Gastrointestinal perforation natural history
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
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Overview
If left untreated, all of patients with gastrointestinal (GI) perforation may progress to develop shock, abdominal abscess, and sepsis. Complications of GI perforation include systemic complications such as pneumonia, renal dysfunction and thromboembolism, surgical site infection, sepsis, intra-abdominal abscess, and shock. Prognosis of GI perforation depends on site of perforation, age of patient, and time of intervention. A delay in diagnosis for more than 24 hours in patients found to have isolated blunt small bowel injury has been known to be associated with a higher mortality compared with diagnosis at <24 hours. Patients with small bowel injury has worse prognosis than patients without small bowel injury. Mortality rates for patients sustaining a ruptured stomach have been reported between 28 and 66 percent. Perforation secondary to colonic injury has been known to be associated with a mortality rate of 1.3 percent. Sepsis has a high mortality rate. Sepsis is responsible for 6 percent of all deaths. Long-term survival of infants with spontaneous intestinal perforation has improved over the past 30 years with reported survival rates of 64 to 90 percent. Patients with spontaneous intestinal perforation appear to have a lower mortality rate compared with patients with surgically treated necrotizing enterocolitis.
Gastrointestinal perforation natural history
The symptoms of gastrointestinal perfoaration develop, and start with complaints of abdominal pain, hematemesis, dysphagia, and abdominal distention. Without treatment, the patient will develop symptoms of peritonitis and sepsis including lethargy, syncope, nausea, vomiting, dizziness, fever, chills and eventually lead to death. Gastrointestinal perforation is a surgical emergency and patients require prompt treatment to control the bleeding and prevent complications.
Complications
The incidence of complications ranges from 22 to 29 percent. Common complications of gastrointestinal perforation and surgery include:[1][2][3][4]
- Systemic complications such as pneumonia, renal dysfunction
- Complications specific to abdominal surgery include:
- Surgical site infection: It is common in patients with gastrointestinal injury. Surgical site infection occurred in 14 percent of patients
- Sepsis
- Intraabdominal abscess
- Shock
- Enterocutaneous fistula
- Incisional hernia
- Ileus
Prognosis
- Prognosis of GI perforation is related to a delay in initial diagnosis. A delay in diagnosis more than 24 hours in patients found to have isolated blunt small bowel injury was associated with a higher mortality compared with diagnosis at <24 hours.[5]
- Patients with small bowel injury has worse prognosis than patients without small bowel injury.
- Mortality rates for patients sustaining a ruptured stomach have been reported between 28 and 66 percent.[1]
- Colon-injury-related mortality rate of 1.3 percent.[6]
- Sepsis has a high mortality rate. Sepsis is responsible for 6 percent of all deaths.[7]
- Mortality rates increase in relation to the severity of sepsis.[8]
- The mortality associated with sepsis was 10 percent while that associated with septic shock was 40 percent.[9]
- Mortality appears to be lower in younger patients. Characteristics that impact the outcome include:[10]
- Patient response to infection
- The site and type of infection
- Timing and type of antimicrobial therapy
- Long-term survival of infants with spontaneous intestinal perforation has improved over the past 30 years with reported survival rates of 64 to 90 percent.[11]
- Patients with spontaneous intestinal perforation appear to have a lower mortality rate compared with patients with surgically treated necrotizing enterocolitis.[12]
References
- ↑ 1.0 1.1 Fakhry SM, Watts DD, Luchette FA, EAST Multi-Institutional Hollow Viscus Injury Research Group (2003). "Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury: analysis from 275,557 trauma admissions from the EAST multi-institutional HVI trial". J Trauma. 54 (2): 295–306. doi:10.1097/01.TA.0000046256.80836.AA. PMID 12579055.
- ↑ Yang XF, Pan K (June 2014). "Diagnosis and management of acute complications in patients with colon cancer: bleeding, obstruction, and perforation". Chin. J. Cancer Res. 26 (3): 331–40. doi:10.3978/j.issn.1000-9604.2014.06.11. PMC 4076711. PMID 25035661.
- ↑ Chalya PL, Mabula JB, Koy M, Mchembe MD, Jaka HM, Kabangila R, Chandika AB, Gilyoma JM (August 2011). "Clinical profile and outcome of surgical treatment of perforated peptic ulcers in Northwestern Tanzania: A tertiary hospital experience". World J Emerg Surg. 6: 31. doi:10.1186/1749-7922-6-31. PMC 3179712. PMID 21871104.
- ↑ Chung KT, Shelat VG (January 2017). "Perforated peptic ulcer - an update". World J Gastrointest Surg. 9 (1): 1–12. doi:10.4240/wjgs.v9.i1.1. PMC 5237817. PMID 28138363.
- ↑ Oncel D, Malinoski D, Brown C, Demetriades D, Salim A (2007). "Blunt gastric injuries". Am Surg. 73 (9): 880–3. PMID 17939417.
- ↑ Demetriades D, Murray JA, Chan L, Ordoñez C, Bowley D, Nagy KK; et al. (2001). "Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study". J Trauma. 50 (5): 765–75. PMID 11371831.
- ↑ Epstein L, Dantes R, Magill S, Fiore A (2016). "Varying Estimates of Sepsis Mortality Using Death Certificates and Administrative Codes--United States, 1999-2014". MMWR Morb Mortal Wkly Rep. 65 (13): 342–5. doi:10.15585/mmwr.mm6513a2. PMID 27054476.
- ↑ Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R (2015). "Systemic inflammatory response syndrome criteria in defining severe sepsis". N Engl J Med. 372 (17): 1629–38. doi:10.1056/NEJMoa1415236. PMID 25776936.
- ↑ Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M; et al. (2016). "The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)". JAMA. 315 (8): 801–10. doi:10.1001/jama.2016.0287. PMC 4968574. PMID 26903338.
- ↑ Kaukonen KM, Bailey M, Suzuki S, Pilcher D, Bellomo R (2014). "Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000-2012". JAMA. 311 (13): 1308–16. doi:10.1001/jama.2014.2637. PMID 24638143.
- ↑ Adderson EE, Pappin A, Pavia AT (1998). "Spontaneous intestinal perforation in premature infants: a distinct clinical entity associated with systemic candidiasis". J Pediatr Surg. 33 (10): 1463–7. PMID 9802791.
- ↑ Fisher JG, Jones BA, Gutierrez IM, Hull MA, Kang KH, Kenny M; et al. (2014). "Mortality associated with laparotomy-confirmed neonatal spontaneous intestinal perforation: a prospective 5-year multicenter analysis". J Pediatr Surg. 49 (8): 1215–9. doi:10.1016/j.jpedsurg.2013.11.051. PMID 25092079.