Bowel Perforation


Article Author:
Mark Jones


Article Editor:
Christopher Zabbo


Editors In Chief:
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James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
2/22/2019 4:12:52 PM

Introduction

Bowel perforation results from insult or injury to the mucosa of the bowel wall resulting from a violation of the closed system. This exposes the structures within the peritoneal cavity to gastrointestinal contents. Bowel perforation can be secondary to many factors, most commonly inflammation, infection, obstruction, trauma, or invasive procedure. Patients presenting with abdominal pain and distension, especially in the appropriate historical setting, must be evaluated for this entity as delayed diagnosis can be life-threatening due to the risk of developing infections such as peritonitis. Management includes stabilizing the patient while making the surgical consultation. Even appropriately managed, bowel perforation can lead to increased morbidity and mortality from post repair complications such as adhesions and fistula formation.[1]

Etiology

Bowel perforations can be separated based on their anatomic locations, but many causes are overlapping:

Small bowel: Erosion from duodenal ulcerations, tumor, infection or abscess, Meckel's diverticulum, hernia with strangulation, IBD/colitis, mesenteric ischemia, foreign body, obstruction, medication/radiation related, iatrogenic, blunt or penetrating abdominal trauma

Large bowel: Tumor, diverticulitis, infection or abscess, colitis, foreign body, obstruction, volvulus, iatrogenic, blunt or penetrating abdominal trauma[2]

Epidemiology

In children, bowel perforation is most likely to follow abdominal trauma. The incidence of bowel perforation is 1% to 7% in pediatric trauma patients.

In adults, ulcerative disease represents the most common etiology of bowel perforation, with duodenal ulcers causing 2- to 3-times the rate of perforation than gastric ulcers do. Perforation secondary to diverticular disease represents up to 15% of cases. In the geriatric population, perforated appendicitis represents the most common cause of perforation.

The overall incidence of perforation from colonoscopy has been reported on average around 2% with higher rates during colonoscopy requiring therapeutic interventions.[3]

Pathophysiology

Bowel perforation results from a violation of the mucosal layers of the intestinal tract resulting in the spilling of air and digestive contents into the peritoneal cavity. These contents can range from highly acidic gastric contents in more proximal bowel perforation, to fecal material from a more distal area of perforation. Areas of partial erosion can become full-thickness tears over time, or a specific insult can cause spontaneous rupture. This means that pain may be gradual or sudden, but it usually progresses in severity. Feelings of abdominal distension and signs of abdominal muscular rigidity representing peritonitis may develop.[4]

History and Physical

Historical factors are exceptionally useful when making the diagnosis of bowel perforation. Lower chest or abdominal pain after recent instrumentation from endoscopy/colonoscopy or laparoscopic/open surgical procedure should raise high suspicion for this diagnosis. Previous medical, surgical, and social history to include a history of a prior hernia, bowel obstruction, known or suspected malignancy, foreign body insertion or ingestion, abdominal trauma, and regular medication use (NSAIDs, corticosteroids, and chemotherapy are the most common) should be elicited. The patient is likely to complain of pain and distension in the abdomen that is worsening. Patients may describe a pain-free period before the worsening of their pain, and this can represent decompression of an inflamed or injured area directly following the perforation.

Diffuse spillage of air and intestinal contents may make the pain difficult to localize during focused abdominal examination, but palpation is likely to identify tenderness. Patients usually have nausea and vomiting. As the situation progresses, peritoneal signs such as guarding and rigidity may develop. Vital signs may be normal, especially in early presentation; however, tachycardia, tachypnea, fever, and other signs of sepsis are likely to develop.[5]

Evaluation

Evaluation of a patient with suspected bowel perforation must focus on a thorough history and physical exam. Laboratory and radiographic workup should mimic that of any patient presenting with abdominal pain. Labs may include a complete blood count, basic metabolic panel, liver function tests, lipase, amylase, and inflammatory markers such as C-reactive protein. However, common findings such as a leukocytosis or elevated amylase or elevated CRP level are non-specific for diagnostic purposes.

Upright chest radiography (50% to 70% sensitive) can be helpful in detecting free intraperitoneal air below the diaphragm suggestive of bowel perforation. The likelihood of diagnosing free air is higher if the patient has been sitting upright for at least 15 minutes prior to the film. Lateral decubitus films can be used if the patient is unable to sit upright.

Computer tomography (CT) scan is the modality of choice for not only diagnosing free air but also for localization of the site of perforation. A CT scan can also help to determine if the area has spontaneously walled off or if there has been a progression to abscess formation or if there is an inflammatory involvement of surrounding structures.

Ultrasound has been used to localize gas collections suggestive of perforation. However, this modality is especially dependent on the experience level of the operator.

Surgical consultation should be pursued early in any patient with abdominal pain and signs of clinical deterioration.[6]

Treatment / Management

Treatment of a patient with suspected bowel perforation involves establishing intravenous (IV) access and initial hemodynamic management, especially if the patient presents with any signs or symptoms concerning for sepsis or shock. Initiation of broad-spectrum antibiotics aimed at gram-negative and anaerobic organisms is essential and should be initiated early. For suspected distal perforation of the intestinal tract, nasogastric decompression should be performed, and the patient made NPO (nothing by mouth).

If the patient is hemodynamically stable and there is no concern for peritonitis, such as in the case of a spontaneously contained perforation, the option for non-surgical management with antibiotics and observation may be pursued in consultation with the surgical team.

Localized abscess formation may be amenable to drainage by interventional radiology.

Most cases will progress to require direct investigation via laparoscopic or open (laparotomy) exploration. This allows for primary repair as well as infection control measures. Minimally invasive exploration and repair are often successfully performed. However, it should be noted that exploratory laparotomy is the surgical intervention of choice for any signs of clinical deterioration or hemodynamic instability.[7]

Prognosis

The patient’s medical state before the perforation occurs best predicts general prognosis. In patients without multiple comorbidities, the outcomes are more favorable. Management of the underlying etiology is key to preventing further episodes.[8]

Complications

Early

Hemodynamic instability leading to hypoperfusion, shock, and multi-organ system failure, infection (whether local abscess formation, peritonitis, or systemic bacteremia)

Late

Delayed wound healing, postoperative adhesions leading to bowel obstruction, fistula formation, and hernias[6]

Postoperative and Rehabilitation Care

Postoperative care should include a continued focus on hemodynamic resuscitation with monitoring of expected urine output, electrolyte repletion, infection monitoring and control measures, pain management, and nutritional considerations.[9]

Consultations

Emergency room consultation may include radiology, internal medicine, and most importantly surgery. In the long term, consultation should be aimed at the specialist team that will assist in the management of the underlying pathology that leads to the perforation. This may include gastroenterology to assist in long-term surveillance and chronic disease management strategies in cases of inflammatory bowel disease or diverticulitis, oncology for the management of malignancy, or the primary care team for assistance with chronic medication management.[10]

Enhancing Healthcare Team Outcomes

Early and correct diagnosis is essential. This involves recognition of a patient with an acute abdomen, proper resuscitation with antibiotics, crystalloid fluids, pain control and correction of other concurrent conditions. The nursing staff must closely monitor patients for clinical deterioration, including hypotension. Proper treatment must involve the surgical team at presentation to ensure expedient surgical intervention which is the best predictor of improving morbidity and mortality.[11]


  • Image 37 Not availableImage 37 Not available
    Contributed by S. Dulebohn, M.D.
Attributed To: Contributed by S. Dulebohn, M.D.

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Bowel Perforation - Questions

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Which of the following suggests a perforation of the ileum?



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What is the best x-ray to order to assess free air in the abdomen from a perforated viscus?



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A patient presents with complaints of generalized abdominal discomfort, fever, and confusion. Laboratory and radiological workup reveal that the patient has free air under the diaphragm and leukocytosis. IV fluid resuscitation is initiated, and the patient is scheduled for the operating room. Before surgical intervention, which of the following treatments is indicated?



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A patient presents with sudden generalized abdominal pain and signs of sepsis. X-rays show pneumoperitoneum. What location of the bowel if perforated would lead to the greatest degree of infection?



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Bowel Perforation - References

References

Long B,Robertson J,Koyfman A, Emergency Medicine Evaluation and Management of Small Bowel Obstruction: Evidence-Based Recommendations. The Journal of emergency medicine. 2018 Dec 6     [PubMed]
Ugwu AU,Kerins N,Malik M, Traumatic small bowel perforation in a case of a perineal hernia. Journal of surgical case reports. 2018 Dec     [PubMed]
Garrido Serrano A,Fernández Álvarez P, A foreign body in the small bowel: a rare entity of acute abdomen. Revista espanola de enfermedades digestivas : organo oficial de la Sociedad Espanola de Patologia Digestiva. 2018 Nov 19     [PubMed]
Dhadlie S,Mehanna D,McCourtney J, Pneumatosis intestinalis a trap for the unwary: Case series and literature review. International journal of surgery case reports. 2018     [PubMed]
Foran AT,Nason GJ,Rohan P,Keane GM,Connolly S,Hegarty N,Galvin D,O’Malley KJ, Iatrogenic Bowel Injury at Exchange of Supra-Pubic Catheter Irish medical journal. 2018 Apr 19     [PubMed]
Ruscelli P,Renzi C,Polistena A,Sanguinetti A,Avenia N,Popivanov G,Cirocchi R,Lancia M,Gioia S,Tabola R, Clinical signs of retroperitoneal abscess from colonic perforation: Two case reports and literature review. Medicine. 2018 Nov     [PubMed]
Sullivan BJ,Kim GJ,Sara G, Treatment dilemma for survivors of rituximab-induced bowel perforation in the setting of post-transplant lymphoproliferative disorder. BMJ case reports. 2018 Dec 13     [PubMed]
Guzman-Pruneda FA,Husain SG,Jones CD,Beal EW,Porter E,Grove M,Moffatt-Bruce S,Schmidt CR, Compliance with preoperative care measures reduces surgical site infection after colorectal operation. Journal of surgical oncology. 2019 Mar     [PubMed]
Li S,Cheng L,Li Y,Ning L,Yu Z,Wang P,Zhou X,Ren J, [Analysis of high risk factors for acute complex appendicitis in adults]. Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery. 2018 Dec 25     [PubMed]
Hsu TC,Huang TM,Yang YC, A surgeon's help with the management of bowel problems related to gynecology is truly needed - comparison of two periods spanning 24 years. Taiwanese journal of obstetrics & gynecology. 2012 Dec     [PubMed]
Cappell MS, Universal lessons learned by a gastroenterologist from a deaf and mute patient: the importance of nonverbal communication and establishing patient rapport and trust. American annals of the deaf. 2009 Summer     [PubMed]

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