Intestinal Perforation - Causes, Symptoms, Complications, and Management

Introduction:

Intestinal perforation is defined as a loss of bowel wall continuity. It is a potentially devastating complication that may occur from various disease conditions affecting the gastrointestinal tract. The common causes of intestinal perforation include inflammation, ischemia, malignancy, infection, over-instrumentation, trauma, and obstruction. It is a major life-threatening condition with high mortality and morbidity that requires emergency surgery. Despite improvements in medical and surgical treatment, the overall mortality rate is around 30 percent, and the mortality rate of diffuse peritonitis is up to 70 percent. This perforation leads to severe tenderness and abdominal pain. The abdomen gets hard to touch and also protrudes. If the hole is in the individual's stomach or small intestine, the pain is sudden, but if the hole is in the large bowel, pain may occur gradually.

What Is Intestinal Perforation?

Intestinal perforation is a devastating complication that results from various disease processes. This occurs due to a loss of bowel wall continuity. Early recognition and treatment are critical to prevent mortality and morbidity due to peritonitis and spillage of intestinal contents. The common causes include instrumentation. Infection, inflammation, obstruction, malignancy, ischemia, and trauma. Four mechanisms can lead to perforation of the intestinal tract, and they are ischemia, infection, erosion, and physical disruption.

The common infectious causes of perforation are diverticulitis and appendicitis. Both disease processes are usually presumed to result from entrapped fecal material leading to increased intraluminal stasis, pressure, and infection resulting in an abscess or frank perforation.

What Are the Causes of Intestinal Perforation?

Different conditions that cause intestinal perforation are:

• Colon cancer- Colon and rectal cancer can affect the digestive tract's lower end.

• Peptic ulcers- Sores that develop in the esophagus and small intestine lining.

• Diverticulitis- Inflammation in one or more pouches of the digestive tract.

• Gallstones- Hardened deposits within the gallbladder fluid are gallstones.

• Gallbladder infection- Acute cholecystitis includes swelling and inflammation of the gall bladder resulting in gall bladder infection.

• Inflammatory bowel disease- Inflammation that involves the lining of the digestive tract.

• Injury, trauma to the abdomen- Any traumatic injury to the abdomen.

• Ischemic colitis is when blood flow to a part of the large intestine is temporarily reduced.

• Volvulus: It is an obstruction due to knotting and twisting of the gastrointestinal tract.

Rare conditions where gastrointestinal perforation occurs during medical procedures include:

• Colonoscopy: A procedure that can diagnose bowel cancer.

• Endoscopy: A medical procedure that uses cameras to look inside the intestine.

What Are the Symptoms of Intestinal Perforation?

The symptoms of intestinal perforation are severe abdominal pain and tenderness, including the protruded abdomen and hard-to-touch abdomen. The sudden onset of pain may be gradual, which worsens when there is pressure on the abdomen. The symptoms include:

• Nausea.

• Fever.

• Vomiting.

• Chills.

• Fatigue.

• Shortness of breath.

• Dizziness.

• Rapid heartbeat.

• Fever.

• Confusion.

What Are the Complications Associated With Intestinal Perforation?

The complications of intestinal perforation are:

• Abscess in the belly.

• A wound infection.

• Bleeding.

• Sepsis is a life-threatening bacterial infection.

• Permanent ileostomy or colostomy.

• Bowel infarction- It is an irreversible injury that occurs in the intestine due to insufficient blood flow. It is a medical emergency.

Surgery can be undertaken if there is a necessity for leakage control; surgical complications include hernia formation, risk of infection, and bleeding. Other risks like thromboembolic events, cardiovascular events, and pulmonary complications. Serious complications after anti reflux surgeries by laparoscopic approach are rare. In-depth, the risk, options, and alternatives to laparoscopic Nissen fundoplication should be discussed with the healthcare provider.

How Is Intestinal Perforation Diagnosed?

A detailed physical examination is done by pressing the abdomen. Also, the vital signs are checked, which include body temperature, heart and pulse rate, blood pressure, and respiratory rate.

• Detailed information of any undergone medical procedures is taken.

• Any family history of inflammatory bowel disease, cancer, and other health conditions is taken.

• A detailed blood test checks signs of infection and assesses liver and kidney function.

• CT scan to produce detailed images.

• Upper endoscopy is done to view the esophagus and upper part of the small intestine.

• X-rays are done.

• A colonoscopy is done that helps in viewing the colon and large intestine.

How Is Intestinal Perforation Managed in Elderly People?

Intestinal perforations may need emergency surgery to repair them. Depending on the location, the severity of the surgery may be decided by the patient's general condition.

• Laparoscopic surgery: With minimally invasive surgery, the camera is used to see the abdomen with a small incision.

• Traditional surgery requires a large incision in the abdomen.

• Endoscopic procedure: The camera guides the instruments through the intestines. This product usually does not require an incision.

• A temporary bypass of stool can be done so that the colon gets enough rest. For this, a small hole is created in the abdomen, called a stoma. A piece of the small intestine orcolon is attached to the stoma, which is connected to the colostomy bag outside the stoma.

• The colostomy bag is sealed, and this pouch collects stool. The caregiver empties the bag daily and usually removes the stoma, and the colostomy bag is removed after the perforation heals.

What Is the Prognosis of Intestinal Perforation in Elderly Individuals?

Age is an important consideration related to the prognosis of intestinal perforation. Medical comorbidities, malignant or benign causes, and tolerance to treatment are essential considerations for prognosis. Individuals who cannot tolerate pain after surgery or do not undergo surgery may worsen their prognosis. Delayed intraabdominal infection risk and hernia formation from surgical bleeding lead to a high morbidity rate. There can be worsened quality of life if thromboembolism (obstruction of the blood vessel by a blood clot that has been disrupted or dislodged from another site in the circulation) and cardiopulmonary complications are higher in older individuals.

Conclusion:

Evaluating an individual with intestinal perforation is the most commonly performed emergency. A detailed physical and family history is essential to suggest an exact diagnosis and give an appropriate treatment for the condition. On average, a full recovery can take up to three months, this is dependent on factors like prior surgeries and physical fitness. Early surgical consultation is recommended. In elderly individuals, conservative management is occasionally an option, with better clinical surveillance. Better nursing care and regular vitals monitoring are essential to avoid patient deterioration. A detailed discussion of postoperative pain management with expectations is essential to use multimodal therapies to decrease the need for opioids.