Intestinal Perforation (Bowel Perforation)

What happens when the bowel perforates

The intestines contain digestive juices, food, stool and large numbers of bacteria. When a hole forms:

• contents spill into the normally sterile peritoneal cavity
• the lining (peritoneum) becomes inflamed: peritonitis
• bacteria and toxins enter the bloodstream, which can cause sepsis and organ failure within hours

Sometimes the body walls off a small perforation, forming an abscess instead of widespread peritonitis. This is more common in diverticulitis.

Causes

Risk factors

• regular NSAID or aspirin use, especially with steroids
• smoking and heavy alcohol use
• older age
• inflammatory bowel disease
• diverticular disease
• recent endoscopic procedures or abdominal surgery
• immunosuppression, which can also mask symptoms

Symptoms

• sudden, severe abdominal pain, sometimes starting in one spot then spreading across the whole abdomen
• pain worse with any movement or coughing, so people tend to lie still
• a rigid, board-like abdomen with marked tenderness
• nausea and vomiting
• fever and chills
• rapid heart rate and breathing
• bloating
• shoulder-tip pain from air under the diaphragm
• signs of shock: low blood pressure, confusion, cold clammy skin

Older adults, people on steroids and people with weakened immune systems may have surprisingly mild symptoms despite a serious perforation.

Diagnosis

• physical examination: guarding, rigidity, rebound tenderness
• blood tests: white cell count, lactate, kidney function, blood cultures
• CT scan of the abdomen: the most accurate test. It shows free air, fluid, the likely site of perforation and any abscess
• upright chest X-ray: may show free air under the diaphragm, useful as a quick first test

Treatment

Immediate care

• intravenous fluids to support circulation
• broad-spectrum IV antibiotics to treat infection
• nothing by mouth, often with a nasogastric tube to decompress the stomach
• pain relief
• treatment of sepsis in intensive care if needed

Surgery

Most perforations need emergency surgery to:

• close the hole (for example, a patch repair of a perforated ulcer)
• remove the damaged section of bowel (resection)
• wash out the abdominal cavity
• sometimes create a temporary stoma (colostomy or ileostomy), bringing the bowel to the abdominal wall, to protect a repair or when the bowel cannot be safely rejoined

Surgery may be done through keyhole (laparoscopic) or open techniques.

Non-surgical management

In selected stable patients, such as a small contained diverticular perforation or a small perforation found immediately after colonoscopy, treatment may be antibiotics, bowel rest, endoscopic clip closure, or drainage of an abscess with a needle under CT guidance.

Complications

• sepsis and septic shock
• intra-abdominal abscesses
• wound infection and wound breakdown
• adhesions and later bowel obstruction
• fistulas
• need for a stoma, which may be permanent in some cases

Outlook

Outcomes depend on the cause, how quickly treatment starts, age and overall health. Prompt surgery and antibiotics save most patients, but mortality remains significant, especially in older adults, with delayed diagnosis or with fecal contamination from a colon perforation.

Prevention

• use NSAIDs only as needed, at the lowest dose, 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 persistent abdominal pain, especially with fever
• report severe pain after any endoscopy immediately

Frequently asked questions

What are the symptoms of a perforated bowel?

The main symptoms are sudden, severe abdominal pain, a hard and very tender belly, fever, nausea, vomiting and a fast heartbeat. People often lie very still because movement worsens the pain. It is a medical emergency.

What causes intestinal perforation?

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

How is a perforated bowel treated?

Most cases need emergency surgery to repair the hole or remove the damaged bowel and clean the abdomen, along with IV fluids and antibiotics. Small, contained perforations in stable patients may be treated with antibiotics and drainage.

Can you survive a perforated bowel?

Yes, most people survive with prompt treatment. The risk of death rises with delays, older age, other health problems and colon perforation with stool contamination. Getting emergency care quickly is the most important factor.