- Perforation of the gastrointestinal tract can occur due to various causes like perforated ulcers, penetrating injuries, or ischemic bowel. Signs include severe abdominal pain, fever, and tenderness. - Diagnosis is suggested by imaging showing free air or fluid in the abdomen. Treatment requires emergency surgery to repair any perforations followed by intensive care and broad-spectrum antibiotics to treat peritonitis. - Surgical management involves thorough irrigation and drainage of the abdominal cavity followed by resection of non-viable bowel and primary anastomosis or stoma formation as needed. Close postoperative monitoring in the ICU is important to support organ function and detect any complications.

1. GIT PERFORATION
BY
DR. CHANDRESH MANGAROLIYA
M.S. - GENERAL SURGERY
(National Institute of Medical Sciences &
Research)

2. PERITONEUM
ANATOMY AND PHYSIOLOGY
• Serous membrane lining the abdominal cavity
• Outer fibrous tissue (provides strength)
• Inner mesothelial layer (lubricating function)
• Parietal peritoneum : lines the inner surface of the abdominal
wall, under surface of diaphragm and pelvic wall.
• Loosely attached to overlying walls.
• Supplied by sometic nerves so pain sensitive
• Viseral peritoneum : lines outer surface of abdominal viscera.
• Firmly adherent
• Supplied by autonomic nervous system

3. PERFORATION
• Causes :
• Perforation of distal oesophagus
• Perforation of stomach
• Perforation of small intestine
• Perforation of large intestine
• Perforation of biliary tract
• Following penerating wound like gunshot injury to abdomen
or stab wound
• Causative organisms:
• Escherichia coli(most common)
• Others: Streptococci, Clostridium welchii, bacteroides,
staphylococci, Klebsiella, Salmonella typhi.

4. • OESOPHAGEAL PERFORATION :
• acute emergency and needs immediate surgical intervention
• Causes :
• INSTRUMENTATION
• Endoscopy (during dilatation of strictures,injection sclerotherapy)
• Corrosive poisoning
• Caustic injury
• OESOPHAGEAL DISEASE
• Carcinoma (barrett’s oesophagus)
• SPONTANEOUS RUPTURE
• Boerhaave’s syndrome (left postero lateral wall of lower 1/3
oesophagus)

5. • Clinical features :
• severe pain in neck , chest , abdomen.
• Dysphagia
• Dyspnoea
• Haemetemesis
• Pleural effusion
• Tachycardia
• Shock
• ‘Hamman’s sign’ : due to escape of air into the mediastinum
gives mediastinal crunch sound which produce by heart beating
against air filled tissues

6. • INVESTIGATIONS
• X RAY CHEST PA VIEW
• Shows pneumomediastinum
• CT CHEST
• Diagnostic
• TREATMENT
• If history of perforation is within 24 hours then closure of perforation
and external drainage should be done.
• If history is of >24 hours then Transhiatal oesophagectomy
• Four phases : Initially, the abdomen is opened and assessed for
metastasis and resectability. The stomach is mobilized in preparation
for resection.
• In the second phase esophageal hiatus is widened and mediastinal
esophagus is mobilized.
• In third phase through the cervical incision the cervical esophagus is
mobilized and upper mediastinal dissection is performed.
• Finally the esophagus is resected and the stomach tube is created which
is brought up in the neck and esophagogastric anastomosis is done.

7. • Procedure
• Upper midline incision is placed. Often upper horizontal or
bilateral subcostal may be used. Self-retaining retractor is
placed.
• Abdomen explored left lobe of the liver is mobilised. Traction is
given to stomach. Oesophagogastric junction is identified .
• Peritoneum and phrenooesophageal ligament is incised .
• Retrooesophageal window is created by sharp and blunt
dissection. Accessory hepatic artery may be ligated. Short gastric
vessels are ligated .
• In the neck an oblique incision is made along the antterior
border of leftt lower sternocleidomastoid muscle extending from
left side of suprasternal notch to level of thyroid
cartilage.through this incision the upper oesophagus is dissected
and freed from trachea.

8. • GASTRIC PERFORATION :
• Less common then duodenal perforation
• Most common site is prepyloric region or lesser curvature
• Pt will have history of taking alcohol,steroids,NSAIDS
• H/O weight loss
• Signs and symptoms
• PAIN
• Initially in epigasrium
• Burning in nature
• Aggravates on taking food and relieved by induced vomitting
• On perforation initially pain is in epigastrium
• Later on it goes to right side of abdomen
• Then it becomes generalised
• TENDERNESS
• Rebound (blumberg sign)
• Abdominal distention
• Dullness over flank

9. • Obliteration of liver dullness
• Fever,Vomitting,Dehydration,Oliguria
• Tenderness in P/R examination

10. • DUODENAL PERFORATION
• Common in males in 1st part of duodenum
• Mostly followed by chronic duodenal ulcers
• Rest due to silent perforation
• Pt will have history of steriods,alcohol,NSAIDS.
• Sign symptoms
• PAIN
• Initially in epigastrium
• Sudden in onset
• Persistently localised to epigastrium relieves on taking food.
• On perforation initially pain is in epigastrium.
• Later on it goes to right side of abdomen
• Then it becomes generalised
• TENDERNESS
• Rebound (blumberg sign)
• Abdominal distention
• Dullness over flank

11. • Obliteration of liver dullness
• Fever,Vomitting,Dehydration,Oliguria
• Tenderness in P/R examination
• INVESTIGATION
• Xray Flat Plate Abdomen (Erect position)
• Gas under diaphragm
• Absence of gas can be. due to Gas leak is < 1ml , Sealed peptic
ulcers
• False diagnosis due to interposition of colon infront and above
the liver.
• USG whole abdomen : Fluid and Gas
• TLC,Electrolytes,S.urea,S.creat
• Four quadrent abdominal tap

12. • SURGICAL INTERVENTION
• Emergency laparotomy should be done.
• Procedure :
• Emergency laparotomy through upper midline incision is
done. All infected fluid is removed by suction. Perforation is
identified.
• Usually duodenal ulcer perforation is less than 1 cm in size.
Giant ulcer is more than 2 cm in size. Omentum will be
adherent to the site of perforation. It is gently separated. If
duodenum is not perforated then stomach, posterior wall of
stomach (lesser sac), small bowel and colon are thoroughly
checked for possible sites.

13. • Once perforation is identified, suction of surrounding area is
done. Liver, colon and proximal stomach are retracted. Suture
material used for perforation is 3-0 vicryl.
• As perforation edge is friable and oedematous, needle bites
should be very gentle. Bite from each edge (5 mm from the edge)
is taken separately. Each suture is kept away using haemostats on
either side untied. Three stitches are taken at equal distances.

14. • SMALL INTESTINAL PERFORATION
• Causes :
• Predisposing conditions like,
• Crohn’s disease
• Enteric perforation
• Tubercular perforation
• Appendicular perforation
• Penetreting injury

15. • Clinical features :
• Crohn’s disease :
• Common in terminal ileum and colon
• Abdominal pain with Chronic diarrhoea
• Perianal ulcers and fissures
• Involves full thickness of intestinal wall
• Skip lesions
• Enteric perforation :
• Mostly occurs in 3rd week of infection
• fever(step ladder)
• Chills
• Abdominal pain
• Distention
• Diarrhoea
• Rose spots on abdomen (due to vasculitis)

16. • Tubercular perforation :
• Mostly occurs in acute ulcerative variety
• Affects ileocaecal region
• Occurs due to swallowing of TB bacilli
• Initially pt will complain of blood and mucus comes in stool
• Associated with diarrhoea
• Abdominal pain
• Distention
• Ulcers will be transverse

17. • LARGE INTESTINE PERFORATION
• Cause :
• Diverticulitis of colon
• Ulcerative colitis
• Carcinoma colon
• Clinical features :
• DIVERTICULITIS
• Left sided lower abdominal pain
• Relieves on passing of flatus or stool
• Associated with bleeding P/R
• Low grade fever
• Tenderness , rigidity
• Mass felt in left iliac region
• Once it rupture it gives features of peritonitis
• INVESTIGATIONS
• Sigmoidoscopy : mucosa may be erythematous and opening of diverticuli seen
• Colonoscopy

18. • ULCERATIVE COLITIS
• Patient comes with H/O excessive urge to pass stool
• Stool contains blood and mucus
• INVESTIGATIONS
• Stool examination to rule out infective cause
(amoebiasis,shigella)
• Sigmoidoscopy : multiple ulcers visible
• Colonoscopy : to find out extent of involvement and to take
biopsy
• CARCINOMA COLON
• C/O unexplained weakness , anaemia
• Occult blood in stools
• Changes in bowel habits
• Perforation more common in left sided ca colon

19. • INVESTTIGATIONS :
• CBC
• Stool examination
• Barium enema : shows persistent filling defect (apple core
deformity)
• USG
• CT scan
• Colonoscopy (growth will be seen)

20. Signs and Symptoms
• Sudden onset of pain which is severe.
• Fever
• Vomiting
• Tenderness—initially localised later becomes diffused.
• Rebound tenderness—Blumberg sign.
• Guarding and rigidity, dull flanks on percussion.
• Tachycardia, tachypnoea.
• Tenderness on P/R examination.
• Distension with silent abdomen.
• Eventually leading to Hippocrates facies, septicaemic shock and
loss of consciousness.
• Bowel sounds are absent due to paralytic ileus.
• Fever may be absent in severe peritonitis due to loss of pyrogenic
reaction. Total count also may be very low in severe peritonitis.

21. INVESTIGATION
• Xray FPA (Erect posture)
• CBC
• USG Whole Abdomen
• Blood urea and Serum creatinine
• S.Amylase and S.Lipase
• BT ,CT,PT INR
• Four quadrant abdominal tap or USG guided aspiration of fluid
• Diagnostic laparoscopy
• CECT Whole Abdomen

22. TREATMENT
1. Medical Management
2. Surgical Management
1. Medical Management
• IV fluids : To correct tissue perfusion,hypovolemia and
improove urine output.
• Nasogastric tube aspiration : To reduce toxic fluid and to
decompress bowel.
• Total parentral nutrition
• Blood,plasma,platelet transfusion
• Catheterisation with maintainence of adequete urine output

23. • Antibiotics : ampicillin, gentamicin, metronidazole, ceftazidime,
cefoperazone, cefotaxime, tazobactum, piperacillin, meropenem,
linezolid, etc.
• Analgesics to relieve pain by drugs
• Surgical correction of underlying cause.

24. SURGICAL INTERVENTION
Exploratory laparotomy
• On laparotomy cause for perforation peritonitis
identified and corrected
• In bowel perforation : Resection and anastomosis
• In perforated appendicitis : Appendicectomy
• Proper peritoneal toilet should be done
• Pus send for c/s

25. • Procedure :
• Antimesenteric border is having least blood supply and is so
critical point in bowel anastomosis. So antimesenteric border
should be cut obliquely while doing bowel anastomosis.
Mesenteric arterial pulsation should be checked. Cut edge
bleeding is very important. If surgeon is not satisfied about cut
edge bleeding then one should trim the edge adequately
• Colour, peristalsis, pulsation in the arcade, bleeding suggests
adequate blood supply.
• Serosal area should be cleared off from fat for 1 cm margin
before doing bowel anastomosis. Fat will interfere with proper
apposition of the cut edges. It also reduces the blood supply .

26. • Luminal size of the anastomotic segments should be near equal
to have proper serosal apposition. If it is not then narrower
segment should be widened by incising antimesenteric border
obliquely to widen the lumen (Cheatle’s cut). Usually distal
collapsed part will be narrower compared to proximal dilated
segment; so commonly distal part needs Cheatle’s cut .
• Knot should be tied with only optimum force.it should be neither
be very tight nor very loose.
• While suturing anterior layer one should be careful in avoiding
inadvertent bites of the posterior layer which will block the
lumen partially causing stricture and obstruction. Bites should be
taken at 5 mm gap with 5 mm thickness of tissue from the cut
edge.

27. • Non traumatic clamps over the bowel should be placed at 30
degrees at antimesenteric border. Clamps should not extend far
into the mesentery. Occlusion clamps are applied at viable part
to prevent spillage of contents into peritoneal cavity, to prevent
oozing from cut edges of the bowel and to stabilize the gut.
Crushing clamps are placed after ligation of mesentery just prior
to cutting the bowel; it is applied on the specimen side. One
should take care about avoiding twisting of mesentery prior to
anastomosis after resection.
• Corners of the cut edge of the bowel should be held with
seromuscular sutures or Babcock’s forceps to allow posterior
layer to drop behind and to facilitate proper bite taking of the cut
edges.

28. • Anastomosis can be done as continuous layer or interrupted
sutures. In acute conditions as there is oedema interrupted one is
better. Single layer interrupted sutures are safer and equally
good. If two layer anastomosis is done outer interrupted silk
sutures are used; inner continuous absorbable sutures like vicryl
are used.

29. POST OP CARE
• Proper critical care (ICU) postoperatively.
• Ventilatory support; monitoring with urine output, temperature,
breathing, pulse rate, blood pressure, arterial blood gas analysis,
total count estimation (both very high and very low counts
signify severe sepsis/septicaemia), platelet count, prothrombin
time analysis, blood urea and serum creatinine, liver function
tests (altered liver function signifies septicaemia). These
investigations need to be repeated as and when required .
• Proper fluid and electrolyte management.
• Total parenteral nutrition .
• Prevention of deep vein thrombosis by leg exercises, low
molecular weight heparin.
• Prevention/identification of ARDS and its management.
• Prevention of bedsore.