Perforation of the Upper Gastrointestinal Tract - Causes, Symptoms, and Treatment

Introduction:

Perforations (holes) occurring at the upper part of the gastrointestinal tract include esophageal (food pipe) perforations, gastric (stomach) perforations, and duodenal (starting part of the small intestine) perforations. These perforations are mostly life-threatening. The symptoms are similar to those of less severe disease conditions, so they cannot be diagnosed early. Appropriate tests are to confirm the perforation site and state, and after that, necessary management is carried out.

What Is Upper Gastrointestinal Tract Perforation?

The esophagus, stomach, and duodenum comprise the upper gastrointestinal tract. A perforation is a loss of continuity in the digestive tract wall which occurs due to a variety of factors like trauma, surgical instrumentation, inflammation, ischemia (a condition in which blood flow is restricted, reducing the oxygen supply to a certain part of the gastrointestinal tract), infection, or malignancy (cancer). Loss of continuity occurring in any region of the esophagus, stomach, or duodenum wall is called perforation in the upper gastrointestinal tract.

What Is Esophageal Perforation?

The esophagus is a hollow tube carrying food and water from the mouth into the stomach. It is also called a food pipe.

What Are the Causes of Esophageal Perforation?

• Iatrogenic (due to medical treatment or examination).

• External trauma.

• In children, it can be caused due to ingestion of caustic fluids (like cleaning solutions and battery liquids).

What Are the Symptoms of Esophageal Perforation?

• Chest pain radiating to the back or left shoulder.

• Vomiting.

• Shortness of breath.

• Subcutaneous emphysema (air getting into tissues under the skin).

• Disorders of voice.

• Difficulty in swallowing.

• Epigastric pain (abdominal pain).

• Hematemesis (blood vomiting).

How Is Esophageal Perforation Diagnosed?

• Plain Chest X-Ray - Indirect signs caused due to perforation can be detected.

• Computed Tomography Scan (CT Scan) Of the Chest and Abdomen - The perforation site is detected on a CT scan rather than a chest X-ray.

• Upper Endoscopy - This procedure is done when the X-rays do not show any evidence of perforation, but the suspicion remains. It provides direct visualization of the esophagus and the stomach.

How Is Esophageal Perforation Managed?

Initial treatment includes:

1. Nil per mouth (food is avoided through the mouth)

2. Intravenous fluids are continuously given.

3. Pain treatment.

4. Broad-spectrum antibiotics are given intravenously (IV).

5. Oxygen saturation levels are monitored.

6. Followed by surgery when needed.

Non-operative treatment has opted chiefly for patients with iatrogenic (unknown) causes.

For perforations with other causes, a surgical procedure called myotomy is performed along with fundoplication (a surgical procedure to relieve obstruction between the stomach and esophagus).

Exclusion and diversion for the secretions of the esophagus are established to fasten the healing process and reduce contamination.

What Is Gastric Perforation?

Perforation of the wall of the stomach creates communication between the stomach and abdomen.

What Are the Causes of Gastric Perforations?

• Peptic ulcer disease (the inner surface of the stomach wall is eroded, causing ulcers).

• Spontaneous gastric perforation (rare perforation occurring in newborns).

• Trauma.

• Malignancy (cancer).

• Iatrogenic (caused during treatments like endoscopy-related gastric perforation).

What Are the Symptoms of Gastric Perforations?

• Loss of appetite (loss of hunger).

• Decreased activity.

• Abdominal distension (swollen abdomen) with pain.

• Chest pain.

How Are Gastric Perforations Diagnosed?

• Image generated using sound waves is called ultrasound, also known as sonography.

• CT (computed tomography) shows the presence of air and free fluid in the abdomen.

• Diagnostic laparoscopy is an accurate diagnostic procedure using a laparoscope (a device with a camera and a light) to visualize the organs directly.

What Is the Treatment for Gastric Perforations?

Initial treatment consists of providing oxygen therapy, intravenous fluids, and broad-spectrum antibiotics. Surgical management includes:

• Primary Repair: The defect is directly closed with a suture.

• Graham Patch Repair: The defect is clogged with tissue having a blood supply.

• Wedge Resection: The infected perforated area can be resected from healthy tissue.

• Reconstruction: Reconstruction after resection can be done by suturing gastric remnants with the duodenum.

What Are the Complications of Gastric Perforations?

• Wound infection.

• Sepsis (chemical substances released into the bloodstream).

• Malnutrition (decreased nutrition).

• Multi-organ failure.

What Is Duodenal Perforation?

Duodenal perforation is a rare but life-threatening condition. Duodenum is a part of the intestine between the stomach and small intestine. It is divided into four parts:

• The first part (proximal part) connects to the liver.

• The second part (descending segment) surrounds the pancreas.

• The third part (horizontal part).

• The fourth part (continues with the small intestine).

What Are the Types of Duodenal Perforations?

It is broadly classified into two types.

• Non-Contained (Free) Perforations: A condition where contents leak freely into the abdominal cavity.

• Contained Perforations: A condition in which an ulcer creates a full-thickness hole wherein free leakage is prevented due to surrounding organs.

What Are the Symptoms of Duodenal Perforations?

• Nocturnal abdominal pain (abdominal pain during the night).

• Feeling hungry.

• Most symptoms are delayed and cannot be identified early.

What Are the Causes of Duodenal Perforations?

• Infectious diseases (bacterial diseases like tuberculosis).

• Chemotherapy (treatment to treat cancer).

• Tumors (cancer).

• Gallstones in the duodenum.

• Iatrogenic (caused due to medical procedures or treatments).

• Trauma.

How Are Duodenal Perforations Diagnosed?

• Laboratory tests are usually to rule out other diseases with similar symptoms.

• Blood cultures.

• Chest X-ray.

• Computed tomography (CT scan).

What Is the Treatment for Duodenal Perforations?

Treatment depends on the type of perforations.

1) Management of Contained Perforations:

• Conservative treatment is provided with IV (intravenous) fluids, IV proton pump inhibitors, broad-spectrum antibiotics, and Helicobacter pylori (a bacteria) eradication.

• Repeat clinical assessment.

• Repeat blood investigations.

• Respiratory and renal support.

• Surgery.

2) Management of Non-Contained Perforations: Treatment depends on the type of non-contained perforations.

3) Major Non-contained Perforations: Need reconstructive surgery duodenoduodenostomy (creating a surgical connection between two parts of duodenum bypassing the obstructed part), duodenojejunostomy (creating a surgical connection between duodenum and jejunum), Billroth II operation (removal of a part of the stomach is done, and the cut end is closed).

4) Minor Non-contained Perforations:

a) Endoscopic management includes

• Through-the-scope clips (TTSC) - For linear perforations less than one centimeter.
• Over-the-scope clips (OTSC) - Management of perforations of one to three centimeters.

b) Detachable snare loops with clips.

c) Self-expandable metal stents (SEMS).

d) Simple surgical repair with or without an omental patch (tissue and blood supply).

What Are the Complications of Management of Perforations of Upper Gastrointestinal Tract?

• Sepsis (chemicals released into the bloodstream).

• Pneumonia (inflammation and accumulation of fluid in lungs).

• Wound dehiscence (partial or total separation of the previously united wound).

• Peritonitis (inflammation of the membrane lining the abdominal wall).

• An abscess (collection of pus).

• Surgical site infection.

Conclusion:

Perforations of the upper gastrointestinal tract are usually fatal and need immediate treatment. Treatment modalities depend on the type, size, and extent of the perforations, along with certain human factors (teamwork, workload, quality of work) that affect the outcome of the treatment. Avoiding the causes decreases the chance of perforation. Seeking Immediate help from the physician when symptoms start can help in early diagnosis and successful management.