Intestinal perforation

Introduction Intestinal perforation is a pathological change in the intestine that is characterized by necrosis of the intestinal wall, which ultimately leads to perforation. After the intestinal contents enter the abdominal cavity, if it is a small amount, it can be confined by the intraperitoneal omentum. If it is a large amount, it will enter the abdominal cavity completely. The whole abdomen will be severely painful, and the abdominal muscles will be tight and may cause shock. This disease does not have much age distinction. The symptoms of intestinal perforation are general pain first, and then suddenly increased. However, during the onset of intestinal perforation, a series of symptoms such as fever may occur, and it is not a simple stomachache. Acute abdominal pain, as well as peritoneal irritation is very obvious, to the hospital to wear abdominal wear can be worn to the peritoneal effusion, usually yellow-green liquid, as well as high fever, white blood cells are extremely high, experienced doctors look at your expression, you can Seen, but nothing is absolute, the elderly are not obvious clinical manifestations are easily misdiagnosed.

Cause

Peptic ulcer, inflammatory bowel disease, intestinal diverticulum, intestinal tumor, mesenteric ischemic disease, strangulated intestinal obstruction, incarcerated hernia and iatrogenic, spontaneous, traumatic intestinal perforation.

1, duodenal ulcer perforation

There is a long history of ulcers. The initial site of pain is located in the upper abdomen or under the xiphoid process, and it spreads to the whole abdomen, but it is still heavy in the abdomen.

2, colorectal tumor perforation

Patients with colon cancer may have symptoms such as abdominal pain, anemia, abdominal mass, mucus and bloody stools; patients with rectal cancer may have frequent bowel movements, changes in bowel habits, thinning of stools, bloody bowel stimulation, intestinal stenosis, and cancerous ulceration. Infection symptoms. The perforation site is often located at the stenosis where the tumor is caused or the proximal intestinal tract of the obstruction. Abdominal CT examination has a hint for this disease.

3, strangulated intestinal obstruction perforation

Intestinal perforation may occur when intestinal obstruction is accompanied by intestinal wall blood supply disorders and ischemic necrosis of the intestine. Strangulated intestinal obstruction has a serious prognosis and must be treated early.

The following manifestations should be considered for the possibility of strangulated intestinal obstruction: 1 sudden onset of abdominal pain, initial severe pain, or persistent pain between paroxysmal aggravation. 2 The disease develops rapidly, and shock occurs early, and the improvement after anti-shock treatment is not significant. 3 There is obvious peritoneal irritation, body temperature rises, pulse rate increases, and white blood cell count increases. 4 Asymmetry of abdominal distension, local abdomen in the abdomen or a tender mass (inflated bowel). 5 vomiting occurs early, intense and frequent. Vomit, gastrointestinal decompression, anal discharge is bloody, or abdominal puncture to draw hemorrhagic fluid. 6 After active non-surgical treatment, the symptoms and signs did not improve significantly. 7 abdominal X-ray examination see isolated, prominent swelling of the intestines, do not change position due to time.

4, perforation of intestinal inflammatory diseases

Crohn's disease

The cause is unclear, related to autoimmunity, and can invade any part of the gastrointestinal tract, which occurs mostly in the terminal ileum and is segmental. Clinical manifestations are associated with rapid onset, location and extent of the lesion, and presence or absence of complications. The onset is often slow and the medical history is longer. The main symptoms are diarrhea, abdominal pain, low fever, and weight loss. The occult blood can be positive, generally no blood in the stool. Abdominal pain is often located in the right lower abdomen or umbilical cord, usually sputum pain, mostly less severe, often accompanied by local tenderness. Intra-abdominal mass may occur when chronic ulcer penetration, intestinal fistula, and adhesions are formed. Some patients have incomplete intestinal obstruction. The incidence of perforation is 1 to 2%, 90% occurs in the terminal ileum, and 10% occurs in the jejunum. Colonoscopy and barium enema examination are helpful for diagnosis.

Acute hemorrhagic enteritis

Acute inflammatory lesions of the intestine, the cause is unclear, and bloody stools are the main symptoms. Mainly in the jejunum and ileum, the colon and stomach are rare. Severe bleeding, necrosis, and perforation can occur. Clinical manifestations include acute abdominal pain, bloating, vomiting, diarrhea, blood in the stool, and systemic poisoning.

Enteral tuberculosis

Mycobacterium tuberculosis invades the chronic infection caused by the intestinal tract. The lesions can be divided into ulcerative and proliferative types, which can be part of systemic tuberculosis or combined with tuberculosis. 85% of the lesions occurred in the ileocecal area. In addition to systemic symptoms such as low fever, night sweats, fatigue, weight loss and loss of appetite, TB patients often have symptoms such as abdominal pain, diarrhea and constipation and abdominal mass. Perforation can form a localized abscess, intestinal fistula or acute peritonitis.

Enteric typhoid perforation

Intestinal perforation is one of the serious complications of typhoid fever caused by Salmonella typhimurium, and the mortality rate is high. The most significant point is at the end of the ileum. 80% of the perforations occur within 50 cm of the ileocecal valve. Most of them are single-shot, and multiple perforations account for about 10% to 20%. It is not difficult to make a diagnosis when acute diffuse peritonitis occurs in patients with typhoid fever. However, the symptoms of a few typhoid patients are not obvious, only mild fever, headache, general malaise, etc., when these patients have perforation, they are often characterized by right lower abdominal pain with vomiting and signs of peritonitis, which is easily misdiagnosed as acute appendicitis perforation. During surgery, it was found that appendicitis only had peripheral inflammation, and there was perforation of the ileum. It should be alert to the possibility of perforation of intestinal typhoid. Abdominal exudate should be taken for typhoid culture, blood should be taken for typhoid culture and fat reaction test to confirm the diagnosis.

an examination

Related inspection

Gastrointestinal CT examination of gastrointestinal diseases, ultrasound examination, gastrointestinal function dynamics examination, gastrointestinal imaging

According to the history, symptoms and signs, X-ray examination can be found under the armpit free gas, abdominal ultrasound, CT and other examinations, not difficult to diagnose. However, in the diagnosis process, it is necessary to clarify the perforation site and the cause of perforation to guide the treatment.

Abdominal pain in acute intestinal perforation often occurs suddenly, with persistent severe pain, which often makes the patient unbearable and exacerbates during deep breathing and coughing. The extent of pain is related to the extent to which peritonitis spreads. The patient took the supine position and the two lower limbs flexed and did not want to turn. Abdominal examination showed that the respiratory movement was significantly weakened, the abdominal muscle plate was hard, the bowel sounds weakened or disappeared, and the liver dullness circle was reduced or disappeared. X-ray examination revealed that there was free gas under the armpit.

Differential diagnosis

Differential diagnosis:

Intestinal perforation is one of the serious complications of typhoid fever with a high mortality rate. The most significant lesion of typhoid fever is in the end of the ileum. The lymph nodes in the lesion are necrotic. The mucosal shedding is more likely to form ulcers in the second to third weeks of the disease. Therefore, the peri-intestinal perforation is also more during this period. 80% of the perforations occur within 50cm from the ileocecal valve, mostly single, and multiple perforations account for about 10% to 20%.

Ulcers of intestinal amebiasis: generally superficial, but when the infection is severe, deep ulcers may occur and intestinal perforation may occur; most patients with fulminant fever have higher mortality. Perforations are often large, mostly in the cecum, appendix, and ascending colon, followed by the rectal sigmoid junction. The perforations can be single or multiple.

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