Perforation

Classification of GIT perforation :

- Non trauma perforation : ulcus ventriculi, typhoid and appendicitis
- Trauma perforation ( sharp and blunt)
-
Pathophysiology
Irritation of peritoneum cavity by gastric acid or blood cause a chemical peritonitis. When a
cause not resolved it will grow to bacterial peritonitis gradually. Bacteri on peritoneal cavity
stimulate a migration of acute inflammatory cell. Omentum and viscera tend to localized an
inflammation.if not handled properly it became a bacteriemia, sepsis, multiorgan failure until syok.

clinical manifestation
clinical manifestation of GIT perforation are suddenly pain in the abdomen,
nausea,vomit,defance musculer, ileus paralitic, and syok. Patognomonic manifestation is decrease or
disappear liver dullness. Free air sudiaphragma and liver on radologic examination.

Perforation stage
according MOYNIHAN (1931) :
Stage I.
Severe pain and defance muscular.because gastric acid and food through to peritoneal cavity, so it
stimulate the peritoneum. Naussea and vomitus (+). Cold skin, normal temperature, increase
frequency of respiratory and shallow. Costal respiratory. Normal or increase pulse. Normal blood
pressure, if sistol < 100 mmHg, the prognosis was bad.
Abdomen auscultation : Bowel sound (-)
Stage II (2 - 6 hours after perforation)
Worsening pain, warm skin, board like abdominal rigidity, costal respiration.
Stage III (6-12 hours after perforation)
Peritonitis generalisata (because invasion of bacteri to the peritoneum cavity). A complain
worsening, such abdomen more distended, worsening pain. Increase of temperature, tachycardia,
shallow and increase of respiratory.
Differential diagnose
- Ulcus ventriculi perforation
Form anamnesis we can ask that a oatient had a history of ulcus perforation. Severe pain
espescially on epigastrium, left from midline on ulcus duodeni. But epigastric pain can disguise
with rigid abdominal wall to prevent viscera from palpation. Free air from gaster can in to
cavity between liver and abdominal wall it cause a disappear of liver dullness. Bowel sound can
decrease or disappear. If the treat its late, it can cause a massiv air in to peritoneal cavity, its
bring a abdomen distension and diffuse tympani on percussion. With 3 position abdomen
examination it will appear a free air subdiaphragma.

Prognosis
If surgery and broad spectrum antibiotics quickly done the prognose dubia ad bonam. Late
diagnose, surgery adn antibiotics can worse the prognosis became dubia ad malam.

Therapy
The right therapy for perforation is surgery, before that we must cure the syok. On ventriculi
perforation :
a. If the patient overcome is good, di the gaster primary resection and do the
gastroenterostomosis.
b. If the patient overcome is bad, do the wound ecsision and closet he hole correctly. Continue
with H.pylori eradication.a surgery can be done if a medicine not effective, do a vagotomy
and piloroplasty.
So with thypoid perforation can be done with laparotomy, ecsision the side of the wound and
close it. On apendicitis perforata do the laparotomy appendectomy and wash the abdominal
cavity until clean.

Peritonitis
 Peritonitis is inflammation response or supuratif from peritoneum due the irritation.
Peritonitis occurred after the perforation, inflammation, infection, or gastrointestinal ,genitourinaria
ischemic trauma. Classification of peritonemun are primary and secondary. Primary peritonitis
happened when microbacterial invasion steril cavum peritoneum from hematogen ways from source
infection or direct. Commonly this process happen to ascites patient or in peritoneal dialysis therapy.
The therapy are antibiotics, remove all medical things in the body such as peritoneal dialysis
catheter, peritoneovenosous shunt) to take out the cause of infection. Secondary peritonitis happen
because peritoneal cavity contamination during perforation or heavy inflammation and infection of
intraabdomenm(ex : appendicitis, GIT perforation or diverticulitis). The therapy is control a infection
source with resection of the organ, debridement, antimicroba for aerob and anaerob bacteri.
Diagnose :
1. Anamnesis
2. Physical examination :
a. Vital sign : Tachycardia, tachypnoe, fever,syok
b. Abdomen :
Inspection : trauma sign, abrasi sign, echymosis, distension, abdominal movement
within respiration( common the patient lay still, sometimes knee flexi)
Percussion : pain,liver dullness
Palpation : pain,defance muscular
Auscultation: bowel sound (-) in peritonitis generalisata
3. examination :
a. Erect photo thorax (PA) :the important examination Free air subdiaphragma (70%)
b. BNO supine & tegak
Free air subdiaphragma (pneumoperitoneum) 50 75% cases
Ligamentum falciforme (oblique structure from RUQ to umbilicus)
Air-fluid level : hydropneumoperitoneum / pyopneumoperitoneum (erect BNO)
Soluble contras sper oral via nasogastric tube (rutine procedure for whom decline an
operation) : detected intraperitoneal leakage.
c. USG abdomen
d. CT scan abdomen
e. Laparoscopy
Discussion
 The patient was diagnosed peritonitis e.c gastric perforation, because from anamnesis he
felt pain on all of the regio of the abdomen happened suddenly, continously and worsening by
moving.
From local physical examination :
At regio Abdomen :
Flat, looks distended,
Darm contour (-), Darm Steifung (-)
Bowel sound (+) weak, pain on percussion
Liver dullnes (-),defance muscular (+)
From Laboratory findings : ( 2 june 2015)
Hematology : Leucocytosis : 25900
Plain abdomen photo: 2 position : free air rght sub diaphragm (+), increase of air
distribution -> peritonitis ec suspect gastric perforation
Patient came to RSK on 2nd june 2015 08.00 am,and then done a plain abdomen photo, a
result was free air right sub diapragm. At Emergency room patient had a fasting, using a NGT for
decompression,and consul to the surgeon.
The next day the patient had a laparotomy eksploration with indication peritonitis,and
during an operation that the antrum was perforated with size 0,5cm, ecsisi a round a wound, gastric
wpund was closed by omental patch.
The prognose was dubia ad bonam,because a cause of peritonitis was handle by surgery.
After an operation the patient had a strong antibiotic.

DAFTAR PUSTAKA
Arif Mansyur, dkk. 2000. Perforasi, dalam: Bedah Digestif. Kapita Selekta Kedokteran. Media
Aesculapius. FK UI. Jakarta. h. 320-321

Jones S., Claridge.,2004. Acute Abdomen, in: Sabiston Textbook of surgery17th edition. Philadephia:
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Mercer D., Robinson E., Stomach,in: Sabiston Textbook of surgery17th edition. Philadephia: Alseviere
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