Perforations du tube digestif

Perforations of the gastrointestinal tract are generally considered to include those freely opening into the peritoneal cavity (free perforations), mainly involving the abdominal and pelvic segments. This classical presentation resulted from the very limited means once available to explore gastrointestinal perforations, i.e. when it was routine to order an acute abdomen x-ray to search for a pneumoperitoneum or possibly a swallowed radiopaque foreign body. Since the advent of computed tomography (CT) and broader indications for the acute abdomen, progress in our understanding of the epidemiology and pathophysiology of “contained” perforations (that means that contiguous intestino-peritoneal structures such as mesentery, great omentum, visceral peritoneum… are able to wall off the area of inflammatory reaction due to mural full-thickness-hole created by perforation) .The capacity of CT scan to easily identify these localized peritonitis and to precise their exact significance has totally transformed the positive and etiologic diagnosis of these conditions. At the present time, most acute abdomens can be safely managed without open surgery, thus enabling a more optimal approach in terms of the best therapeutic option and schedule. Improved management practices for these conditions, dominated by the perforative complications of diverticular sigmoid disease, have totally revolutionized early explorations of acute abdominal syndromes. In routine practice, open surgery can generally be safely avoided, making emergency exploratory laparotomy an almost extinct species in these acute situations. It is therefore important to recognize inaugural pain and fever symptoms caused by perforations largely or completely “contained” by adjacent intestinal or mesenteric structures. The CT scan is the key examination, allowing accurate visualization of inflammatory reactions of adjacent structures (mediastinum for esophageal perforations, abdominal or pelvic mesenterico-intestinal structures for perforations of other segments). The observed alterations may be located in the immediate proximity of the perforation or on the contrary very remote, resulting from the dissemination of intra- and/or retroperitoneal air-fluid mixtures or fluid collections that must be carefully identified and linked to their cause. The CT scan is essential to visualize etiologies such as sharp swallowed foreign bodies still in an endoluminal position, inflammatory processes related to tumor, trauma, or iatrogenic events (surgery, complicated endoscopic or radiological interventional procedures).