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Gastrointestinal perforation

Last updated: January 20, 2025

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Summarytoggle arrow icon

Gastrointestinal perforation is a full-thickness loss of bowel wall integrity that results in perforation peritonitis. Perforation of a duodenal ulcer is the most common cause of perforation peritonitis. Patients typically present with an acute onset of severe abdominal pain associated with nausea, vomiting, and fever. Signs of peritoneal irritation are evident on examination and include decreased bowel sounds and diffuse or localized abdominal guarding and rebound tenderness. CT abdomen with IV contrast is the preferred imaging modality to confirm the presence of free air within the peritoneal cavity (pneumoperitoneum) and localize the site of the perforated viscus. Most patients will require an emergency exploratory laparotomy. Patients with evidence of a well-contained perforation (e.g., a small localized appendicular or diverticular perforation) and no signs of sepsis may be given a trial of conservative management with antibiotics, bowel rest, close monitoring of vital signs, and serial abdominal examination. The prognosis depends on the etiology, degree of intraabdominal contamination, and other comorbidities.

See also esophageal perforation.

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Etiologytoggle arrow icon

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Clinical featurestoggle arrow icon

Bowel perforation is a surgical emergency. In some cases, clinical features alone are sufficient to warrant emergency explorative laparotomy.

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Diagnosistoggle arrow icon

Laboratory analysis

Imaging [6][7]

Immediate studies

Before an upright x-ray, patients must be sitting up for at least 10 minutes in order to allow free air to move upward and collect under the diaphragm. [8]

Confirmatory studies

IV contrast is preferred if bowel perforation is suspected. If oral contrast must be used, a water-soluble contrast agent is preferred.

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Differential diagnosestoggle arrow icon

See “Differential diagnoses” in “Acute abdomen”.

The differential diagnoses listed here are not exhaustive.

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Treatmenttoggle arrow icon

Initial management

Supportive care

Ketorolac is contraindicated in patients with suspected bowel perforation.

Opioids are contraindicated in patients with suspected bowel obstruction.

Surgical management [13]

Most patients with GI tract perforation should be managed with urgent explorative laparotomy.

Conservative management [11][15]

Patients with only localized peritonitis and no signs of sepsis may be candidates for conservative (nonsurgical) management.

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Traumatic hollow viscus injurytoggle arrow icon

See “Primary survey” for the general approach to trauma patients; see also “Blunt abdominal trauma” (BAT) and “Penetrating abdominal trauma.”

Diagnosis [17][18]

Maintain a high index of suspicion for hollow viscus injury in patients with blunt abdominal trauma as clinical features may initially be very subtle. [18]

Management

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Acute management checklisttoggle arrow icon

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Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

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