What are the causes of a perforated viscus?

Causes of Perforated Viscus

Perforated viscus is most commonly caused by peptic ulcer disease, particularly duodenal ulcers, followed by trauma, inflammatory conditions, and malignancy. 1, 2

Common Causes of Perforated Viscus

Gastrointestinal Causes

• Peptic Ulcer Disease

  • Duodenal ulcers (most common overall cause) 1, 2
  • Gastric ulcers
  • Risk factors: H. pylori infection, NSAID use, smoking, alcohol consumption

• Inflammatory Conditions

  • Appendicitis with progression to appendicular abscess 3
  • Diverticulitis with perforation 1
  • Inflammatory bowel disease (Crohn's disease, ulcerative colitis)

• Malignancy

  • Colorectal cancer 1
  • Gastric cancer
  • Advanced tumors causing obstruction and subsequent perforation

Traumatic Causes

• Blunt Abdominal Trauma

  • High-impact mechanisms affecting fixed segments of intestine 4
  • Most commonly affects jejunum and transverse colon 4
  • Motor vehicle accidents, falls from height, direct abdominal blows

• Penetrating Trauma

  • Stab wounds
  • Gunshot wounds
  • Iatrogenic injuries during procedures 1

Iatrogenic Causes

• Endoscopic Procedures

  • Account for approximately 60% of esophageal perforations 1
  • Diagnostic and therapeutic endoscopies
  • Esophageal dilation, varices ligation, sclerotherapy

• Surgical Complications

  • Anastomotic leaks
  • Inadvertent injury during abdominal surgery

Other Causes

• Foreign Body Ingestion

  • Sharp objects (bones, toothpicks, etc.)
  • Caustic ingestion leading to esophageal perforation 1

• Spontaneous Perforation

  • Boerhaave syndrome (barogenic rupture of esophagus due to forceful vomiting) 1
  • Occurs in the left border of lower third of thoracic esophagus

Clinical Presentation and Diagnostic Considerations

Classic Presentation

• Sudden onset of severe abdominal pain
• Peritonitis (present in approximately two-thirds of patients) 1
• Abdominal rigidity and guarding
• Fever, tachycardia, hypotension in advanced cases

Atypical Presentations

• May present as biliary colic with right upper quadrant pain radiating to shoulder 5
• Can be masked in elderly, immunocompromised, or patients on steroids
• Patients with contained leaks may have minimal symptoms initially

Diagnostic Approach

• Imaging Studies

  • Plain radiographs may show free air under diaphragm (30-85% sensitivity) 1
  • CT scan is the gold standard (higher sensitivity for detecting free air and determining perforation site) 1
  • CT findings suggestive of perforation: pneumoperitoneum, free fluid, bowel wall thickening, mesenteric fat stranding 1

• Laboratory Tests

  • Leukocytosis, metabolic acidosis, elevated serum amylase commonly associated with perforation 1

Management Considerations

Timing of Intervention

• Prompt source control is critical
  • Delayed diagnosis and treatment significantly increase mortality and morbidity 1
  • Operating room latency >60 hours increases risk of relaparotomy 1

Treatment Approaches

• Surgical Management

  • Primary repair or resection of perforated segment
  • Peritoneal lavage
  • Drainage of collections

• Non-operative Management

  • May be considered in highly selected patients with contained perforations 1
  • Examples: small perforated diverticulitis (<4 cm abscess), peri-appendiceal mass, or contained perforated peptic ulcer in stable patients 1

Pitfalls and Caveats

• Diagnostic Challenges

  • CT scan may miss up to 12% of perforations 1
  • Hollow viscus injuries are particularly difficult to diagnose on imaging 1
  • Diaphragmatic and pancreatic injuries have low sensitivity on CT (61% and 30% respectively) 1

• Treatment Delays

  • Mortality increases fourfold when surgical delay exceeds 24 hours after bowel perforation 1
  • Misdiagnosis of the extent and location of abscess is the principal cause of failure in percutaneous drainage 1

• Mimics of Perforation

  • Superior mesenteric artery syndrome with gastric distension can mimic hollow viscus perforation on ultrasound 6
  • Aortic dissection and esophageal intramural hematoma can mimic esophageal perforation 1

Remember that early recognition and appropriate management of perforated viscus are crucial for reducing morbidity and mortality in these patients.