GI Perforations

Gastrointestinal (GI) perforations are a rare but potentially dangerous complication that can occur anywhere in the GI tract — in the esophagus, in the stomach, or in the intestines. certain types of perforations are more common and may occur in specific patient cohorts.

American Society for Gastrointestinal Endoscopy (ASGE) spokesperson Mark B. Pochapin, MD, is the director of The Jay Monahan Center for Gastrointestinal Health; the chief of gastrointestinal endoscopy at New York-Presbyterian Hospital; and an associate professor of clinical medicine at Weill Medical College of Cornell University in New York.

“Perforations are rare complications of endoscopy,” he observes. “They occur when the scope breaks through the wall of the bowel. Large polypectomies may increase the risk of perforation at the site of the polyp removal.”

Patients with a colonic perforation will typically develop severe abdominal pain and a more tense abdomen soon after the procedure, he adds. “They are most commonly diagnosed by abdominal X-ray (looking for free air), computed tomography (CT) or a gastrograffin swallow under fluoroscopy.”

Gastrograffin is a radio-contrast agent used in medical imaging. It is sometimes used as an alternative to barium sulfate for imaging the gastrointestinal tract. Indications for use as an alternative to barium sulfate are in patients with allergies to barium or shellfish, or in cases where the contrast dye might leak into the abdominal cavity. Gastrograffin is available both as a liquid drink, and as an enema.

Pochapin notes that tiny perforations may be capable of closing on their own with antibiotics and conservative treatment. However, larger perforations will require surgery to fix them. “The nurse or technician must watch the patient closely during and after the procedure to assure that they are comfortable when discharged,” he comments.

“There are three main causes of GI perforations,” says Deborah Nagle, MD, chief of colon and rectal surgery at Beth Israel-Deaconess Medical Center in Boston and chair of the public relations committee for the American Society of Colon and Rectal Surgeons (ASCRS). “These include the following: mechanical (the scope literally tears the wall of the colon, either from too much force being used or at a diseased segment of bowel); pneumatic (overdistension with air); and therapeutic (after removing a polyp or controlling bleeding).”

Signs and symptoms of GI perforations can vary, depending on the type and timing of the perforation. “Most patients complain of severe abdominal pain, but not immediately after the procedure,” Nagle says. Most commonly, the pain will develop within 24 hours, although delayed perforations at a week to ten days are possible.

“It is important that [this potential delay] is recognized,” she adds. “And persistent abdominal distension may be another sign of perforation. Fever, tachycardia, and elevated white blood cells after endoscopy are not normal and may be signs of perforation.”

When patients complain of abdominal pain, it will typically be rated as 8 to 10 or higher, Nagle says. However, she notes, “A patient who has a contained perforation or microperforation can have less severe pain, though.”

Diagnosis and treatment differ based on the severity of the perforation. “We should be vigilant in evaluating patients who complain of excessive pain, who do not get pain relief with passing gas, or who develop pain hours after the procedure when they were initially well,” Nagle cautions. “The diagnosis is suspected by history and physical exam. Rebound tenderness after colonoscopy is not normal. A plain upright film of the abdomen may show free air. However, a plain film may be normal in the setting of a small or localized perforation. A CT scan with oral contrast is the best test for evaluation of a patient with suspected perforation.”

Rebound tenderness, she adds, is an examination finding in which the patient experiences less abdominal pain when you push into the abdomen than when you release the pressure. “This is suggestive of peritonitis, but probably beyond the scope of nursing practice,” and would more likely be diagnosed by a physician, she continues.

If the patient does undergo diagnostic imaging to diagnose a suspected perforation, it is important to remember that the traditional barium contrast agent may be problematic. First, says Nagle, “We don’t want to give barium to people with suspected perforations, because it can cause quite a mess in the abdominal cavity. And CT scans can’t be done when barium is given. A special CT contrast is given, and the one chosen is based on institutional preference.”

Historically, the management of perforation was always operative. However, she adds, medical professionals now know that small perforations in well-prepared bowels can sometimes be managed non-operatively. “The clinically stable, non-toxic patient may be treated with NGT, IVF, IV ABX and bowel rest, and serial abdominal exams,” she says. “If there is clinical deterioration, surgery is indicated. Surgery is indicated for patients with peritonitis after perforation, or with an underlying disease process (i.e., cancer) that would necessitate intervention.”

Although the nurse or technician may not be involved in diagnosing the perforation, it is important for them to be ever-watchful in following up with the patient. “Be vigilant in evaluating patients’ complaints of abdominal pain after endoscopy, especially within the first 24 hours when follow-up phone calls are often made. Keep the patient NPO after the procedure if there is concern at the time of a complex endoscopy. Bring the patient’s complaints to the attention of the endoscopists as soon as possible,” Nagle adds.

Although GI nurses would typically see perforations that are scope-related, there are other triggers for this complication. “The other causes of perforation are the main GI pathologies that you would expect: diverticulitis, ulcer, inflammatory bowel disease, cancer, or toxic megacolon. These patients, when acute, do not usually have endoscopy as part of their care,” she notes.

Deborah D. Proctor, MD, associate professor of medicine for Yale University School of Medicine and spokesperson for the American Gastroenterological Association, agrees, saying, “The most common time perforations occur will be during a procedure, most commonly during a colonoscopy. Usually, these occur when the endoscopist is taking off a large polyp, or if the patient has a tortuous sigmoid colon and the scope is winding its way around. Those are procedural complications.”

The other times when a GI nurses might see perforations, she says, are because a patient is sick with diverticulitis and has a perforation and abscess with that. It can also occur with Crohn’s disease, malignancies, or with peptic ulcer diseases.

“Patients will present with abdominal pain (always), usually fever and an elevated white count, and will be looking very sick,” Proctor adds. “They’ll be tachycardic (a raised heartbeat), and they might be a little hypotensive, because they have become septic from bacteria in the colon that have escaped into the bloodstream.”

The first step, she cautions, is to be aware of the possibility of perforation. Second, she says, look for abdominal pain. Third, she says, the nurse should check the patient’s temperature and vital signs (blood pressure, pulse, heart rate). To make a diagnosis, it may be necessary to do a CT scan. Typically, the patient will be placed on antibiotics. If the perforation is large, there is a risk of peritonitis or abscess formation, and the patient will be given broad-spectrum antibiotics, such as Cipro and Flagyl.

Although they may not occur frequently, GI perforations are a known risk in endoscopy patients, and nurses and techs can support their physicians by remembering that this complication can occur, and remaining ever watchful.