What is Surgery – gastrointestinal perforation / perforations in stomach

What is Surgery – gastrointestinal perforation / perforations in stomach 
DEFINITION 
Perforation of the gastrointestinal  tract wall, resulting in bowel contents spilling out. 

AETIOLOGY 
Perforated duodenal or gastric ulcer are the most prevalent gastroduodenal conditions, followed by gastric cancer (1–2%) in gastroduodenal.

Diverticulitis and colorectal cancer (80 percent) are the most prevalent conditions in the large bowel, and a perforated appendix is a common consequence of appendicitis. Other causes include volvulus, ulcerative colitis (toxic megacolon), trauma, radiation enteritis, post-operative anastomotic leaks, and colonoscopy complications. 

Trauma, infection (typhoid, tuberculosis), Crohn's disease, cancer, vasculitis, and radiation enteritis (rarely lead to perforation  in small bowel).

Boerhaave's syndrome may cause  the oesophagus perforation while iatrogenic perforation occurs less frequently during OGD and more frequently after stricture dilatation.

 EPIDEMIOLOGY
 The rate of occurrence is determined by the cause. However, presenting with abdominal pain as a result of intestinal perforation is a rather common and possibly life-threatening emergency. 
HISTORY 
It all depends on the situation. Abdominal discomfort that is sometimes rapid in onset and is accompanied by nausea and vomiting may be one of the presenting symptoms. 

 EXAMINATION 
The patient is sick, with indications of localised or generalised peritonitis, including abdominal stiffness and guarding, as well as diminished or missing bowel sounds. Overlying gas causes a loss of liver dullness. Shock, pyrexia, pallor, and dehydration are all signs of dehydration. 

INVESTIGATIONS 
FBC, U&Es, LFT, amylase (levels may be elevated in perforation), ABGs, and clotting are all blood tests. Gas under the diaphragm may be visible on an erect CXR (70 percent of perforated peptic ulcer cases). 

AXR: Abnormal gas shadows in tissues can be seen. Gas on each side of the intestinal wall is referred to as Rigler's sign; alternatively, intraperitoneal gas can be seen on a lateral decubitus film. 

CT scan: Can identify underlying pathology and is very sensitive for free intraperitoneal gas. 

Chest X Ray : Gas under the diaphragm on an erect chest radiograph, indicating bowel perforation. 

MANAGEMENT 
Resuscitation: Intravenous rehydration and electrolyte imbalances correction, broad spectrum IV antibiotics, analgesics, urinary catheter and central line placement if needed. 

Conservative: For people with little symptoms, little contamination, or a high anaesthetic risk. Bowel rest, high-dose PPIs, IV fluids and antibiotics, NG tube, and monitoring are all used to treat gastroduodenal perforations.

Surgical: The perforation is closed and an omental patch is inserted. 

Gastroduodenal: Laparoscopy or laparotomy and peritoneal lavage: The perforation is closed and an omental patch is placed. Biopsies of gastric ulcers should be performed to check for malignancy. Closure is more difficult than with duodenal ulcers, however a Billroth I partial gastrectomy with gastroduodenal anastomosis is possible. If Helicobacter pylori is found after surgery, it must be eradicated. 

Large intestine: Peritoneal lavage and identification of the perforation location via laparoscopy or laparotomy. Resection of the affected colon, commonly as part of a Hartmann's procedure, followed by the development of an end colostomy and closure of the distal stump or exteriorization as a mucous fistula. Resection and primary anastomosis with a defunct ileostomy are other options. The right colon may be perforated, allowing surgical resection and a main anastomosis. In ulcerative colitis toxic megacolon, a subtotal colectomy is performed with a terminal ileostomy with the rectal stump preserved (allows future reconstruction of ileoanal pouch). 

COMPLICATIONS

 Sepsis, peritonitis, fistula formation, and death are all possible outcomes. 

PROGNOSIS 
Perforated stomach ulcers have a higher morbidity and mortality rate than duodenal ulcers, and perforated gastric carcinomas have a very dismal prognosis. With little or local contamination in the large bowel, the prognosis is better. Faecal peritonitis is linked to a mortality rate of more than 50%.

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