Gastrointestinal perforation history and symptoms: Difference between revisions
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Revision as of 19:36, 31 December 2017
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
History
A careful history is important in evaluating patients with neck, chest, and abdominal pain.
The history should include questioning about prior bouts of abdominal or chest pain, prior instrumentation (nasogastric tube, abdominal trauma, endoscopy), prior surgery, malignancy, possible ingested foreign bodies, and medical conditions (eg, peptic disease, medical device implants), including medications (nonsteroidal anti-inflammatory drugs [NSAIDs], glucocorticoids) that predispose to gastrointestinal perforation. (See 'Risk factors' above.)
Presentations
Sudden, severe chest or abdominal pain following instrumentation or surgery is very concerning for perforation.
Patients on immunosuppressive or anti-inflammatory agents may have an impaired inflammatory response, and some may have little or no pain and tenderness. Many patients will seek medical attention with the onset or worsening of significant chest or abdominal pain, but a subset of patients will present in a delayed fashion. These patients may present with an abdominal mass reflecting abscess formation, or fistula drainage, and some may present with abdominal sepsis.
Acute pain
Dysphagia
As the spilled gastrointestinal contents irritate the mediastinum or peritoneum, a more constant pain will develop.
Acute symptoms associated with free perforation depend upon the nature and location of the gastrointestinal spillage (mediastinal, intraperitoneal, retroperitoneal).
Cervical esophageal perforation can present with
pharyngeal or neck pain associated with
odynophagia,
dysphagia
pain radiating to the shoulder
If perforation is confined to the retroperitoneum or lesser sac
the presentation may be more subtle. Retroperitoneal perforations often lead to back pain.
Because the pH of gastric contents is 1 to 2 along the gastric luminal surface, a sudden release of this acid into the abdomen causes severe and sudden peritoneal irritation and severe pain.
The leakage of small intestinal contents into the peritoneal cavity may also cause severe pain, and for this reason, any severe pain after, particularly, a laparoscopic procedure should cause the surgeon to suspect leakage.
Abdominal 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. (See "Clinical manifestations and diagnosis of acute diverticulitis in adults".)
Fistula formation (discussed below) can lead to a mass felt in the abdominal wall prior to spontaneous decompression and drainage.
Fistula formation
A fistula is an abnormal communication between two epithelialized surfaces. It can occur from bowel injury during instrumentation or surgery, anastomotic leak, or foreign body erosion. Fistulas are often related to inflammatory bowel diseases such as Crohn disease. Rarely, perforated colon carcinoma can fistulize to adjacent structures or to the abdominal wall.
The initial gastrointestinal perforation is contained between two loops of bowel, and subsequent inflammatory changes lead to the abnormal communication, which spontaneously decompresses any fluid collection or abscess that has formed. Patients who develop an external fistula will complain of the sudden appearance of drainage from a postoperative wound, or from the abdominal wall or perineum in the case of spontaneous fistulas. (See "Overview of enteric fistulas".)
Sepsis
- Sepsis can be the initial presentation of perforation, but its frequency is difficult to determine.
- Sepsis in itself can contribute to the causation of perforation by reducing intestinal wall perfusion [72].
- These patients are very ill appearing, may or may not be febrile, and may be hemodynamically unstable with altered mental status. Anastomotic leak can be associated with increased fluid and blood transfusion requirements. [73]
- Organ dysfunction may be present, including acute respiratory distress syndrome, acute kidney injury, and disseminated intravascular coagulation
- Spontaneous intestinal perforation and necrotizing enterocolitis are gastrointestinal complications that typically occur in
- very low birth weight and extremely low birth weight
- preterm infants with a gestational age between 25 and 27 weeks
Physical findings
Infants with SIP present with an acute onset of abdominal distension and hypotension.
Abdominal distention usually occurs without the abdominal wall erythema, crepitus, and induration commonly seen in patients with NEC.
A black-bluish discoloration of the abdominal wall is often seen in SIP, and is not typical of NEC (picture 2) [1,4,27,33,35,36].
The discoloration may extend into the groin and, in males, the scrotum.
Associated infections
In several case series, concomitant sepsis due to coagulase-negative Staphylococcus or fungemia due to Candida albicans have been reported in neonates with SIP and may be a major cause of morbidity and mortality [1,2,11,33].
It is unknown whether the infections precede or are a result of bowel perforation.