Continuing Education Activity

Perforation of the stomach is a full-thickness injury of the wall of the organ. Since the peritoneum completely covers the stomach, perforation of the wall creates a communication between the gastric lumen and the peritoneal cavity. If the perforation occurs acutely, there is no time for an inflammatory reaction to wall off the perforation, and the gastric content is free to enter the general peritoneal cavity, causing chemical peritonitis. Perforations occurring over a prolonged period may be contained locally by the inflammatory reaction. Perforation may be suspected based upon the patient's clinical presentation, or the diagnosis becomes obvious through a report of extraluminal free air on diagnostic imaging performed to evaluate for abdominal pain or another symptom. Treatment is a surgical repair. This activity reviews the evaluation of a suspected gastric perforation and the role of the interprofessional team in managing this condition.

Objectives:

• Summarize the pathophysiology of gastric perforation.
• Describe when to suspect a gastric perforation.
• Identify the most likely locations of gastric perforation.
• Outline the evaluation of a suspected gastric perforation and the role of the interprofessional team in managing this condition.

Introduction

Perforation of the stomach is a full-thickness injury of the wall of the organ. Since the peritoneum completely covers the stomach, perforation of the wall creates a communication between the gastric lumen and the peritoneal cavity. If the perforation occurs acutely, there is no time for an inflammatory reaction to wall off the perforation, and the gastric contents freely enter the general peritoneal cavity, causing chemical peritonitis. Perforations occurring over a prolonged period may be contained locally by the inflammatory reaction. Perforation may be suspected based upon the patient’s clinical presentation, or the diagnosis become obvious through a report of extraluminal ”free air” on diagnostic imaging performed to evaluate for abdominal pain or another symptom. Treatment is a surgical repair. During surgery, most of the perforations are linear and found high in the stomach and along the greater curvature. The perforation is usually closed with a patch made of omentum or the perforated area may undergo a wedge resection. [1][2][3]

Etiology

The etiology of most gastric perforations is secondary to peptic ulcer disease but can also be caused by trauma, malignancy, interventional procedures, and intrinsic gastric pathology or can occur spontaneously in the newborn.[4]

Peptic Ulcer Disease (PUD)

PUD is the most common cause of stomach perforation. Owing to the advancement of medical management; the incidence of gastric perforation occurs in less than 10% of patients with peptic ulcer disease. It occurs most commonly in elderly patients taking NSAIDs and in patients consuming excess alcohol. Perforation of gastric ulcer or duodenal ulcer into the peritoneal cavity causes initially chemical peritonitis as opposed to bacterial peritonitis, unlike more distal bowel perforation. If posterior wall gastric ulcers perforate, they leak gastric contents into the lesser sac, which tends to confine the peritonitis. These patients may present with less marked symptoms.[5]

Spontaneous Gastric Perforation

Spontaneous perforation of the stomach is an uncommon event mainly seen in the neonatal period, the first few days of life, as a cause of pneumoperitoneum. Beyond the neonatal period, perforation is rare and usually secondary to trauma, surgery, caustic ingestion, or peptic ulcer.

Trauma

Traumatic perforation is more frequently the result of a penetrating injury or instrumentation of the stomach, although perforation and organ rupture can occur with severe blunt abdominal trauma. Injuries of the stomach can occur in association with any penetrating trauma of the abdomen, such as gunshot and stab wounds. About 8% of abdominal wounds involve the stomach, and in approximately five percent the stomach is the only organ injured. The type of gastric wound produced by a bullet or sharp instrument is a function of the size, shape, course, and velocity of the missile. With penetrating wounds, both the anterior and posterior walls of the stomach may be injured, and the posterior wall of the organ should always be visualized at the time of surgery. With blunt trauma to the upper abdominal region, the stomach may become lacerated, or it may even rupture if the organ is filled and distended at the moment of impact. The stomach is relatively protected by its anatomical location and is the third most frequently injured hollow intra-abdominal organ after small bowel and colon and then stomach. [6]

Malignancy-Related Gastric Perforation

 Neoplasms can perforate by direct penetration and necrosis, or by producing obstruction. Perforations related to tumors can also occur spontaneously, following chemotherapy or as a result of radiation treatments. It can be related also to interventions like stent placement for malignant gastric outlet obstruction.

Iatrogenic

The stomach may be injured in the course of a number of procedures. Upper endoscopy is the main cause of iatrogenic perforations. The incidence of perforation related to endoscopy increases with procedural complexity and perforation is less common with diagnostic than with therapeutic procedures. The proximal stomach is at the greatest risk as this is where its wall is the thinnest. The overall perforation rate is 0.11% for rigid endoscopy compared to 0.03% for flexible endoscopy. Iatrogenic perforations are more frequent in patients with pre-existing gastric pathology. Rupture of the stomach due to excessive insufflation of the stomach can occur in the course of endoscopy or even unrelated procedures, such as cardiopulmonary resuscitation, and is typically located on the lesser curve, where the organ is least distensible.[7]

Causes of Endoscopy-Related Gastric Perforation

• Polypectomy
• EMR-ESD
• Dilation of anastomotic stricture
• Scope or barotrauma
• Medications, other ingestions, foreign body: medications or other ingested substances (caustic injury) and foreign bodies such as sharp objects (toothpicks), food with sharp surfaces, for example, chicken bones, or fish or gastric bezoar.[8]

Epidemiology

In children, the majority of gastric perforations are trauma-related. Data reveal that such perforations are on the rise from both blunt and penetrating trauma. In adults, the most common cause in the past was peptic ulcer disease. However, since the introduction of the proton pump inhibitors, these perforations have become very rare today. Overall, duodenal perforations are more common than gastric perforations. At least 30% of gastric perforations are associated with malignancy.[9]

A common cause of gastric perforation in hospitals today is endoscopy-related. The exact numbers are not known because the diagnosis of perforation is usually altered and stated as peptic ulcer disease.[10]

Pathophysiology

The stomach usually has no microorganism because of the high acidity. Hence the majority of individuals who experience gastric perforation are not at risk for immediate bacterial growth. However, the leakage of acidic juices in the abdominal cavity can lead to severe chemical peritonitis. Within a few hours of the perforation, the patient will develop an acute abdomen and signs of peritonitis. When food leaks inside the abdominal cavity, it can lead to an inflammatory reaction and numerous pockets of infection or abscesses. If left untreated, the patient will develop systemic sepsis followed by multiorgan failure.

History and Physical

The clinical presentation of any perforating injury of the stomach is often very dramatic. Depending upon the size of the wound, the loss of blood, and the presence or absence of concomitant injuries, clinical symptoms may range from mild localized pain to signs of peritonitis and shock.

History

A careful history is important in evaluating patients with neck, chest, and abdominal pain. It should include questions about prior bouts of abdominal or chest pain, prior instrumentation (nasogastric tube, endoscopy), prior trauma, prior surgery, malignancy, possible ingestion of foreign bodies, medical conditions (PUD), and medication (NSAIDs, glucocorticoids)

Signs and Symptoms

Signs and symptoms can include refusal to feed, vomiting, and decreased activity. The most common presenting manifestation is a sudden onset of abdominal distension and pain; less common presenting symptoms are ileus, respiratory distress, fever, emesis, hematemesis, or hematochezia.

Patients with perforation invariably complain of acute onset of severe abdominal pain or chest pain; patients often note the exact time of onset of pain. Severe chest or abdominal pain following instrumentation should be viewed with a high degree of suspicion for gastric perforation. Patients on immunosuppressive or anti-inflammatory agents may have an impaired inflammatory response and some may have less pain and tenderness. Many of them will seek medical attention with the onset of pain but a few will present in a delayed fashion (may present with sepsis). Irritation of the diaphragm may occur leading to pain radiating to the shoulder. Sepsis can be the initial presentation of perforation. The ability of the peritoneal surfaces to wall off a perforation may be impaired in patients with severe medical comorbidities particularly frail, elderly, and immunosuppressed patients, resulting in sepsis.

Physical Examination

Should include vital signs, a thorough examination of the abdomen. The majority of patients will have tachycardia, tachypnea, fever, and generalized abdominal tenderness. Bowel sounds may be absent and rebound and guarding are likely to be present.

Evaluation

Diagnosis usually confirmed by radiological imaging showing free intraperitoneal air. Another reported suggestive sign is the lack of an air-fluid level in the stomach in a horizontal beam view and a relative paucity of gas in the distal bowel.

Imaging 

The diagnostic approach in patients with abdominal pain starts with plain films. The sensitivity of plain films for detecting extraluminal free air ranges from 50% to 70%. Ultrasound (US) has also been studied and shows excellent potential for identifying pneumoperitoneum. The most useful imaging modality is a CT scan that is highly sensitive and specific for free air.

CT Findings for Perforation

Pneumoperitoneum

• Mesenteric air
• Discontinuity of the hollow viscus wall
• Extraluminal enteric contrast
• Free intraabdominal fluid
• Extravasated intravenous contrast
• Bowel wall thickening or edema
• Mesenteric hematoma.

In complex cases, one may need to perform a diagnostic laparoscopy to determine the cause and obtain and fluid for culture and biochemistry.

Treatment / Management

Initial management consists of aggressive resuscitation, oxygen therapy, intravenous fluids, and broad-spectrum antibiotics. A nasogastric tube should also be placed. Intravenous analgesia and PPIs should be given as necessary. A urinary catheter enables close monitoring of urine output. Surgical management is the mainstay of treatment for most stomach perforations. Emergency surgical repair (open or laparoscopic) is indicated in nearly all cases.

Broad-spectrum antibiotics have been shown to reduce the risk of wound infection. Metronidazole and either a cephalosporin or an aminoglycoside will suffice.[11]

Definitive surgical treatment should be done at the earliest possible time. In a gunshot or stab wound the posterior, as well as the anterior wall, may be injured simultaneously. Accordingly, exploration of the posterior wall is obligatory in every instance by adequately detaching the gastrocolic ligament and pulling the stomach upward. There are cases where the posterior wall alone was injured by GSW or a stab wound to the anterior abdominal wall. This can happen if, at the time of the accident, the stomach was so tightly filled that the greater curvature rotating around the longitudinal axis of the stomach, has turned forward and upward 

Surgical Management

• Primary repair: The defect is primarily closed with suture, this is appropriate for most traumatic perforations
• Graham patch repair: The defect is simply plugged with a well-vascularized omental pedicle
• Modified Graham patch repair: primary closure of the defect then application of the flap.
• Wedge resection: The perforated area may be resected from healthy tissue, particularly if it is on the greater curvature and distant from the gastroesophageal junction or the pylorus

Options for reconstruction:

• Billroth I: Gastroduodenostomy, anastomosis between the gastric remnant and the duodenum
• Billroth II: Gastrojejunostomy, side to side anastomosis between gastric remnant and loop of jejunum with the closure of duodenal stump
• Roux-en-Y gastrojejunostomy: The creation of jejuno-jejunostomy forming y shaped figure of the small bowel.

Differential Diagnosis

The differential diagnosis for the sudden onset abdominal pain seen with a gastric perforation is broad and includes but is not limited to:

• Peptic ulcer
• Duodenal ulcer
• Biliary disease
• Splenic infarction
• Embolic mesenteric insufficiency
• Gastritis
• Esophageal perforation
• Abdominal aortic aneurysm rupture

Prognosis

Over the past 3 decades, the prognosis of patients with gastric perforation has significantly improved. But delays in diagnosis and treatment can still lead to death. Factors linked to high mortality include:

• Presence of comorbid disease
• Advanced age
• Malnutrition
• Presence of complications
• Type and location of the perforation

Complications

Complications following gastric perforation include the following:

• Wound infection
• Sepsis
• Malnutrition
• Multiorgan failure
• Adhesions and bowel obstruction
• Delirium

The risk of complications is increased in the presence of:

• Advanced age
• Dementia
• Sepsis
• Electrolyte and metabolic abnormalities
• Hypoxia
• Intraoperative complications

Postoperative and Rehabilitation Care

Patients who present early after perforation normally recover well and may be fed a day or two after the operation and discharged once they are tolerated sufficient intake. Patients who present late in a septic state or have multiple comorbidities may have a more protracted recovering including time in the ICU to treat them for their sepsis.

Consultations

Most patients with gastric perforation present to the emergency department. Once the diagnosis is made, an immediate general surgery consultation should be obtained. These patients may also need a bed in the intensive care unit depending on the condition in which they present.

Deterrence and Patient Education

Given that the most common cause of gastric perforations is peptic ulcer disease ensuring patients with this pathology are on an effective proton pump inhibitor regimen can significantly reduce their risk of perforation. Patients should be educated to take their proton pump inhibitor regularly and not only when they have symptoms. Eradication of H pylori infection, if it is present, is also imperative and patients should be educated about the need for this if they test positive for H Pylori. 

Physicians should also attempt to minimize the risk of gastric perforations during endoscopy by:

• Avoid excessive endoscope looping in the stomach, consider left upper quadrant pressure or use of an overtube
• Submucosal injection of fluid before resecting large sessile lesions
• Perform EUS before resecting subepithelial lesions
• Proper training and use of cap-assisted EMR kit
• Consider the use of fluoroscopy for dilating surgical gastric outlet strictures
• Consider the use of carbon dioxide insufflation for therapeutic cases.

Pearls and Other Issues

• Gastric perforation is rare today because of the availability of PPIs.
• Iatrogenic and trauma account for most gastric perforations today.
• The patient will present with signs of an acute abdomen.
• Free air will be visualized on plain x-rays or CT scans.
• Surgery is the only viable treatment for gastric perforation.
• When treated promptly, the prognosis is improved, but the risk of complications is high.

Enhancing Healthcare Team Outcomes

The diagnosis and management of gastric perforation necessitate an interprofessional team that consists of a surgeon, an emergency department physician, a radiologist, a gastroenterologist, and a nurse practitioner. Once the diagnosis is made, the only curative treatment is surgery. Gastric perforation can be managed via an omental patch or wedge resection in the setting of ulcer disease or with primary repair in the setting of trauma. In the postoperative period, the patient must be continued on PPI to prevent recurrence. Untreated or delayed cases carry a very high mortality.