Gastrointestinal perforation history and symptoms: Difference between revisions
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* History of medications such as nonsteroidal anti-inflammatory drugs or glucocorticoids. | * History of medications such as nonsteroidal anti-inflammatory drugs or glucocorticoids. | ||
'''Presentations''' | '''Presentations''' | ||
* Acute pain | |||
* Sudden severe chest or abdominal pain | * Sudden severe chest or abdominal pain | ||
* Patients on [[Immunosuppressive|immunosuppressives]] or [[Anti-inflammatory medication|anti-inflammatory]] agents may present with an [[abdominal mass]] reflecting [[abscess]] formation, or [[fistula]] drainage, and some may present with abdominal sepsis due to impaired inflammatory reaction. | * Patients on [[Immunosuppressive|immunosuppressives]] or [[Anti-inflammatory medication|anti-inflammatory]] agents may present with an [[abdominal mass]] reflecting [[abscess]] formation, or [[fistula]] drainage, and some may present with abdominal sepsis due to impaired inflammatory reaction. | ||
Dysphagia | Dysphagia | ||
Acute symptoms associated with free perforation depend upon the nature and location of | Acute symptoms associated with free perforation depend upon the nature and location of perforation: | ||
Cervical esophageal perforation | Cervical esophageal perforation | ||
Pharyngeal or neck pain: Pain radiating to the shoulder | |||
Odynophagia | |||
Dysphagia | |||
Because the pH of gastric contents is 1 to 2 along the gastric luminal surface, a sudden release of this acid into the abdomen causes severe and sudden peritoneal irritation and severe pain. | Because the pH of gastric contents is 1 to 2 along the gastric luminal surface, a sudden release of this acid into the abdomen causes severe and sudden peritoneal irritation and severe pain. | ||
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The leakage of small intestinal contents into the peritoneal cavity may also cause severe pain, and for this reason, any severe pain after, particularly, a laparoscopic procedure should cause the surgeon to suspect leakage. | The leakage of small intestinal contents into the peritoneal cavity may also cause severe pain, and for this reason, any severe pain after, particularly, a laparoscopic procedure should cause the surgeon to suspect leakage. | ||
Abdominal mass | |||
It is not uncommon for perforation to lead to abscess or phlegmon formation that can be appreciated on examination as an abdominal mass or with abdominal exploration. Diverticulitis is the most common etiology leading to intra-abdominal abscess formation. | |||
Fistula formation | |||
* Fistulas are often related to inflammatory bowel diseases such as Crohn disease. | |||
* Patients who develop an external fistula will complain of the sudden appearance of drainage from a postoperative wound, or from the abdominal wall or perineum in the case of spontaneous fistulas. | |||
Sepsis | |||
* Sepsis can be the initial presentation of perforation, but its frequency is difficult to determine. | * Sepsis can be the initial presentation of perforation, but its frequency is difficult to determine. | ||
* | * ill appearing | ||
* | * hemodynamically unstable | ||
* Organ dysfunction | * altered mental status | ||
* Organ dysfunction including acute respiratory distress syndrome, acute kidney injury, and disseminated intravascular coagulation may be present. | |||
* Spontaneous intestinal perforation and necrotizing enterocolitis are gastrointestinal complications that typically occur in | * Spontaneous intestinal perforation and necrotizing enterocolitis are gastrointestinal complications that typically occur in | ||
* very low birth weight and extremely low birth weight | * very low birth weight and extremely low birth weight | ||
Revision as of 18:36, 8 January 2018
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
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Overview
History
- The history of prior bouts of abdominal or chest pain, prior instrumentation, surgery, malignancy, or ingested foreign bodies
- Medical conditions such as peptic disease or medical device implants
- History of medications such as nonsteroidal anti-inflammatory drugs or glucocorticoids.
Presentations
- Acute pain
- Sudden severe chest or abdominal pain
- Patients on immunosuppressives or anti-inflammatory agents may present with an abdominal mass reflecting abscess formation, or fistula drainage, and some may present with abdominal sepsis due to impaired inflammatory reaction.
Dysphagia
Acute symptoms associated with free perforation depend upon the nature and location of perforation:
Cervical esophageal perforation
Pharyngeal or neck pain: Pain radiating to the shoulder
Odynophagia
Dysphagia
Because the pH of gastric contents is 1 to 2 along the gastric luminal surface, a sudden release of this acid into the abdomen causes severe and sudden peritoneal irritation and severe pain.
The leakage of small intestinal contents into the peritoneal cavity may also cause severe pain, and for this reason, any severe pain after, particularly, a laparoscopic procedure should cause the surgeon to suspect leakage.
Abdominal mass
It is not uncommon for perforation to lead to abscess or phlegmon formation that can be appreciated on examination as an abdominal mass or with abdominal exploration. Diverticulitis is the most common etiology leading to intra-abdominal abscess formation.
Fistula formation
- Fistulas are often related to inflammatory bowel diseases such as Crohn disease.
- Patients who develop an external fistula will complain of the sudden appearance of drainage from a postoperative wound, or from the abdominal wall or perineum in the case of spontaneous fistulas.
Sepsis
- Sepsis can be the initial presentation of perforation, but its frequency is difficult to determine.
- ill appearing
- hemodynamically unstable
- altered mental status
- Organ dysfunction including acute respiratory distress syndrome, acute kidney injury, and disseminated intravascular coagulation may be present.
- Spontaneous intestinal perforation and necrotizing enterocolitis are gastrointestinal complications that typically occur in
- very low birth weight and extremely low birth weight
- preterm infants with a gestational age between 25 and 27 weeks
Physical findings
Infants with SIP present with an acute onset of abdominal distension and hypotension.
Abdominal distention usually occurs without the abdominal wall erythema, crepitus, and induration commonly seen in patients with NEC.
A black-bluish discoloration of the abdominal wall is often seen in SIP, and is not typical of NEC (picture 2) [1,4,27,33,35,36].
The discoloration may extend into the groin and, in males, the scrotum.
Associated infections
In several case series, concomitant sepsis due to coagulase-negative Staphylococcus or fungemia due to Candida albicans have been reported in neonates with SIP and may be a major cause of morbidity and mortality [1,2,11,33].
It is unknown whether the infections precede or are a result of bowel perforation.