Gastrointestinal perforation and the acute abdomen. Acute appendicitis with sudden perforation is usually associated with illness of several hours. If only one book about surgery could be made available to physicians from all specialties, it should probably be silens recent revision of copes early diagnosis of the acute abdomen. Perforation of an organ can be caused by a variety of factors. The acute abdomen accounts for up to 40% of all emergency surgical hospital admissions.
Esophageal, gastric, and duodenal perforation tends to manifest suddenly and catastrophically, with abrupt onset of acute abdomen with severe generalized abdominal pain, tenderness, and peritoneal signs. Abdominal pain is a leading reason for emergency department visits. Practice guidelines for primary care of acute abdomen 2015. Common causes of pneumoperitoneum can be divided into intraabdominal causes eg, perforated peptic ulcer disease. Recent important developments in ct, including multislice ct and multiplanar reconstructions, receive particular attention. Gastrointestinal perforations of the upper gastrointestinal tract are extremely rare. The acute abdomen, an issue of radiologic clinics of north. By sn janet khoo acute abdomen acute abdomen is peritonitis the term acute abdomen refers to a sudden, severe pain in the abdomen that is less than 24 hours in duration.
Gastrointestinal tract perforations can occur for various causes peptic ulcer, inflammatory disease, blunt or penetrating trauma, iatrogenic factors. Mo1757 diagnostic strategy for acute abdomen caused by perforation of the gastrointestinal tract. Upper gi perforation stomach and duodenum is most commonly caused by peptic ulcer disease with severe epigastric or back pain, with acute onset. The grouping of symptoms appendicitis the differential diagnosis of appendicitis perforation of. The cause of the perforation was an ingested bone long arrow that had migrated more. In rare cases, people can be treated with antibiotics alone if the perforation has closed. Ct features are clearly illustrated, and pitfalls and differential diagnoses are discussed. Patients may suffer from acute surgical abdomen, acute abdomen with. Acute abdominal pain accounts for 40% of emergency surgical hospital admissions. Acute perforation of the gi tract gastrointestinal. Learn gastrointestinal and urologic emergencies with free interactive flashcards. Gastrointestinal perforation an overview sciencedirect topics. Gastrointestinal perforation is often the end stage of obstructing, inflammatory, or ischemic disorders. Historically, laparotomy has been the intervention of choice for acute abdomen.
Choose from 500 different sets of gastrointestinal and urologic emergencies flashcards on quizlet. The symptoms can have both abdominal and extra abdominal etiology. Less commonly, malignancy or traumatic perforation are possibilities. Intestinal perforation is an emergency medical situation presented as an acute abdomen, and it is only rarely diagnosed clinically. Gastrointestinal perforation, also known as ruptured bowel, is a hole in the wall of part of the gastrointestinal tract. Spontaneous perforation of pyometra presenting as acute. Mistakes in ct for the acute abdomen and how to avoid them.
Gastrointestinal perforation is one of the most common cause of intraperitoneal free air. It may also suggest gastrointestinal perforation, ischemia of the organ. Gastrointestinal perforation results in severe abdominal pain intensified by movement, nausea, vomiting and hematemesis. Imaging of gi tract perforation in different patient groups, such as pediatric patients, the elderly, and oncologic patients, is also addressed. In 1894, henry percy dean from london was the first surgeon to report successful repair of a perforated duodenal ulcer. Pdf imaging of gastrointestinal tract perforation in the. Pain often worsens when someone touches or palpates the area or when the patient moves. With colour frontispiece illustration of the partial abdomen muscles. If you have pain in the abdomen, see your provider right away. Definition of acute abdomen acute abdomen is a symptom complex. Ct is also useful to determine the cause of the perforation and is therefore very helpful before surgical intervention. Tumors of the gastrointestinal gi tract are most commonly adenocarcinomas, which arise from the mucosa, and in advanced stages can result in transmural invasion and perforation. Any part of the gastrointestinal tract may become perforated, releasing gastric or intestinal contents into the peritoneal space.
Because there is frequently a progressive underlying intra abdominal disorder, undue delay in diagnosis and treatment may adversely affect outcome. Perforation of peptic ulcer is one of the causes of acute abdomen in which early diagnosis and treatment dramatically decrease morbidity and mortality 1. This problem may occur in the esophagus, stomach, small intestine, large intestine, rectum, or gallbladder. Symptoms develop suddenly, with severe pain followed shortly by signs of shock. Evaluating the patient with left upper quadrant pain. Ct is often the initial modality used to assess patients with. Injuries of the stomach can occur in association with any penetrating trauma of the abdomen, such as gunshot and stab wounds. Traumatic perforation is more frequently the result of a penetrating injury or instrumentation of the stomach, although perforation and organ rupture can occur with severe blunt abdominal trauma. Ct abdomen pelvis with iv contrast and po contrast if possible iv contrast improves soft tissue resolution in the abdomen and pelvis and improves diagnostic accuracy and should be considered even in the presence of acute kidney injury.
Imaging of alimentary tract perforation springerlink. Although sonography is useful as a firstline diagnostic tool for acute abdomen in the emergency department, it is less helpful in the diagnosis of peptic. This book is distributed under the terms of the creative commons. Perforation of the gastrointestinal tract may be suspected based upon the patients clinical presentation, or the diagnosis becomes obvious through a report of extraluminal free gas or fluid or fluid collection on diagnostic imaging performed to evaluate abdominal pain or another symptom. Prevention people will often have a few days of pain before the intestinal perforation occurs. Perforation of the jejunum or ileum carries an incidence of 1 in 300350,000 and accounts for 0. The acute abdomen requires rapid and specific diagnosis as several etiologies demand urgent operative intervention.
When youve had a gastrointestinal perforation and peritonitis occurs, the abdomen feels very tender. The pain is typically localized in the right lower quadrant of the abdomen, unless the disease process has progressed to generalized peritonitis. A drain from the abdomen or other organ may also be needed. Acute abdomen is not a single disease entity, but a blanket term for a number of often vague symptoms constituting a lifethreatening abdominal condition warranting urgent medical attention. Since acute abdomen requires accurate diagnosis and treatment within a. Ct scans can be useful for evaluating the cause of acute gastrointestinal bleeding, particularly small and large bowel sources that cannot be reached via upper gastrointestinal endoscopy. Can computed tomography detect perforated site even in the small and large bowel.
It is in many cases an emergent condition requiring urgent and. The acute abdomen accounts for up to 40% of all emergencysurgical hospital admissions and is considered in the differential in the more than 7 million visits to the emergency department annually for abdominal pain in the united states. Treatment is much simpler and safer when it is started before the perforation occurs. It may also be caused by surgery in the abdomen or procedures such as colonoscopy or upper endoscopy. Gastrointestinal perforation indicates the development of a hole or perforation in the wall of the gastrointestinal gi tract, allowing its contents to leak into the abdominal cavity the gastrointestinal perforation may occur in any of the following regions or organs, along the gi tract. The presence of pneumoperitoneum secondary to spontaneously perforated pyometra is an interesting yet confusing finding given the absence of gastrointestinal gi perforation, because pyometra is more common in postmenopausal women. This volume will greatly assist residents in radiology, radiologists, and physicians who are daily involved in the management of patients with clinically suspected alimentary tract perforation. One end of the intestine may be brought out through an opening stoma made in the abdominal wall. Diseases of the gastrointestinal tract are the leading cause, but extra abdominal diseases such as basal pneumonia may also underlie an acute abdomen. Intussusception acute obstruction of the large intestine the early diagnosis of. Gastrointestinal perforation may occur at any anatomical location from the upper oesophagus to the anorectal junction delay in resuscitation and definitive surgery will progress rapidly into septic shock, multi organ dysfunction, and death, hence it should be one of the first diagnoses considered and excluded in all patients who present with acute abdominal pain.
Po contrast improves bowel resolution and the identification of perforation. Bowel perforation summary radiology reference article. Evaluating the patient with right upper quadrant pain. Symptoms include severe abdominal pain and tenderness. Mo1757 diagnostic strategy for acute abdomen caused by. Acute abdomen in the pediatric intensive care patient. Patients typically present with acute abdominal pain, cramping, distention, and constipation. Sometimes there are chronic symptoms leading up to the perforation event, such as dyspepsia, bloating, nausea, and early satiety.
Perforation affects approximately 20% of patients with acute abdominal emergencies. It may progress to mesentery vasculitis intestinal ischemia, infarction or perforation. Its presence varies with the type of leukemia and has been decreasing over time due to improved chemotherapy. Diagnosis is usually made by the presence of free air in the abdomen on. The gastrointestinal tract includes the esophagus, stomach, small intestine, and large intestine. Although the term acute abdomen sometimes refers to conditions requiring urgent surgery, the term most often refers to any patient who develops abdominal pain over a relatively short time interval. Gastrointestinal manifestations of leukemia ebert 2012. Causes of intestinal perforation include the following. Sometimes, a small part of the intestine must be removed. Peptic ulcer symptoms decrease during pregnancy due to healthier maternal habits during pregnancy in addition to pregnancyinduced hormonal gastroprotection. Acute abdominal pain is one of the most frequent indications for radiographic examinations in children. Perforated viscus international emergency medicine education. Yet, ct scan is the best alternative for diagnosing intra abdominal injury. Suspected gastrointestinal perforation should be excluded in patients who have an acute abdomen.
Nonsurgical causes of acute abdominal pain intechopen. Initial stabilization is with intravenous iv fluids and broadspectrum antibiotics. Robert gore coeditor of textbook of gastrointestinal radiology has assembled an expert panel of authors on the topic of the acute abdomen. Penetrating injury to the lower chest or abdomen eg, knife injuries in cases of penetrating trauma, the small bowel is the most commonly. Patients typically present with an acute onset of severe abdominal pain associated with nausea, vomiting, and fever. Gastrointestinal gi perforation accounts for over 90% of acute abdomen and pneumoperitoneum. Gastrointestinal perforation information mount sinai. Upperbowel perforation can be described as either free or contained. Perforation at other gi sites often occurs in the setting of other painful. Surgery is the definitive treatment in all unstable patients, but endoscopic decompression may be a suitable initial option for stable patients. Bowel perforation is an acute surgical emergency where there is a release of gastric or intestinal contents into the peritoneal space. For acute abdominal pain in adults, an abdominal xray has a low sensitivity and accuracy in general, as well as for specific conditions such as gastrointestinal perforation, bowel obstruction, ingested foreign body, and ureteral stones.
Mistakes in ct performed for the acute abdomen and how to. The first section of the book presents epidemiological and clinical data. Gastrointestinal gi manifestations of leukemia occur in up to 25% of patients at autopsy, generally during relapse. Gastrointestinal perforation is a fullthickness loss of bowel wall integrity that results in perforation peritonitis. Gastrointestinal perforation knowledge for medical. Free perforation occurs when bowel contents spill freely into the abdominal cavity. Intestinal perforation, defined as a loss of continuity of the bowel wall, is a. Lau and leow have indicated that perforated peptic ulcer was clinically recognized by 1799, but the first successful surgical management of gastric ulcer was by ludwig heusner in germany in 1892. Presentation is nonspecific, consisting of abrupt onset persistent abdominal pain unresponsive to medication which evolves into sepsis and peritonitis if left untreated 2, 5, 39. Perforation is a hole that develops through the wall of a body organ. The abdomen may stick outward farther than normal and feel hard. Perforation of a duodenal ulcer is the most common cause of perforation peritonitis.