Intestinal Perforation


Article Author:
Jessica Hafner


Article Editor:
Omar Marar


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
2/19/2019 4:14:21 PM

Introduction

Intestinal perforation, defined as a loss of continuity of the bowel wall, is a potentially devastating complication that may result from a variety of disease processes. Common causes of perforation include trauma, instrumentation, inflammation, infection, malignancy, ischemia, and obstruction. Early recognition and prompt treatment are critical to prevent the morbidity and potential mortality of peritonitis and its systemic sequelae that result from the spillage of intestinal contents. A thorough history and physical exam, along with the aid of adjunctive studies, can help establish the diagnosis promptly and better direct therapy.[1]

Etiology

There are ultimately four mechanisms that can lead to a perforation of the intestinal tract.

  1. Ischemia (bowel obstruction, necrosis)
  2. Infection (appendicitis, diverticulitis)
  3. Erosion (malignancy, ulcerative disease)
  4. Physical disruption (trauma, iatrogenic injury)

Epidemiology

The common causes of a perforated viscus vary by patient age and geography. For instance, the most common cause in premature infants is necrotizing enterocolitis[2]; whereas in children and teenagers, appendicitis is a more common etiology. In adults, there are numerous causes without a particular gender predilection. This article reviews causes in adults in developed countries. 

Pathophysiology

As described above, four main mechanisms can lead to intestinal perforation. A thorough understanding of these mechanisms is critical to guide the appropriate workup and management.

Numerous etiologies can lead to ischemia and perforation. In the case of bowel obstruction (small or large), the physical distention of the bowel wall results in decreased perfusion.[3] This ultimately leads to full thickness wall necrosis and subsequent perforation. Bowel obstruction is more common in patients with a prior history of surgery (adhesions), but can also result from herniation and strangulation, inflammation, tumors, and foreign bodies. Decreased end organ perfusion secondary to thrombotic or embolic disease can also result in full-thickness ischemia and perforation. As expected, this is more common in the elderly, particularly those with a history of smoking, coronary artery disease, or clotting disorders.[4]

The most common infectious causes of perforation are appendicitis and diverticulitis. Appendicitis can be considered at any age; whereas, diverticulitis is more common beyond middle age.[5] Both disease processes are usually presumed to be the result of entrapped fecal material in a blind ending structure, leading to increased intraluminal pressure, stasis, and infection leading to a localized abscess or frank perforation. Inflammatory diseases of the bowel such as Crohn's disease and ulcerative colitis can also lead to perforation, especially Crohn's, which is characterized by full thickness inflammation of the bowel wall.[6]

Erosive diseases, such as the local invasion of the wall of a viscus by a tumor or ulcerative disease, also can cause perforation. In peptic ulcer disease, there is direct erosion through the layers of the bowel wall by the ulcer itself, usually due to Helicobacter pylori infection, acid overproduction, or lack of acid protective mechanisms.[7] Tumors of the gastrointestinal (GI) tract are most commonly adenocarcinomas, which arise from the mucosa, and in advanced stages can result in transmural invasion and perforation.[8]

Mechanical injury to the wall of a hollow viscus can be caused by penetrating or blunt trauma to the abdomen, or iatrogenic injury from instrumentation, for example, endoscopy.[9][10][11]

In addition to the mechanism, the variation in bacterial flora between the upper and lower intestinal tract must also be considered. For instance, upper intestinal perforations proximal to the ligament of Trietz result in significantly less bacterial contamination than distal colonic perforations. In the treatment of distal perforations, antibiotics must include gram-negative and anaerobic coverage.[12]

History and Physical

The importance of a thorough history and physical cannot be overstated and is usually sufficient to ascertain the etiology of the perforation. Almost all patients experience some element of abdominal pain, and this is usually accompanied by nausea, vomiting, decreased bowel function, or fever. Details about the symptoms including the length of time, prior episodes, recent procedures such as ERCP and colonoscopy,[13][14] and exacerbating and relieving factors can be crucial in determining the cause of the perforation. A family history of cancer and a personal history of colonoscopy can be important to determine the likelihood of occult cancer or inflammatory bowel disease.

At the time of the initial evaluation, vital signs should be promptly assessed. These can show signs of SIRS or septic shock, and an urgent need for resuscitation and treatment may be warranted. On physical examination, it is important to visually inspect the abdomen for surgical scars, visible hernias or injuries, and distension. Palpation of the abdomen usually elicits discomfort and may yield peritoneal signs which are commonly present with perforation, peritonitis, or localized abscess.

Evaluation

There are multiple imaging modalities and laboratory tests that can be useful to identify the presence and etiology of a hollow viscus perforation. Abdominal and upright chest x-rays are quick and cheap and can identify even small amounts of pneumoperitoneum. Evidence of small and large bowel obstructions can also be visualized. CT of the abdomen and pelvis, however, is the most sensitive and specific test to diagnose a perforation and ascertain the most likely etiology.[15] Disease processes such as diverticulitis, appendicitis, and bowel obstructions can be readily identified on CT. The use of intravenous contrast is recommended to aid in visualizing potential areas of ischemia. Complications from a perforation such as an abscess and secondary bowel obstruction can also be identified with CT and guide management accordingly.

In children, the preferred primary test is ultrasound given its ease and lack of radiation exposure. If necessary, secondary testing such as x-ray, MRI, and CT are reasonable options.[16]

Treatment / Management

Once the initial assessment is complete and an intestinal perforation is suspected, management can ensue. Many, but not all causes of perforated viscus, require surgery. However, all cases should be evaluated by a surgeon.[17] For both operative and nonoperative patients, initial treatment includes bowel rest, intravenous fluids, intravenous broad-spectrum antibiotics, and frequent abdominal examinations. Instances that are accompanied by sepsis and peritonitis are more likely to require surgery, whereas those that do not may amenable to conservative management.[18][1] Contained or controlled perforations can be managed conservatively with interventional radiology guided drainage of fluid collections.[19] However, the failure of conservative management with persistence of symptoms and/or development of sepsis necessitate surgical intervention. Historically, laparotomy has been the intervention of choice for acute abdomen; recently, however, laparoscopic exploration has emerged as a viable option to identify and treat the source of perforation.[20] Resection or repair of the perforated site with or without drainage and diversion is usually undertaken. Duodenal perforations, on the other hand, are generally treated with omental patch repair without resection. Risks and benefits of surgery, particularly amongst elderly patient and those with medical comorbidities, should be thoroughly discussed before offering surgical intervention.[21]

Differential Diagnosis

The differential diagnosis for the location of intestinal perforation can be narrowed down based on several factors. A thorough history and physical taking can help to diagnosis acute and chronic onsets of disease and likely location of the perforation. Importantly, being able to narrow down the likely location of the perforation along the intestinal tract helps to narrow down the intervention. Chronic discomfort related to diverticular disease, with localized peritonitis and focal, left lower quadrant abscess or free intraperitoneal air on CT, for example, can most commonly be treated conservatively.[22] However, the acute onset of crampy periumbilical pain associated with severe nausea and vomiting, and signs of small bowel obstruction on CT may require surgery. Rarely, free intraperitoneal air can be caused by benign pneumatosis intestinalis unrelated to ischemia and can be managed without surgical intervention.[23]

Prognosis

Short- and long-term prognoses of a patient with bowel perforation depend on multiple factors. For instance, age, medical comorbidities, benign or malignant cause, and tolerance to treatment are important considerations when discussing prognosis. Since surgery is commonly necessary, patients who are unable to tolerate or choose not to undergo surgery when it is required may have a worse prognosis. Morbidity can also be quite high, including delayed intraabdominal infection risk and hernia formation from surgical healing. Thromboembolism and cardiopulmonary complications are higher in older patient populations, as well as a worsened quality of life. These factors must be discussed candidly with patients and families before surgery, in the elderly especially, to determine their expectations and desires.

Complications

Complications caused by an intestinal perforation can be related to the disease process that caused it or the treatments that are enlisted. Perforation and subsequent leakage of intestinal contents can lead to peritonitis and eventually sepsis if left untreated. Adequate resuscitation and antibiotic initiation early on are important to decrease the physiologic detriment of the infection.

If necessary for control of leakage, surgery can be undertaken, and it is important to discuss potential complications of surgery with patients and their families. Risks of infection, bleeding, potential anastomotic leakage, hernia formation exist. Other risks of pulmonary complications, thromboembolic events, cardiovascular events, and possible prolonged need for ventilator support must also be discussed as well as expected recovery and possible level of function.

Deterrence and Patient Education

A frank discussion of the risks and potential complications, based on patient's current medical status, likely cause of the obstruction, and possible postoperative outcomes. Setting expectations from the surgical perspective and understanding a patient's wishes for recovery and return to expectations is imperative. Living will and other legal documentation of patient's wishes are essential when patients are unable to communicate with the care team physically. A discussion of postoperative pain management and expectations are important as well and to use multimodal therapies to decrease the need for opioids.[24]

Enhancing Healthcare Team Outcomes

Initially, the evaluation of a patient with an intestinal perforation is most commonly performed by the emergency department physician. A thorough history and physical examination can suggest the diagnosis of perforation and help initiate appropriate diagnostic studies and therapeutic modalities. Early surgical consultation is recommended, regardless of whether operative intervention is warranted. Conservative management is occasionally an option, with close clinical surveillance. If surgery is necessary, direct communication between the surgeon and the anesthesia team is imperative to avoid complications associated with the induction of anesthesia. Close nursing care and monitoring are vital to for early recognition of patient deterioration. Discharge coordination is also important to direct the plan for discharge and arrange for post-hospital needs and care.


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

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Intestinal Perforation - Questions

Take a quiz of the questions on this article.

Take Quiz
A patient is admitted to the hospital with abdominal pain and fever. Workup is consistent with colonic perforation with spillage of colonic contents. Antibiotic therapy is initiated prior to surgical intervention. Which organisms are commonly found in the colon and must be accounted for during antibiotic coverage?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 73-year-old female from a nursing home is admitted with a diagnosis of diverticulitis. The CT done at another hospital revealed an inflamed sigmoid colon. She had a fever and abdominal pain for 2 days. Her WBC count was 22 cells/mm3. She was started on IV antibiotics and administered IV fluids. Over the ensuing few days, her WBC count started to come down. She had no nausea, vomiting, or fever. Her abdominal exam revealed guarding and tenderness in the left quadrant. She developed a coughing spell, and an upright chest x-ray was done the following day. It revealed free air under the left diaphragm, some air-fluid levels in the large bowel, and an ileus pattern in the small bowel. What is the best next step in management?

(Move Mouse on Image to Enlarge)
  • Image 37 Not availableImage 37 Not available
    Contributed by S. Dulebohn, M.D.
Attributed To: Contributed by S. Dulebohn, M.D.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65-year-old female with a history of breast cancer presents to the emergency department with complaints of diffuse abdominal pain, vomiting, and bloating. She has had some mild discomfort with nausea and vomiting for the last two days, but it became much worse today. She had minimal flatus over the previous 24 hours, and her last bowel movement was three days ago. An abdominal x-ray series shows marked dilated small bowel and minimal air in the colon. She is admitted with a diagnosis of small bowel obstruction, and an NG is placed. The next day her status deteriorates, she complains of more pain and her heart rate is now 115 bpm with a temperature of 102.4 F. A new x-ray is obtained, showing free air under the diaphragm, and exam shows rebound tenderness throughout the abdomen. What is the best next treatment?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 12-year-old female presents to the emergency department with 5 days of worsening right lower quadrant abdominal pain. She has had a fever of 101.7 F at home, heart rate of 96 bpm, and otherwise, her vitals are normal. She has focal discomfort in the right lower quadrant without rebound tenderness and is asking for food. She is not sexually active and has not had menarche. An ultrasound of the right lower quadrant shows a complex fluid collection near the cecum, with a fecalith present in the collection. What is the best immediate intervention for this problem?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Intestinal Perforation - References

References

Tanner TN,Hall BR,Oran J, Pneumoperitoneum. The Surgical clinics of North America. 2018 Oct;     [PubMed]
Titos-García A,Aranda-Narváez JM,Romacho-López L,González-Sánchez AJ,Cabrera-Serna I,Santoyo-Santoyo J, Nonoperative management of perforated acute diverticulitis with extraluminal air: results and risk factors of failure. International journal of colorectal disease. 2017 Oct;     [PubMed]
Nimmagadda N,Matsushima K,Piccinini A,Park C,Strumwasser A,Lam L,Inaba K,Demetriades D, Complicated appendicitis: Immediate operation or trial of nonoperative management? American journal of surgery. 2019 Jan 3;     [PubMed]
Rich BS,Dolgin SE, Necrotizing Enterocolitis. Pediatrics in review. 2017 Dec;     [PubMed]
Krüger PC,Mentzel HJ, [Radiological evaluation of acute abdomen in children]. Der Radiologe. 2018 Oct 26;     [PubMed]
Paolantonio P,Rengo M,Ferrari R,Laghi A, Multidetector CT in emergency radiology: acute and generalized non-traumatic abdominal pain. The British journal of radiology. 2016;     [PubMed]
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]
Pavlović-Calić N, [Ulcerative colitis and Crohn's disease]. Medicinski arhiv. 2003;     [PubMed]
Špičák J,Kučera M,Suchánková G, Diverticular disease: diagnosis and treatment. Vnitrni lekarstvi. 2018 Summer;     [PubMed]
Lim S,Halandras PM,Bechara C,Aulivola B,Crisostomo P, Contemporary Management of Acute Mesenteric Ischemia in the Endovascular Era. Vascular and endovascular surgery. 2018 Oct 25;     [PubMed]
Kavitt RT,Lipowska AM,Anyane-Yeboa A,Gralnek IM, Diagnosis and Treatment of Peptic Ulcer Disease. The American journal of medicine. 2019 Jan 3;     [PubMed]
Biffl WL,Leppaniemi A, Management guidelines for penetrating abdominal trauma. World journal of surgery. 2015 Jun;     [PubMed]
Song WC,Lv WW,Gao XZ, Iatrogenic Gastrointestinal Perforation Following Therapeutic Endoscopic Procedures: Management and Outcome. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 2017 Sep;     [PubMed]
Wada K,Takeuchi N,Emori M,Takada M,Nomura Y,Otsuka A, Two Cases of Pneumatosis Cystoides Intestinalis With Intraperitoneal Free Air. Gastroenterology research. 2017 Jun;     [PubMed]
Li D,Baxter NN,McLeod RS,Moineddin R,Nathens AB, The Decline of Elective Colectomy Following Diverticulitis: A Population-Based Analysis. Diseases of the colon and rectum. 2016 Apr;     [PubMed]
Zhao N,Li Q,Cui J,Yang Z,Peng T, CT-guided special approaches of drainage for intraabdominal and pelvic abscesses: One single center's experience and review of literature. Medicine. 2018 Oct;     [PubMed]
Bill JG,Smith Z,Brancheck J,Elsner J,Hobbs P,Lang GD,Early DS,Das K,Hollander T,Doyle MBM,Fields RC,Hawkins WG,Strasberg SM,Hammill C,Chapman WC,Edmundowicz S,Mullady DK,Kushnir VM, The importance of early recognition in management of ERCP-related perforations. Surgical endoscopy. 2018 May 16;     [PubMed]
Wang H,Li A,Shi X,Xu X,Wang H,Wang H,Yu E, [Diagnosis and treatment of iatrogenic colonoscopic perforation]. Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery. 2018 Jun 25;     [PubMed]
Siragusa G,Gelarda E,Epifanio E,Geraci F,Geraci G, [Video laparoscopy in abdominal emergencies]. Minerva chirurgica. 1999 Apr;     [PubMed]
Tengberg LT, Perioperative treatment of patients undergoing acute high-risk abdominal surgery
. Danish medical journal. 2018 Feb;     [PubMed]
Fan YC,Peery AF, Therapeutic management of acute uncomplicated diverticulitis. Minerva gastroenterologica e dietologica. 2017 Jun;     [PubMed]
Ko BM, [Small Bowel Tumors and Polyposis: How to Approach and Manage?] The Korean journal of gastroenterology = Taehan Sohwagi Hakhoe chi. 2018 Dec 25;     [PubMed]
Vanaclocha-Espi M,Ibáñez J,Molina-Barceló A,Valverde-Roig MJ,Pérez E,Nolasco A,de la Vega M,de la Lastra-Bosch ID,Oceja ME,Espinàs JA,Font R,Pérez-Riquelme F,Arana-Arri E,Portillo I,Salas D, Risk factors for severe complications of colonoscopy in screening programs. Preventive medicine. 2019 Jan;     [PubMed]
Abualnadi N,Dizon AM,Schiff L, Opioid Adjuncts: Optimizing Opioid Therapy With Nonopioid Medications. Clinical obstetrics and gynecology. 2019 Jan 4;     [PubMed]
Bower KL,Lollar DI,Williams SL,Adkins FC,Luyimbazi DT,Bower CE, Small Bowel Obstruction. The Surgical clinics of North America. 2018 Oct;     [PubMed]
Ho VP,Schiltz NK,Reimer AP,Madigan EA,Koroukian SM, High-Risk Comorbidity Combinations in Older Patients Undergoing Emergency General Surgery. Journal of the American Geriatrics Society. 2018 Dec 2;     [PubMed]
Cooper Z,Lilley EJ,Bollens-Lund E,Mitchell SL,Ritchie CS,Lipstiz SR,Kelley AS, High Burden of Palliative Care Needs of Older Adults During Emergency Major Abdominal Surgery. Journal of the American Geriatrics Society. 2018 Nov;     [PubMed]
Grotelüschen R,Bergmann W,Welte MN,Reeh M,Izbicki JR,Bachmann K, What predicts the outcome in patients with intestinal ischemia? A single center experience. Journal of visceral surgery. 2019 Feb 8;     [PubMed]
Low ZX,Bonney GK,So JBY,Loh DL,Ng JJ, Laparoscopic versus open appendectomy in pediatric patients with complicated appendicitis: a meta-analysis. Surgical endoscopy. 2019 Feb 25;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of PA-Hospital Medicine. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for PA-Hospital Medicine, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in PA-Hospital Medicine, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of PA-Hospital Medicine. When it is time for the PA-Hospital Medicine board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study PA-Hospital Medicine.