İnce Bağırsak Perforasyonları
Özet
İnce bağırsak perforasyonu, bağırsak duvar bütünlüğünün tam kat bozulmasıyla lümen içeriğinin periton boşluğuna sızması sonucu gelişen ve hızlı tedavi edilmediğinde yüksek morbidite ve mortaliteye yol açan katastrofik bir tablodur. Anatomik olarak duodenum, jejunum ve ileum olmak üzere üç bölümden oluşan ince bağırsağın perforasyon patofizyolojisinde, proksimal bölgede kimyasal peritonit, yoğun bakteri barındıran distal bölgede ise bakteriyel peritonit ve sepsis riski ön plana çıkar. Etiyolojisinde iskemi (bağırsak obstrüksiyonu, mezenterik iskemi), inflamasyon (Crohn hastalığı, enfeksiyonlar, divertikülit), erozyon (neoplazmlar, peptik ülser) ve travma (penetran/künt yaralanmalar, iyatrojenik enstrümantasyonlar) olmak üzere dört ana mekanizma rol oynar. Tanı sürecinde aniden şiddetlenen karın ağrısı öyküsü ve peritonit bulguları içeren fizik muayene temel oluştururken; laboratuvarda lökositoz ve amilaz yüksekliği saptanabilir. Görüntülemede direkt grafiler serbest havayı %50-70 oranında gösterirken, bilgisayarlı tomografi (BT) perforasyonun yerini ve nedenini belirlemede altın standarttır. Tedavide hastaya acilen intravenöz sıvı, geniş spektrumlu antibiyotik ve nazogastrik dekompresyon uygulanarak medikal resüsitasyon sağlanır. Cerrahi yaklaşımda ise perforasyonun boyutuna göre primer onarım veya rezeksiyon-anastomoz tercih edilerek periton boşluğu temizlenir.
Small bowel perforation is a catastrophic condition resulting from full-thickness injury to the intestinal wall, leading to the leakage of luminal contents into the peritoneal cavity, which causes high morbidity and mortality if not treated promptly. Anatomically divided into the duodenum, jejunum, and ileum, the small intestine exhibits different pathophysiology upon perforation: proximal leaks trigger chemical peritonitis, while distal leaks involving high bacterial loads risk bacterial peritonitis and sepsis. The etiology involves four primary mechanisms: ischemia (bowel obstruction, mesenteric ischemia), inflammation (Crohn's disease, infections, diverticulitis), erosion (neoplasms, peptic ulcer disease), and trauma (penetrating/blunt injuries, iatrogenic instrumentation). Diagnosis relies on a history of sudden, severe abdominal pain and a physical examination revealing peritoneal irritation; laboratory findings may show leukocytosis and elevated amylase. While plain radiography detects pneumoperitoneum in only 50-70% of cases, computed tomography (CT) remains the gold standard for identifying the exact site and cause. Management requires immediate medical resuscitation, including intravenous fluids, broad-spectrum antibiotics, and nasogastric decompression. Surgical treatment is definitively guided by the lesion size, utilizing primary repair or bowel resection with anastomosis to clear the peritoneal contamination.
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