Intestinal perforation is a process in which intestinal lesions penetrate the wall of the intestinal canal and cause spillage of intestinal contents into the peritoneal cavity. It is one of the serious complications of many intestinal diseases and causes severe diffuse peritonitis, mainly manifesting as severe abdominal pain, abdominal distention, peritonitis and other signs and symptoms, which can lead to shock and death.
Site: Duodenum, small intestine, colorectum
Main symptoms: severe abdominal pain, abdominal distension, peritonitis, which can lead to shock and death
Main causes: peptic ulcer, inflammatory bowel disease, etc.
Disease classification
According to the onset site, it can be classified as duodenal perforation, small intestine perforation, colorectal perforation.
According to the etiology, it can be classified as peptic ulcer, inflammatory bowel disease, intestinal diverticulum, intestinal tumor, mesenteric ischemic disease, strangulated intestinal obstruction, incarcerated hernia, and medical, spontaneous, and traumatic intestinal perforation.
Causes
Peptic ulcer, inflammatory bowel disease, intestinal diverticulum, intestinal tumor, mesenteric ischemic disease, strangulated intestinal obstruction, incarcerated hernia and medical, spontaneous and traumatic intestinal perforation.
1.Duodenal ulcer perforation
Most of them have a long history of ulcer, and the initial site of pain is located in the upper abdomen or under the saber, and soon spreads to the whole abdomen, but the upper abdomen is still heavy.
2.Colorectal tumor perforation
Patients with colon cancer can have symptoms such as abdominal pain, anemia, abdominal mass, mucus and blood stool; patients with rectal cancer can have symptoms of rectal irritation, narrowing of intestinal cavity, cancer breaking infection such as frequent bowel movement, change of bowel habit, deformation and thinning of stool and blood in stool. The perforation site is often located at the stenosis caused by the tumor or at the proximal end of the obstructed intestinal canal. Abdominal CT examination is suggestive of this disease.
3.Strangulated intestinal obstruction perforation
When intestinal obstruction is accompanied by blood flow obstruction of intestinal wall and ischemic necrosis of intestinal canal, intestinal perforation can occur. Strangulated intestinal obstruction has a serious prognosis and must be treated by surgery as early as possible.
The possibility of strangulated intestinal obstruction should be considered if the following manifestations are present:
(1) The onset of abdominal pain is rapid, starting with persistent severe pain or still persistent pain between paroxysmal exacerbations.
(ii) Rapid development of the disease, early appearance of shock, and insignificant improvement after anti-shock treatment.
③There are obvious signs of peritoneal irritation, rising body temperature, increased pulse rate and higher white blood cell count.
(iv) Asymmetric abdominal distension, with localized bulging or palpable painful masses in the abdomen (distended intestinal mix).
⑤ Vomiting appears early, violent and frequent. The vomitus, gastrointestinal decompression aspirate, anal discharge is bloody, or bloody fluid is drawn by abdominal puncture.
(6) No significant improvement in symptoms and signs with active non-surgical treatment.
(7) Isolated, protruding distended intestinal mix, which does not change position due to time, is seen on abdominal X-ray.
4.Intestinal inflammatory disease perforation
Crohn’s disease
The etiology is unclear, related to autoimmunity, and can invade any part of the gastrointestinal tract, mostly in the terminal ileum, with a segmental distribution. The clinical presentation is related to the urgency of onset, the location and extent of the lesion, and the presence of complications. The onset of the disease is often slow and the history of the disease is often long. The main symptoms are diarrhea, abdominal pain, hypothermia, and weight loss. Stool occult blood may be positive, but there is usually no blood in the stool. The abdominal pain is usually located in the right lower abdomen or around the umbilicus and is usually spasmodic and not severe, often accompanied by localized light pressure pain. When there is chronic ulcer penetration, intestinal fistula and adhesion formation, an intra-abdominal mass may appear. Some patients present with incomplete intestinal obstruction. The incidence of perforation is 1 to 2%, with 90% occurring in the terminal ileum and 10% in the jejunum. Colonoscopy and barium enema are useful for diagnosis.
Acute hemorrhagic enteritis
Acute inflammatory lesions of the intestinal canal with unclear etiology and bloody stools as the main symptom. It is mainly in the jejunum and ileum, and is rare in the colon and stomach. Severe hemorrhage, necrosis, and perforation may occur. The clinical manifestations are mainly acute abdominal pain, abdominal distension, vomiting, diarrhea, blood in stool and systemic toxic symptoms.
Intestinal tuberculosis
Chronic infection caused by invasion of the intestinal canal by Mycobacterium tuberculosis. The lesions can be of ulcerative or hyperplastic type and can be part of systemic tuberculosis or combined with pulmonary tuberculosis. In addition to systemic symptoms such as low fever, night sweats, fatigue, emaciation and loss of appetite, abdominal pain, diarrhea, constipation and abdominal masses are often present. Perforation can form a limited abscess, intestinal fistula or acute peritonitis.
Intestinal typhoid perforation
Intestinal perforation is one of the serious complications of typhoid fever caused by S. typhi and has a high mortality rate. The most significant place is at the end of the ileum, 80% of perforations occur within 50 cm from the ileocecal valve, mostly single, multiple perforations account for about 10% to 20%. The diagnosis of acute diffuse peritonitis is not difficult to make in patients with definite intestinal typhoid fever. However, a few patients with typhoid fever do not have obvious symptoms, only mild fever, headache, general malaise, etc. When perforation occurs in these patients, they mostly present with right lower abdominal pain with vomiting and signs of peritonitis, which is easily misdiagnosed as acute appendicitis perforation. When the appendicitis is found to have only peripheral inflammation with ileal perforation during surgery, the possibility of perforated intestinal typhoid should be alerted. Peritoneal exudate should be taken for typhoid culture, and blood should be taken for typhoid culture and fertilizer reaction test to clarify the diagnosis.
Pathogenesis
Primary or secondary diseases of the intestine lead to necrosis and rupture of the intestinal wall and perforation, and the intestinal contents spill into the peritoneal cavity, causing acute diffuse peritonitis, infectious toxic shock and even death.
Clinical manifestations
1, manifestations related to the primary disease, such as intestinal typhoid, intestinal tuberculosis, Crohn’s disease, etc.
2, abdominal pain, abdominal distension. Abdominal pain often occurs suddenly, with persistent knife-like pain, and is aggravated by deep breathing and coughing. The extent of pain is related to the degree of spread of peritonitis.
3, systemic infection toxic symptoms fever, chills, rapid heart rate, blood pressure drop and other toxic shock manifestations.
4, abdominal examination abdominal breathing is weakened or disappeared, there is obvious pressure pain rebound pain throughout the abdomen, muscle tension plate-like ankylosis, percussion hepatic turbid tone scale disappears, there may be mobile turbid sounds, intestinal tones are weakened or disappeared.
Diagnostic differentiation
Auxiliary examination
According to the medical history, symptoms and signs, X-ray examination can find subdiaphragmatic free gas, abdominal ultrasound, CT and other examinations, it is not difficult to diagnose. However, the diagnosis process must clarify the site of perforation and the cause of perforation to guide the treatment.
Differential diagnosis
Differentiate from related diseases presenting as acute diffuse peritonitis.
(1) Acute pancreatitis The site of abdominal pain is mostly located to the left of the upper abdomen and radiates to the back, the abdominal muscle tension is mild, the amylase in serum and peritoneal puncture fluid is significantly elevated, there is no free gas under the diaphragm on X-ray, and CT examination shows swelling of the pancreas and peripancreatic exudate.
(2) Acute cholecystitis Right upper abdominal colic or persistent pain with paroxysmal intensification, accompanied by chills and fever. The signs are mainly pressure pain and rebound pain in the right upper abdomen, sometimes the enlarged gallbladder can be palpated, and the Murphy’s sign is positive. Ultrasound suggests stone or non-stone cholecystitis.
(3) Acute appendicitis Acute appendicitis usually has mild symptoms, abdominal signs are usually confined to the right lower abdomen, and there is no subdiaphragmatic free gas on X-ray.
In addition, it needs to be differentiated from ectopic pregnancy rupture, ovarian cyst torsion, and primary peritonitis.
Disease treatment
1.Basic treatment of the primary disease
2.Diagnosis of intestinal perforation should be clearly defined along with the site and cause of intestinal perforation.
3, because perforation causes acute diffuse peritonitis, infectious toxic shock and even death, so once diagnosed, active surgical treatment.
4.Surgical methods should be selected according to the etiology of intestinal perforation and perforation site, perforation time, degree of abdominal cavity contamination, and general status of the patient. Perforation repair, partial intestinal resection or enterostomy can be performed.
Prognosis of disease
The prognosis of intestinal perforation is determined by the timing of treatment and the appropriate surgical treatment. Early surgery has a better prognosis, but if surgery is delayed, the mortality rate is higher.