mo: WB Saunders; 2008:chap 43.

Reviewed By

Review Date: 06/28/2010

Jacob L. Heller, MD, Emergency Medicine, Virginia Mason Medical Center, Seattle, Washington, Clinic. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.