Lower Gastrointestinal Tract Perforation Research Articles

Histamine-2 receptor antagonists versus proton pump inhibitors for septic shock after lower gastrointestinal tract perforation: a retrospective cohort study using a national inpatient database

BackgroundStudies have shown the potential benefit of stress ulcer prophylaxis including histamine-2 receptor antagonists (H2RA) and proton pump inhibitors (PPI) in critically ill patients. However, the adverse effects of stress ulcer prophylaxis such as Clostridioides difficile infection (CDI) and hospital-acquired pneumonia have been reported. Abdominal septic shock is associated with increased risk of bleeding, CDI, and pneumonia; however, which ulcer prophylaxis might be associated with better outcomes in patients with septic shock after lower gastrointestinal tract perforation is unknown.MethodsIn this retrospective cohort study using the Japanese Diagnosis Procedure Combination database from July 2010 to March 2015, we identified patients aged 18 years or older who received open abdominal surgery for lower gastrointestinal tract perforation and who used vasopressors and antibiotics within 2 days of admission. We performed propensity score matching and inverse probability of treatment weighting (IPTW) to compare the outcomes between patients who received H2RA and those who received PPI within 2 days of admission. The outcomes included gastrointestinal bleeding requiring endoscopic hemostasis within 28 days of admission, 28-day mortality, CDI, and hospital-acquired pneumonia.ResultsThe propensity score matching created 1088 pairs of patients who received H2RA or PPI within 2 days of admission. There were no significant differences between the H2RA and PPI groups regarding gastrointestinal bleeding requiring endoscopic hemostasis within 28 days of admission (0.74% vs 1.3%, risk ratio 0.57 (0.24–1.4), and P = 0.284), 28-day mortality (11.3% vs 12.9%, risk ratio 0.88 (0.68–1.1), and P = 0.386), CDI (0.64% vs 0.46%, risk ratio 1.4 (0.45–4.4), and P = 0.774), and hospital-acquired pneumonia (3.0% vs 4.3%, risk ratio 0.70 (0.45–1.1), and P = 0.138). IPTW analysis showed similar results.ConclusionsThere were no significant differences in gastrointestinal bleeding requiring endoscopic hemostasis within 28 days of admission, 28-day mortality, CDI, and hospital-acquired pneumonia between H2RA and PPI in patients with septic shock after lower gastrointestinal tract perforation.

The value of ultrasound in diagnosis of neonatal upper and lower gastrointestinal perforation

Objective To explore the value of ultrasound in the differential diagnosis of neonatal upper and lower gastrointestinal tract(GIT)perforation. Methods We retrospectively reviewed the ultrasound findings of 42 neonates of surgery-confirmed neonatal GIT perforation in our hospital from January 1, 2015 to December 31, 2018.The accuracy of ultrasound for detecting GIT perforation and the ultrasound features of upper and lower GIT perforation were evaluated. Results (1)Of the 42 neonates with GIT perforation, 1 case didn′t undergo ultrasound, 2 cases were missed, and 1 case was misdiagnosed.Thirty-eight neonates were diagnosed of GIT perforation by ultrasound preoperatively, with a detection rate of 92.7%(38/41). The locations of GIT perforation were identified by ultrasound in 30 cases(78.9%, 30/38), including 11 cases of upper GIT perforation and 19 cases of lower GIT perforation.(2)A common sonographic finding of GIT perforation in 38 cases was pneumoperitoneum, which appeared as an echogenic line with posterior reverberation artifact under diaphragm or anterior to hepatic/splenic surface and a stratosphere sign in M-mode sonography.Free gas changed position when the patient′s position was changed, and didn′t change due to respiratory change.Besides, free gas dispersed with compression on abdomen, and gathered without compression.(3)Upper GIT perforation was showed that poor filling of the stomach cavity, and the abdominal free gas sharply increased.Lower GIT perforation was characterized by collapsed bowel, blurred and interrupted intestinal wall structure, and more accompanied with intestinal obstruction.(4)There was no significant difference of detection rate between ultrasound and X-ray in diagnosing GIT perforation[92.7%(38/41)vs.83.3%(35/42)](P>0.05), whereas ultrasound more sensitive for a very small amount of free gas in the early stage of perforation.(5)Helicobacter pylori infection was found in two cases of GIT perforation. Conclusion Ultrasound can be used for differential diagnosis of upper and lower GIT perforation, and could be recommended as the first choice for detecting GIT perforation in neonatal patients. Key words: Ultrasound; Upper gastrointestinal tract perforation; Lower gastrointestinal tract perforation; Intestinal obstruction

Low psoas muscle index is a poor prognostic factor for lower gastrointestinal perforation: a single-center retrospective cohort study

BackgroundVarious body composition indices have been reported as prognostic factors for different cancers. However, whether body composition affects prognosis after lower gastrointestinal tract perforation requiring emergency surgery and multidisciplinary treatment has not been clarified. This study examined whether body composition evaluations that can be measured easily and quickly from computed tomography (CT) are useful for predicting prognosis.MethodsSubjects comprised 64 patients diagnosed with perforation at final diagnosis after emergency surgery for a preoperative diagnosis of lower gastrointestinal tract perforation and penetration. They were divided into a survival group and a non-survival (in-hospital mortality) group and compared. Body composition indices (psoas muscle index (PMI); psoas muscle attenuation (PMA); subcutaneous adipose tissue index (SATI); visceral adipose tissue index (VATI); visceral-to-subcutaneous fat area ratio (VSR)) were measured from preoperative CT. Cross-sectional psoas muscle area at the level of the 3rd lumbar vertebra was quantified. Optimal cut-off values were calculated using receiver operating characteristic curve analysis. Poor prognostic factors were investigated from multivariate logistic regression analyses that included patient factors, perioperative factors, intraoperative factors, and body composition indices as explanatory variables.ResultsThe cause of perforation was malignant disease in 12 cases (18.7%), and benign disease in 52 cases (81.2%). The most common cause was diverticulum of the large intestine. Emergency surgery for the 64 patients led to survival in 52 patients and death in 12 patients. On multivariate logistic regression analysis, independent predictors of poor prognosis were Sequential Organ Failure Assessment score (odds ratio 1.908; 95% confidence interval (CI) 1.235–3.681; P = 0.0020) and PMI (odds ratio 13.478; 95%CI 1.342–332.690; P = 0.0252). The cut-off PMI was 4.75 cm2/m2 for males and 2.89 cm2/m2 for females. Among survivors, duration of hospitalization was significantly longer in the low PMI group (29 days) than in the high PMI group (22 days, p = 0.0257).ConclusionsPMI is easily determined from CT and allows rapid evaluation of prognosis following lower gastrointestinal perforation.

The spectrum of nontraumatic perforation peritonitis in Al Noor Specialist Hospital, Makkah

Introduction: Nontraumatic perforation peritonitis is the most common emergency in Saudi Arabia. The spectrum of etiology of perforation in Saudi Arabia continues to be different from the western countries. The objective of this study is to highlight the spectrum of etiology of nontraumatic perforation peritonitis and the predictor factors for increasing mortality in those patients. Patients and Methods: This is a prospective study (case series); all patients admitted with nontraumatic perforation peritonitis were included in the study from January 2005 to December 2010 and followed up in the outpatient department for 6 months up to 2 years. One hundred and thirty patients of nontraumatic perforation peritonitis were included in the study and their clinical presentation, operative findings, and postoperative course were recorded in Al Noor Specialist Hospital in Makkah (Holy city), Saudi Arabia. Results: The most common cause of perforation in our series was perforated duodenal ulcer (56 cases), followed by appendicitis (44 cases), perforated gastric ulcer (11 cases), typhoid fever (8 cases), and perforated gastrointestinal cancers (8 cases). Twenty-eight cases (22%) developed complication and three patients died (2.3%). Conclusion: This study shows that the upper gastrointestinal tract perforation due to nontrauma causes constitutes the majority of cases in Holy city, Makkah, in contrast to the western countries where lower gastrointestinal tract perforation is more common. Our study also highlights the outcome of nontraumatic perforation peritonitis.

The applicated value of intraperitoneal free gas in diagnosis of the site of gastrointestinal perforation using multi-slice CT

Objective To study the distribution characteristics of intraperitoneal free gas and the location value of the site of gastrointestinal perforation using multi-slice CT (MSCT). Methods 60 cases of gastrointestinal perforation were retrospectively collected.The distribution of the intraperitoneal free gas in CT image was analyzed and observed.The digestive tract were divided to the upper digestive tract and the lower digestive tract by Treitz ligament.The distribution of the intraperitoneal free gas was analyzed using χ2 test.The distribution of the intraperitoneal free gas between each different perforational site was analyzed. Results 38 cases of the site of gastrointestinal perforation located in upper gastrointestinal tract and 22 cases located in lower gastrointestinal tract, there was statistically significant difference between the upper digestive tract and the lower digestive tract about the distribution of the intraperitoneal free gas(χ2=22.33, P 0.05). In the cases of lower gastrointestinal tract perforation, 11 cases of the site located in bowel and 11 cases located in colon, there was statistically significant difference between bowel and colon(χ2=8.98, P<0.05). Conclusion The MSCT distribution of the intraperitoneal free gas has important value in localization diagnosis of gastrointestinal perforation. Key words: Gastrointestinal perforation; Intraperitoneal free gas; Tomography, X-ray computer

A Clinical Study of the Spectrum of Gastro Intestinal Perforation Peritonitis in Rural Southern East Rajasthan

Background: Perforation peritonitis is the most common surgical emergency encountered India and all over world. The etiology of perforation peritonitis as seen in India is different from its western counterpart. The objective of the study was to highlight the spectrum of perforation peritonitis as encountered by us in rural southern east Rajasthan. Methods: It is descriptive, retro-prospective study of 100 (hundred) cases of perforation peritonitis seen and treated over a period of two years. Results: The maximum number of patients in our study was in age group of 31- 40 years (23%) with a mean age was 40.29, years. There were 89 males (89%) as compared to 11 females (11%). The most common site of perforation in our series was gastroduodenal (81%) followed by small bowel perforation (13%), appendicular perforations (4%), colonic perforation (1%) and rectal perforation (1%). The rate of complication was 21%. Mortality rate was 7% and significantly high (100%) in patients coming to the hospital after 24 hours. Conclusion: In contrast to western literature, where lower gastrointestinal tract perforation, upper gastrointestinal tract perforation constitute the majority of cases in India. The high rates of mortality among these who presented late divert attention to the fact early recognition of symptoms and referral of patients is very important in reducing mortality and morbidity.

Postoperative Polymyxin B Hemoperfusion and Mortality in Patients With Abdominal Septic Shock

To examine the effect of postoperative polymyxin B hemoperfusion on mortality in patients with abdominal septic shock triggered by lower gastrointestinal tract perforation, identifying subpopulations of patients who may benefit from this treatment. Propensity-matched analysis. We used a nationwide inpatient database in Japan. We included patients who are 18 years old or older hospitalized during a period of 34 months between July 2007 and October 2011, who had open abdominal surgery on the day of admission (day 0) for perforation of lower gastrointestinal tract, and who required noradrenaline and/or dopamine. We excluded patients who died on day 0 or 1 and patients starting polymyxin B hemoperfusion on day 2 or later. The main outcome was 28-day mortality. Of 2,925 eligible patients, 642 received one or two polymyxin B hemoperfusion sessions, starting the first one on day 0 or 1. Propensity score matching created a matched cohort of 1,180 patients (590 pairs with and without polymyxin B hemoperfusion). The 28-day mortality was 17.1% (101 of 590) in the polymyxin B hemoperfusion group and 16.3% (96 of 590) in the control group (p = 0.696). Subgroup analyses by number of polymyxin B hemoperfusion sessions (one or two), timing of polymyxin B hemoperfusion initiation (day 0 or 1), the use of noradrenaline, and number of dysfunctional organs (one to six) did not show any significant difference in 28-day mortality between the groups. Multiple logistic did not show a significant association between the use of polymyxin B hemoperfusion and 28-day mortality (adjusted odds ratio, 1.10; 95% CI, 0.80-1.51; p = 0.569). Age, end-stage renal disease requiring maintenance hemodialysis, the use of noradrenaline, and number of dysfunctional organs were positively associated with 28-day mortality. In this retrospective study, postoperative polymyxin B hemoperfusion did not show any survival benefit for the overall study population or any of the studied subgroups of patients with abdominal septic shock. A large multicentered prospective randomized trial is warranted to identify the true role of polymyxin B hemoperfusion in sepsis caused by Gram-negative bacteria.

Prophylactic Fluconazole Does Not Improve Outcome in Patients with Purulent and Fecal Peritonitis due to Lower Gastrointestinal Perforation

The benefit of anticandida treatment in addition to standard antibiotic therapy in the presence of perforation/leakage of the lower gastrointestinal tract (LGIT) is still controversial. We retrospectively assessed the clinical effects of empiric anticandida treatment in patients with LGIT perforation who had undergone exploratory laparotomy due to perforated/leaking bowel or appendix between 1999 and 2004, including generalized fecal/purulent peritonitis. Two groups of patients emerged: those receiving empiric anticandida treatment (fluconazole, n = 24) and those who did not (n = 77). All the fluconazole-treated and 40/77 nonfluconazole-treated patients required intensive care unit care and were the subject of this assessment. Postoperative candida infection and mortality rates were similar in the critically-ill fluconazole-treated and nontreated patients (4% vs 7%, 21% vs 22.5%, respectively, P = NS); resistant candidiasis rates were also similar. Hospital and intensive care unit stays were longer in the treated group, however not reaching statistical difference (26.5 +/- 18 vs 21.4 +/- 18.3 days, 14.8 +/- 14.2 vs 9.3 +/- 14.1 days, respectively). The rates of morbidity, pneumonia, and multiorgan failure were significantly higher (P < 0.05) in the treated patients (87% vs 63%, 37% vs 7.5%, and 58% vs 35%, respectively). Empiric fluconazole in patients with peritonitis associated with LGIT perforation did not improve patients' outcome compared with those without empiric treatment.

What determines the periportal free air, and ligamentum teres and falciform ligament signs on CT: Can these specific air distributions be valuable predictors of gastroduodenal perforation?

Purpose The purpose of this retrospective study was to determine what gives rise to the periportal free air, and ligamentum teres and falciform ligament signs on CT in patients with gastrointestinal (GI) tract perforation, and whether these specific air distributions can play a clinically meaningful role in the diagnosis of gastroduodenal perforation. Material and methods Ninety-three patients who underwent a diagnostic CT scan before laparotomy for a GI tract perforation were included. The readers assessed the presence of specific air distributions on CT (periportal free air, and ligamentum teres and falciform ligament signs). The readers also assessed the presence of strong predictors of gastroduodenal perforation (focal defects in the stomach and duodenal bulb wall, concentrated extraluminal air bubbles in close proximity to the stomach and duodenal bulb, and wall thickening at the stomach and duodenal bulb). The specific air distributions were assessed according to perforation sites, and the elapsed time and amount of free air, and then compared with the strong predictors of gastroduodenal perforation by using statistical analysis. Results All specific air distributions were more frequently present in patients with gastroduodenal perforation than lower GI tract perforation, but only the falciform ligament sign was statistically significant ( p < 0.05). The presence of all three specific air distributions was demonstrated in only 13 (20.6%) of 63 patients with gastroduodenal perforation. Regardless of the perforation sites, the falciform ligament sign was present significantly more frequently with an increase in the amount of free air on multiple logistic regression analysis (adjusted odds ratio, 1.29; p < 0.001). The sensitivity, specificity, accuracy, and positive predictive and negative predictive values of each strong predictor for the diagnosis of gastroduodenal perforation were higher than those of specific air distributions. The focal wall thickening (accuracy, 95.7%) was the most useful parameter for the diagnosis of gastroduodenal perforation. Conclusion The prediction of the perforation site of the GI tract on CT should be based on the presence of strong predictors of the site of bowel perforation, and the specific free air distribution should be regarded as complementary predictors.

Distinction between upper and lower gastrointestinal perforation: Usefulness of the periportal free air sign on computed tomography

Purpose To evaluate the usefulness of the periportal free air (PPFA) sign on computed tomography (CT) to distinguish upper from lower gastrointestinal (GI) tract perforation. Materials and methods During a 30-month period, we retrospectively analyzed abdominal CT images of 53 consecutive patients with surgically proven GI tract perforation. We divided the patients into two groups, i.e. upper and lower GI tract perforation groups. According to the distribution of free air, we divided the peritoneal cavity into supramesocolic compartment and inframesocolic compartment. We observed the presence or absence of free air in each compartment in each group. When there was free air in the periportal area, it was defined as periportal free air (PPFA) and the sign was positive. To evaluate the usefulness of the PPFA sign, we compared the PPFA sign with the falciform ligament sign and the ligamentum teres sign, both of which are well-known CT signs of pneumoperitoneum. Statistical analyses were performed with univariate and multivariate analyses using SPSS version 11.5 for significant findings among the CT signs. Results Free air was seen in supramesocolic compartment in 29 of 30 (97%) patients in the upper GI perforation group and in 17 of 23 (74%) in the lower GI perforation group. Free air in inframesocolic compartment did not show significant difference in either group ( p = .16). The PPFA sign was seen in 28 of 30 (93%) patients with upper GI tract perforation, but in only 8 of 23 (35%) patients with lower GI tract perforation ( p < .0001). The falciform ligament sign was seen in 24 of 30 (80%) patients with upper GI tract perforation and in 10 of 23 (43%) patients with lower GI tract perforation ( p = .020). The ligamentum teres sign was seen in 16 of 30 (53%) patients with upper GI tract perforation and in 2 of 23 (8%) patients with lower GI tract perforation ( p = .008). Multivariate logistic regression analysis showed that the PPFA sign was the only variable, which adjusted odds ratio of 15.5 ( p = .002). Conclusion The PPFA sign is a useful finding which can help to distinguish upper from lower GI tract perforation. When this sign is present, upper GI tract perforation is strongly suggested.

High-Dose Oral Erythromycin Decreased the Incidence of Parenteral Nutrition-Associated Cholestasis in Preterm Infants

Background & Aims: Feeding intolerance because of functional gastrointestinal dysmotility and parenteral nutrition-associated cholestasis (PNAC) are common problems in preterm, very-low-birth-weight (VLBW) infants. This double-blind, randomized, placebo-controlled study aimed to assess the effectiveness of “high-dose” oral erythromycin as a prokinetic agent in decreasing the incidence of PNAC. Two secondary end points, including the time to achieve full enteral feeding and the duration of parenteral nutrition, were also evaluated. Methods: Infants consecutively admitted to the neonatal unit were randomized to receive erythromycin (12.5 mg/kg/dose every 6 hours for 14 days) or an equivalent volume of normal saline (placebo) if they attained less than half the total daily fluid intake (<75 mL/kg/day) as milk feeds on day 14 of life. Results: Of 182 VLBW infants enrolled, 91 received erythromycin. The incidence of PNAC was significantly lower in erythromycin-treated infants (18/91) compared with placebo infants (37/91; P = .003). Treated infants achieved full enteral nutrition significantly earlier (mean, 10.1; SE, 1.7 days; P < .001), and the duration of parenteral nutrition was also significantly decreased by 10 days (P < .001). Importantly, fewer infants receiving erythromycin had 2 or more episodes of septicemia (n = 4) compared with placebo patients (n = 13, P = .03). No serious adverse effect was associated with erythromycin treatment. Conclusions: High-dose oral erythromycin can be considered as a rescue measure for VLBW infants who fail to establish adequate enteral nutrition and in whom anatomically obstructive pathologies of the gastrointestinal tract have been excluded.

Lower gastrointestinal tract perforation in preterm infants treated with dexamethasone for bronchopulmonary dysplasia

Lower gastrointestinal tract perforation in preterm infants treated with dexamethasone for bronchopulmonary dysplasia

Lower gastrointestinal tract perforation in preterm infants treated with dexamethasone for bronchopulmonary dysplasia

Two cases of ileal perforation in preterm infants treated with high-dose dexamethasone for bronchopulmonary dysplasia are described. Corticosteroid-induced gastroduodenal haemorrhage or perforation has been well documented, but less known to most clinicians is that the lower gastrointestinal tract can also be involved. Unlike previous reported cases in which affected infants deteriorated rapidly and became moribund within hours of onset of symptoms, "silent" perforations detected on routine radiograph or escaping clinical recognition until at an advanced stage can be the initial presentation. The need for greater vigilance and a low threshold for abdominal investigations are emphasised in preterm infants treated with dexamethasone.

Clinical Studies on Perforation of Lower Gastrointestinal Tract

Clinical Studies on Perforation of Lower Gastrointestinal Tract

Perforation of Lower Gastrointestinal Tract due to Colorectal Carcinoma

Perforation of Lower Gastrointestinal Tract due to Colorectal Carcinoma