Gastrointestinal Perforation

What happens in a perforation

The digestive tract normally keeps acid, digestive juices, food and bacteria contained. When a hole forms, these spill into the abdominal cavity (or the chest, with esophageal perforation). The result is:

• Chemical peritonitis: acid and bile irritate the abdominal lining, causing intense pain.
• Bacterial peritonitis: especially with colon perforation, where stool contains many bacteria.
• Sepsis: infection spreading into the bloodstream, which can cause organ failure.

Causes

Other risk factors include steroids, chemotherapy, older age, ischemia (poor blood supply to the bowel), and certain medicines such as bevacizumab.

Symptoms

• sudden, severe abdominal pain, often starting in one area and spreading across the abdomen
• a rigid, tender belly; pain worse with movement, coughing or bumps on the road
• fever and chills
• nausea and vomiting
• swelling of the abdomen
• rapid heartbeat and breathing
• low blood pressure, dizziness and confusion if sepsis develops

With esophageal perforation, chest pain, pain on swallowing, shortness of breath and air under the skin of the neck (a crackling feeling) can occur.

Older adults, people on steroids and those with weakened immunity may have milder pain and few signs, which can delay diagnosis.

Diagnosis

• Physical exam: tenderness, guarding and rigidity point to peritonitis.
• CT scan: the best test, showing free air outside the bowel, leaking contrast, fluid or abscesses, and often the site.
• Upright chest X-ray: can show air under the diaphragm, a quick first test.
• Blood tests: white cell count, lactate, kidney function, and blood cultures.

Treatment

1. Resuscitation: IV fluids, oxygen and pain relief.
2. Broad-spectrum IV antibiotics started promptly.
3. Nothing by mouth, sometimes a nasogastric tube to decompress the stomach.
4. Surgery in most cases: - Perforated ulcer: repair of the hole, often with a patch of fatty tissue (omental patch), frequently by keyhole surgery. - Colon perforation: removal of the affected segment; a temporary colostomy may be needed. - Appendix: appendectomy and washout.
5. Non-surgical management: selected small, contained perforations in stable patients may be treated with antibiotics, drainage of abscesses by a radiologist, or endoscopic clips or stents.

After surgery, a perforated ulcer is treated with acid-suppressing medicine and H. pylori eradication, and NSAIDs are avoided.

Complications

• sepsis and septic shock
• abdominal abscesses
• wound infection and breakdown
• prolonged bowel paralysis (ileus)
• need for a stoma
• death, more likely in older adults and with delayed treatment

Outlook

Outcomes depend on the cause, the location, how quickly treatment starts and overall health. Perforated ulcers treated promptly in otherwise healthy people usually have a good outcome. Colon perforations with fecal contamination, older age and delayed treatment carry higher risk.

Prevention

• Use NSAIDs at the lowest effective dose for the shortest time, and ask about stomach protection if you need them long term.
• Get tested and treated for H. pylori if you have ulcer symptoms.
• Seek prompt care for worsening abdominal pain, especially with fever.

Frequently asked questions

What are the symptoms of a perforated bowel?

The main symptom is sudden, severe abdominal pain that spreads and gets worse with movement. The belly may become hard and very tender. Fever, nausea, vomiting, a fast heartbeat and, later, low blood pressure and confusion can follow. It needs emergency care.

What causes a bowel perforation?

Common causes include perforated stomach or duodenal ulcers, diverticulitis, ruptured appendicitis, bowel obstruction, inflammatory bowel disease, cancer, trauma and complications of endoscopy or surgery.

Can a bowel perforation heal on its own?

Small, contained perforations in stable patients are sometimes treated with antibiotics and drainage without surgery. Most perforations, though, require emergency surgery to close the hole and clean the abdomen.

What is the survival rate for a perforated bowel?

It varies widely. Prompt surgery for a perforated ulcer in a healthy adult has a good outlook. Older age, sepsis, colon perforation with stool spillage and delayed treatment increase the risk of death. Early diagnosis and surgery are the most important factors.