Bowel Perforation (Perforated Bowel)

What happens when the bowel perforates

The intestine is normally a sealed tube. A perforation lets air, digestive juices, food and stool leak into the peritoneal cavity, the space around the abdominal organs. This causes:

• chemical irritation, especially from stomach acid in a perforated ulcer
• bacterial infection, particularly from the colon, which is packed with bacteria
• peritonitis: inflammation of the abdominal lining
• sepsis and septic shock as infection spreads to the bloodstream

Sometimes the body walls off a small perforation, forming an abscess instead of widespread peritonitis.

Symptoms

• sudden, severe abdominal pain, often the worst the person has felt
• a rigid, board-like abdomen and pain on any movement, coughing or bumping
• people often lie very still with knees drawn up
• fever and chills
• nausea, vomiting and a swollen belly
• fast heart rate, fast breathing, low blood pressure
• pain in the shoulder tip from irritation of the diaphragm
• confusion in older adults

Older adults, people on steroids, and people with weakened immune systems may have much milder pain, which can delay diagnosis.

Causes

Steroids and some biologic and cancer medicines raise the risk and can hide symptoms.

Diagnosis

• Examination: tenderness, guarding and rigidity of the abdominal wall.
• Blood tests: white blood cells, CRP, lactate, kidney function, blood cultures.
• Upright chest X-ray: may show free air under the diaphragm.
• CT scan of the abdomen and pelvis: the most accurate test, showing free air, fluid, abscesses and often the site and cause.

Treatment

Immediate care

• nothing by mouth
• IV fluids and correction of electrolytes
• broad-spectrum IV antibiotics as soon as possible
• pain relief and anti-sickness medicine
• a nasogastric tube to decompress the stomach

Surgery

Most perforations need emergency surgery, by keyhole (laparoscopic) or open approach:

• Perforated ulcer: the hole is closed, often with a patch of fatty tissue (omental patch), followed by treatment of H. pylori and acid suppression.
• Colon perforation: the damaged segment is removed. The surgeon may join the ends or bring the bowel out as a stoma (such as a Hartmann's procedure), which can often be reversed months later.
• Small bowel perforation: repair or resection of the segment.
• The abdomen is washed out to remove contamination.

Non-surgical management

Selected patients with small, contained perforations (for example, a walled-off diverticular perforation with a small abscess) and stable vital signs may be treated with antibiotics and CT-guided drainage, with close monitoring. Some colonoscopy perforations can be closed with clips during the procedure.

Complications and outlook

Possible complications include abscess, wound infection, anastomotic leak, prolonged ileus, organ failure and the need for a stoma. Survival depends on age, the cause, the degree of contamination and how quickly treatment starts. Perforations treated within hours have a much better outcome than those diagnosed late; mortality is substantially higher in older adults with fecal peritonitis and sepsis.

Frequently asked questions

What are the symptoms of a perforated bowel?

The main symptoms are sudden, severe belly pain, a hard and tender abdomen, fever, chills, nausea, vomiting and a fast heart rate. Pain often worsens with any movement. Older or immunosuppressed people may have milder symptoms. It is an emergency.

What causes a bowel perforation?

Common causes include diverticulitis, peptic ulcers, appendicitis, bowel obstruction, inflammatory bowel disease, colorectal cancer, reduced blood supply to the bowel, trauma, swallowed foreign bodies and, rarely, complications of colonoscopy or surgery.

Can a perforated bowel heal on its own?

Rarely. Small, walled-off perforations in stable patients are sometimes treated with antibiotics and drainage, and some heal. Most perforations need surgery because leaking gut contents cause peritonitis and sepsis, which can be fatal without treatment.

What is the survival rate for a perforated bowel?

It varies widely. Young, otherwise healthy people treated promptly usually survive. Risk of death rises with age, other illnesses, fecal contamination, sepsis and delays in treatment. Early surgery and antibiotics are the most important factors in survival.

How long is recovery after surgery for a perforated bowel?

Hospital stays typically range from 1 to 3 weeks. Full recovery often takes 6 to 12 weeks. People with a stoma learn to manage it before discharge, and reversal surgery may be considered after 3 to 6 months.