Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 1348 - файл.pdf
Acute Perforation
Any part of the gastrointestinal tract may become perforated from a
variety of causes, releasing gastric or intestinal contents into the
peritoneal space. Symptoms develop suddenly, with severe pain
followed shortly by signs of shock. Diagnosis is usually made by the
presence of free air in the abdomen on imaging studies in the majority
of the cases. Treatment is with fluid resuscitation, antibiotics, and
surgery. Mortality could be high, varying with the underlying disorder
and the patient's general health general health.
Etiology
Both blunt and penetrating trauma can result in perforation of any part
of the gastrointestinal tract. Swallowed foreign bodies, even sharp
ones, rarely cause perforation unless they become impacted, causing
ischemia and necrosis from local pressure. Foreign bodies inserted via
the anus may perforate the rectum. Pathologic perforations, e.g. peptic
gastroduodenal ulcer, diverticulitis, or colonic carcinoma etc.
201
Causes of Gastro-intestinal Tract Perforation
Perforation Site Causes Comments
All sites Trauma
Foreign bodies
Esophagus Forceful vomiting Termed Boerhaave's syndrome
Iatrogenic causes
Stomach or
duodenum
Intestine
Colon Obstruction
Diverticulitis
Toxic megacolon
Sometimes spontaneous
Gallbladder
Ingestion of corrosive
material
Peptic ulcer disease
Ingestion of corrosive
material
Strangulating
obstruction
Possibly acute
appendicitis and
Meckel's diverticulitis
Inflammatory bowel
disease (ulcerative
colitis, Crohn's disease)
Iatrogenic damage
during cholecystectomy
Rarely, acute
cholecystitis
Typically perforation with an
esophagoscope, balloon
dilator, or bougie
About 1/3 have no previous
history of ulcer symptoms
Typically stomach
Free air rarely present on
x-rays
Typically perforates at cecum.
High risk: colon > 13 cm
diameter, patients receiving
prednisone
or other immunosuppressants
(symptoms may be minimal in
this group)
Perforation of biliary tree
Usually walled off by
omentum
202
Symptoms and Signs
Esophageal, gastric, and duodenal perforation tend to present suddenly
and catastrophically, with abrupt onset of acute abdomen with severe
generalized abdominal pain, tenderness, and peritoneal signs. Pain may
radiate to the shoulder.
Perforation at other gastrointestinal sites often occurs in the setting of
other painful, inflammatory conditions. Because such perforations are
often small initially and frequently walled off by the omentum, pain
often develops gradually and may be localized. Tenderness also is more
focal. Such findings can make it difficult to distinguish perforation from
worsening of the underlying disorder or lack of response to treatment.
Perforation of peptic ulcer is one of the complications of peptic ulcer
disease. It happens suddenly with severe epigastric pain. Some patients
with perforated ulcer could have no history of peptic ulcer. Subphrenic
air collection is found in more than 70% of the cases with perforated
peptic ulcer. In all types of perforation, nausea, vomiting, and anorexia
are common. Bowel sounds are quiet to absent.
Free air collection under right diaphragm.
203
Diagnosis.
· Abdominal x-ray series
· If nondiagnostic, abdominal CT
An abdominal series (supine and upright abdominal x-rays and chest
x-rays) may be diagnostic, showing free air under the diaphragm in up
to 75% of cases. As time passes, this sign becomes more common. A
lateral chest x-ray is more sensitive for free air than a postero-anterior
x-ray. In unclear suspected cases a water soluble contrast (gastrografin)
swallow will show a peritoneal leakage, and measuring of serum amylase
are helpful for distinguishing between peptic ulcer perforation and acute
pancreatitis.
If the abdominal series is nondiagnostic, abdominal CT usually with oral
and IV and/or rectal contrast may be helpful. Barium should not be used
if perforation is suspected because of the toxicity of the barium ions.
Free air under diaphragm
Treatment
· Surgery
· IV fluids and antibiotics
204
If a perforation is noted, immediate surgery is necessary because mortality
from peritonitis increases rapidly the longer treatment is delayed. If an
abscess or an inflammatory mass has formed, the procedure may be
limited to drainage of the abscess and complications are expected.
A naso-gastric tube is inserted before operation. Patients with signs of
volume depletion should have urine output monitored with a catheter.
Fluid status is maintained by adequate IV fluids and electrolytes
replacement. IV antibiotics are needed and effective against intestinal
flora should be given e.g., cefotetan and metronidazole.
Surgery is performed accordingly. Peptic ulcer perforation is oversutured
and covered with omentum (omentoplasty). Colonic perforation is closed
with suture and protective colostomy is often indicated. Definitive
treatment with major surgery including resection is in some cases possible.
205
Acute Appendicitis
Appendicitis is an acute inflammation of the vermiform appendix,
typically resulting in abdominal pain, anorexia, and abdominal
tenderness..
It is the most common cause of acute abdomen in young adults.
The incidence of acute appendicitis: it is relatively rare in infants and
increasingly common in childhood and early adult life. The peak
incidence in the teens and early twenties. The incidence decrease with
age. Male to female ratio is 1:1 before puberty, and 3:2 in teenagers
and young adults. Mortality is improved because of early diagnosis
and better management
In Europe and the USA, acute appendicitis is the most common cause
of acute abdominal pain requiring surgery. Over 5% of the population
develops appendicitis at some point.
Other conditions affecting the appendix include carcinoids, cancer,
villous adenomas, and diverticula. The appendix may also be affected
by Crohn's disease or ulcerative colitis with pancolitis.
207
Acute appendicitis.
Etiology
Appendicitis is thought to result from obstruction of the appendiceal
lumen, typically by lymphoid hyperplasia, but occasionally by a fecolith,
foreign body, or even worms (rare). The obstruction leads to distention,
bacterial overgrowth, ischemia, and inflammation. If untreated, necrosis,
gangrene, and perforation occur. If the perforation is contained by the
omentum, an appendiceal abscess results.. Obstruction of the lumen (80%
of cases) result in mixed bacterial proliferation: E. coli in 80% of cases
and enterococci 20% of cases. Non haemolytic streptococci, anaerobic
streptococci and cl. welchi are found also.
Symptoms and Signs
The classic symptoms of acute appendicitis are epigastric or periumbilical
pain followed by brief nausea, vomiting, and anorexia; after a few
hours, the pain shifts to the right lower quadrant. Pain increases with
cough and motion. Classic signs are right lower quadrant direct and
208
rebound tenderness located at McBurney's point (junction of the middle
and outer thirds of the line joining the umbilicus to the anterior superior
spine). Additional signs are pain felt in the right lower quadrant with
palpation of the left lower quadrant (Rovsing sign), an increase in pain
from passive extension of the right hip joint that stretches the iliopsoas
muscle (psoas sign), or pain caused by passive internal rotation of the
flexed thigh (obturator sign). Low-grade fever (rectal temperature 37.7
to 38.3° C [100 to 101° F]) is common.
Unfortunately, these classic findings appear in < 50% of patients.
Many variations of symptoms and signs occur. Pain may not be
localized, particularly in infants and children. Tenderness may be
diffuse or, in rare instances, absent. Bowel movements are usually less
frequent or absent; if diarrhea is a sign, a retrocecal appendix should
be suspected. RBCs or WBCs may be present in the urine. Atypical
symptoms are common among elderly patients and pregnant women;
in particular, pain is less severe and local tenderness is less marked.
ACUTE GANGRENOUS APPENDICITIS.
209