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Acute perforation
Medical expert of the article
Last reviewed: 05.07.2025
Acute perforation can occur in any part of the gastrointestinal tract due to various causes with the entry of gastric or intestinal contents into the abdominal cavity. Symptoms of acute perforation develop suddenly, with severe pain, accompanied by rapidly developing signs of shock. The diagnosis is usually established by instrumental examination based on the presence of free air in the abdominal cavity. Treatment of acute perforation includes infusion intensive therapy, antibiotics and surgical treatment. Mortality is high, depending on the cause of perforation and the general condition of the patient.
[ What causes acute perforation?
Perforation of any part of the gastrointestinal tract can result from closed and penetrating trauma. Swallowed foreign bodies, even sharp ones, rarely cause perforation unless they cause local pressure on the wall, leading to ischemia and necrosis.
Perforation of the esophagus usually occurs above the diaphragm (Boerhaave syndrome), but it can also occur in the intra-abdominal part of the esophagus due to severe vomiting or iatrogenic injury (e.g., perforation by an esophagoscope, balloon dilation, or bougienage). Ingestion of a large amount of a caustic substance can cause perforation of the esophagus or stomach.
Perforation of the stomach or duodenum is usually a consequence of peptic ulcer, but approximately one third of patients have no history of ulcer symptoms.
Perforation of the intestine may result from strangulation obstruction. Acute appendicitis and Meckel's diverticulitis may also be complicated by perforation.
Colonic perforation is usually caused by obstruction, diverticulitis, ulcerative colitis, Crohn's disease, and toxic megacolon. Occasionally, perforation occurs spontaneously. In the presence of colonic obstruction, perforation usually occurs in the cecum; this catastrophe is inevitable if the cecum is > 13 cm in diameter. Patients receiving prednisone or other immunosuppressants are predisposed to perforation, and perforation occurs without obvious symptoms.
Gallbladder perforation associated with acute cholecystitis is rare. Perforation of the biliary tree may occur during cholecystectomy due to iatrogenic injury. Gallbladder perforation usually results in a localized abscess limited by the omentum and rarely results in generalized peritonitis.
Symptoms of acute perforation
Perforation of the esophagus, stomach, and duodenum usually occurs suddenly and catastrophically, with an abrupt onset of acute abdomen, severe generalized abdominal pain, tenderness, and abdominal symptoms. The pain may radiate to the shoulder.
Perforation of other parts of the gastrointestinal tract often occurs against the background of other inflammatory processes accompanied by pain syndrome. Since perforations are often initially small and mainly limited by the omentum, pain often develops gradually or can be localized. The pain is also more localized.
Nausea, vomiting, and anorexia are common with all types of perforation. Bowel sounds are diminished or absent.
Diagnosis of acute perforation
The diagnosis can be made by abdominal and chest radiography (supine and upright) in 50-75% of patients if free air is visualized under the diaphragm. This symptom becomes more obvious over time. Lateral chest radiography is more useful in detecting free air than anteroposterior radiography. If this examination does not allow diagnosis, CT with oral or intravenous contrast may be used.
Treatment of acute perforation
If perforation is verified, surgical intervention is indicated, since mortality from peritonitis increases rapidly if treatment is delayed. If an abscess or inflammatory infiltrate has formed, surgery may be limited to drainage of the abscess.
Nasogastric drainage is performed before surgery. Patients with signs of dehydration require diuresis monitoring by bladder catheterization. Water and electrolyte balance is corrected by adequate intravenous infusion of fluids and electrolytes. Intravenous antibiotics (e.g., cefotetan 1-2 g 2 times a day or amikacin 5 mg/kg 3 times a day plus clindamycin 600-900 mg 4 times a day) are effective against intestinal flora.