Spontaneous free perforation of the small intestine

In western cultures, spontaneous free perforation of the small intestine in adults is rare. The vast majority of published reports are of isolated cases. A review of 19 patients treated at the Lahey Clinic over the past 23 years is presented. All patients presented with an acute onset of peritoneal signs, and free perforation subsequently was documented at operation or at autopsy. Causes of the perforations were malignancy, six; inflammatory small bowel disease, four; combinations of radiotherapy, chemotherapy, or steroids, four; mechanical, three; and iatrogenic, two. Of the 19 patients, 15 had a history of previous abdominal surgery or recent steroid use, chemotherapy, or radiation therapy. Although the underlying disease may be of prime importance in causing perforation, these treatment modalities may be important factors in enhancing predisposition to perforation. Of the 16 patients operated on, ten had intestinal resection with primary anastomosis, and six had primary closure of the perforation. Four major complications included two deaths, and five minor complications occurred. In general, earlier operative intervention decreased mortality. A population of patients who may be at risk for small bowel perforations is identified. A review of the pertinent literature is presented. Read at the meeting of the American Society of Colon and Rectal Surgeons, San Francisco, California, May 2 to 6, 1982.     

Spontaneous free perforation of the small intestine in adults

Spontaneous free perforation of the small intestine is uncommon,especially if there is no prior history of visceral trauma.However,free,even recurrent,perforation may complicate a defined and established clinical disorder,such as Crohn’s disease.In addition,free perforation may be the initial clinical presentation of an occult intestinal disorder,such as a lymphoma complicating celiac disease,causing diffuse peritonitis and an acute abdomen.Initial diagnosis of the precise cause may be difficult,but now has been aided by computerized tomographic imaging.The site of perforation may be helpful in defining a cause(e.g.,ileal perforation in Crohn’s disease,jejunal perforation in celiac disease,complicated by lymphoma or collagenous sprue).Urgent surgical intervention,however,is usually required for precise diagnosis and treatment.During evaluation,an expanding list of other possible causes should be considered,even after surgery,as subsequent management may be affected.Free perforation may not only complicate an established intestinal disorder,but also a new acute process(e.g.,caused by different infectious agents)or a longstanding and unrecognized disorder(e.g.,congenital,metabolic and vascular causes).Moreover,new endoscopic therapeutic and medical therapies,including use of emerging novel biological agents,have been complicated by intestinal perforation.Recent studies also support the hypothesis that perforation of the small intestine may be genetically-based with different mutations causing altered connective tissue structure,synthesis and repair.     

Spontaneous free perforation of the small intestine in Crohn's disease.

Spontaneous free perforation of the small intestine is a rare but often dramatic event in the clinical course of Crohn's disease. Fifteen new cases of spontaneous free perforation of the small intestine--nine female patients and six male patients--were discovered in a series of 1000 consecutively evaluated patients with Crohn's disease seen during a period spanning 20 years, for an estimated frequency of 1.5%. Spontaneous free perforation was the presenting clinical feature of Crohn's disease in nine (60%) of the newly discovered cases. Most perforations were located in the ileum rather than in the jejunum, and there were no duodenal free perforations. One patient with extensive intestinal disease presented with concomitant free perforations of the jejunum and ileum, while a second patient had two free ileal perforations that developed independently, separated by about six years. No perforations were the result of a superimposed malignant process, ie, adenocarcinoma or lymphoma. There have been no mortalities, and the subsequent clinical course of these patients has been limited to a minority requiring corticosteroid or immunosuppressive medications, or further surgical resections.     

Involvement of the small intestine in systemic scleroderma]

INTRODUCTION: Though impairment of the gastrointestinal tract is commonly encountered in patients with systemic sclerosis, the most frequent abnormalities are esophageal and anorectal disorders. Involvement of the small intestine is also common, reaching a 40-80% prevalence. It often leads to life-threatening complications. CURRENT KNOWLEDGE AND KEY POINTS: The occurrence of small intestine impairment and its potential relationships with other organ impairment is still unknown. However, it rarely indicates the existence of the disease (10%) which remains asymptomatic for a long period. As clinical symptoms are non-specific and radiological tests (upper intestinal tract barium meal, gastrointestinal transit times of radiolabeled meal, computerized tomography scan) not sensitive enough to detect the symptoms, diagnosis of small intestine impairment is delayed, i.e., when severe complications such as malabsorption or pseudo-obstruction are present. The physiopathology of small intestine disorders is still unclear, leading to both collagenous fibrosis and atrophy of muscle fibers. As well, its treatment is difficult. FUTURE PROSPECTS AND PROJECTS: Knowledge of the mechanisms at the origin of small intestine impairment in the course of systemic sclerosis is important for the development of efficacious therapies. Manometry of the small intestine would be a useful tool to assess the various motor abnormalities that may occur in patients presenting with systemic sclerosis associated with either malabsorption or pseudo-obstruction. It would also provide a useful test in selecting patients whose treatment require somatostatin analogs.     

Free perforation of the small intestine in collagenous sprue

A 67-year-old man with celiac disease developed recurrent diarrhea, profound weakness and weight loss, with evidence of marked protein depletion. His clinical course was refractory to a strict gluten-free diet and steroid therapy. Postmortem studies led to definition of unrecognized collagenous sprue that caused ulceration and small intestinal perforation. Although PCR showed identical monoclonal T-cell populations in antemortem duodenal biopsies and postmortem jejunum, careful pathological evaluation demonstrated no frank lymphoma. Rarely, overt or even cryptic T-cell lymphoma may complicate collagenous sprue, however, small intestinal ulcers and perforation may also develop independently. The dramatic findings here may reflect an underlying or early molecular event in the eventual clinical appearance of overt T-cell lymphoma.     

Ganglioneuroma of small intestine presenting with perforation peritonitis.

We report a 42-year-old man with benign solitary small intestinal ganglioneuroma presenting with perforation peritonitis. The patient had no evidence of MEN IIB syndrome. Simple segmental resection was done; the patient is well on follow up one year later.     

Decreased beta-adrenergic responses of rat small intestine due to non-insulin-dependent diabetes

Relaxing responses to salbutamol of duodenum, jejunum and ileum isolated from alloxan-induced non-insulin-dependent diabetic rats were investigated by means of pharmacodynamic analysis using pD2 (apparent receptor affinity) and alpha E (intrinsic activity) values. beta-Adrenergic responses of these three intestinal parts of diabetic rats were found to be significantly decreased when compared to controls. The decreased responses may be attributable to a decrease in the number of beta-adrenergic receptors. The gastro-intestinal manifestations reported in diabetic patients are possibly linked to the occurrence of a decrease in beta-adrenergic receptors. Furthermore, this model seems to be useful for the investigations of gastro-intestinal complications resulting from non-insulin-dependent diabetes.     

Management of perforation due to colonoscopy

Six patients who underwent emergency laparotomy for perforations secondary to colonoscopy or polypectomy are described. Three patients had the laceration closed primary, two required colostomy, and one needed resection. When contamination is minimal and the colon is mechanically prepared, primary closure without diversion is the treatment of choice. Colostomy is rarely indicated and may lead to increased morbidity, in view of the need for closure. However, resection should be considered if suspicion of carcinoma is great. Factors that contribute to perforation include sedation, forceful introduction of the colonoscope, inadequate equipment for hemorrhage control, and prolonged application of electrocoagulation to the colonic wall. The opinions or assertions contained herein are the private ones of the authors and are not to be construed as official or reflecting the view of the Navy Department or the Naval service at large.