• Clinical science
  • Physician

Gastrointestinal perforation (Bowel perforation)

Summary

Gastrointestinal perforation is a full-thickness loss of bowel wall integrity that results in perforation peritonitis. Perforation of a duodenal ulcer is the most common cause of perforation peritonitis. Patients typically present with an acute onset of severe abdominal pain associated with nausea, vomiting, and fever. Signs of peritoneal irritation are evident on examination and include decreased bowel sounds and diffuse or localized abdominal guarding and rebound tenderness. Abdominal CT abdomen with IV contrast is the preferred imaging modality to confirm the presence of free air within the peritoneal cavity (pneumoperitoneum) and localize the site of the perforated viscus. Most patients will require an emergency exploratory laparotomy. Patients with evidence of a well-contained perforation (e.g., a small localized appendicular or diverticular perforation) and no signs of sepsis may be given a trial of conservative management with antibiotics, bowel rest, close monitoring of vital signs, and serial abdominal examination. The prognosis depends on the etiology, degree of intra-abdominal contamination, and other comorbidities.

See also esophageal perforation.

Etiology

Clinical features

Bowel perforation is a surgical emergency. In some cases, clinical features alone are sufficient to warrant emergency explorative laparotomy.

Diagnostics

Laboratory analysis

Imaging [5][6]

  • First line: CT abdomen and pelvis with IV contrast (most sensitive)
    • Indications: acute non-localized abdominal pain
    • Findings
  • Alternative imaging modalities
    • X-ray of the abdomen ; (upright and supine) and chest (upright)
      • Indications: Consider in patients with contraindications to IV contrast.
      • Findings: free intraperitoneal air (pneumoperitoneum) under the diaphragm; and/or between liver and lateral abdominal wall :
    • Ultrasound abdomen
      • Indication: preferred in patients with contraindications to radiation exposure (e.g., pregnancy)
      • Findings: pneumoperitoneum, localized fluid collection, localized thickening of a bowel segment

IV contrast is preferred if bowel perforation is suspected. If oral contrast must be used, a water-soluble contrast agent is preferred.

Differential diagnoses

See “Differential diagnoses” in acute abdomen.

The differential diagnoses listed here are not exhaustive.

Treatment

General principles

Supportive care

Ketorolac is contraindicated in patients with suspected bowel perforation.

Opioids are contraindicated in patients with suspected bowel obstruction.

Surgical management [8]

Most patients with GI tract perforation should be managed with urgent explorative laparotomy.

  • Indications:
  • Procedure: Exploratory laparotomy with midline incision is usually preferred.
    • Obtain peritoneal fluid for cultures.
    • Thorough peritoneal lavage with saline [9]
    • Closure of the perforation, if feasible
      • Primary closure with/without an omental pedicle
      • Resection of the perforated segment of bowel with primary anastomosis or temporary stoma creation
    • If perforated appendix identified: Perform an appendectomy.
    • If malignancy is identified (e.g., perforated colon cancer):
      • Consider curative resection.
      • Obtain intraoperative biopsies of the mass if resection is not possible.
    • Place peritoneal drains and close the abdomen.
  • Postoperative care
    • Continue bowel rest, IV fluids, and NG tube with suction until normal bowel function returns (see “conservative management” below).
    • Identify and treat the underlying condition. [10]

Conservative management [10][11]

Patients with only localized peritonitis and no signs of sepsis may be candidates for conservative (nonsurgical) management.

  • NPO, maintenance IV fluids, and IV PPI (see supportive care above)
  • IV broad-spectrum antibiotics: See “severe infection” in empiric antibiotic therapy for intra-abdominal infection
  • If imaging shows evidence of an abscess: Consider image-guided percutaneous drainage of abscess. [12]
  • Serial abdominal examination
  • Further management:
    • If there are clinical signs of improvement : Obtain an abdominal x-ray with water-soluble contrast to confirm that the perforation has sealed.
      • No leakage of contrast: Initiate enteral feeds and switch to oral antibiotics.
    • If there are clinical signs of deterioration : exploratory laparotomy

Acute management checklist

Complications

We list the most important complications. The selection is not exhaustive.

  • 1. Jones MW, Zabbo CP. Bowel Perforation. url: https://www.ncbi.nlm.nih.gov/pubmed/30725909 Accessed November 25, 2019.
  • 2. Behrman SW. Management of Complicated Peptic Ulcer Disease. Arch Surg. 2005; 140(2): p. 201. doi: 10.1001/archsurg.140.2.201.
  • 3. Helderman H, Goral S. Gastrointestinal Complications of Transplant Immunosuppression. Journal of the American Society of Nephrology. 2002; 13(1). url: https://jasn.asnjournals.org/content/13/1/277.
  • 4. Mayumi T, Yoshida M, Tazuma S, et al. Practice Guidelines for Primary Care of Acute Abdomen 2015. Journal of Hepato-Biliary-Pancreatic Sciences. 2015; 23(1): pp. 3–36. doi: 10.1002/jhbp.303.
  • 5. Scheirey CD, Fowler KJ, et al. American College of Radiology ACR Appropriateness Criteria® Acute Nonlocalized Abdominal Pain. https://acsearch.acr.org/docs/69467/Narrative/. Updated January 1, 2018. Accessed March 30, 2018.
  • 6. Kuzmich S, Burke CJ, Harvey CJ, Kuzmich T, Fascia DTM. Sonography of Small Bowel Perforation. American Journal of Roentgenology. 2013; 201(2): pp. W283–W291. doi: 10.2214/ajr.12.9882.
  • 7. Rushfeldt CF, Sveinbjørnsson B, Søreide K, Vonen B. Risk of anastomotic leakage with use of NSAIDs after gastrointestinal surgery. Int J Colorectal Dis. 2011; 26(12): pp. 1501–1509. doi: 10.1007/s00384-011-1285-6.
  • 8. Weledji EP, Ngowe MN. The challenge of intra-abdominal sepsis. International Journal of Surgery. 2013; 11(4): pp. 290–295. doi: 10.1016/j.ijsu.2013.02.021.
  • 9. Sartelli M, Catena F, Di Saverio S, et al. Current concept of abdominal sepsis: WSES position paper. World Journal of Emergency Surgery. 2014; 9(1). doi: 10.1186/1749-7922-9-22.
  • 10. Søreide K, Thorsen K, Harrison EM, et al. Perforated peptic ulcer. Lancet. 2015; 386(10000): pp. 1288–1298. doi: 10.1016/s0140-6736(15)00276-7.
  • 11. Chung KT, Shelat VG. Perforated peptic ulcer - an update. World Journal of Gastrointestinal Surgery. 2017; 9(1): p. 1. doi: 10.4240/wjgs.v9.i1.1.
  • 12. Khalil HA, Yoo J. Colorectal emergencies: perforated diverticulitis (operative and nonoperative management). J Gastrointest Surg. 2014; 18(4): pp. 865–8. doi: 10.1007/s11605-013-2352-9.
  • Kutlu OC, Garcia S, Dissanaike S. The successful use of simple tube duodenostomy in large duodenal perforations from varied etiologies. International Journal of Surgery Case Reports. 2013; 4(3): pp. 279–282. doi: 10.1016/j.ijscr.2012.11.025.
  • Lal P, Vindal A, Hadke NS. Controlled tube duodenostomy in the management of giant duodenal ulcer perforation—a new technique for a surgically challenging condition. The American Journal of Surgery. 2009; 198(3): pp. 319–323. doi: 10.1016/j.amjsurg.2008.09.028.
  • Mazuski JE, Tessier JM, May AK, et al. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt). 2017; 18(1): pp. 1–76. doi: 10.1089/sur.2016.261.
  • Akgul GG, Yenidogan E, Ozsoy Z, et al. Conservative Management of Large Rectosigmoid Perforation under Peritoneal Reflection: Case Report and Review of the Literature. Case Reports in Surgery. 2015; 2015: pp. 1–4. doi: 10.1155/2015/364576.
  • Macaluso C, McNamara. Evaluation and management of acute abdominal pain in the emergency department. International Journal of General Medicine. 2012: p. 789. doi: 10.2147/ijgm.s25936.
  • Søreide J, Viste A. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2011; 19(1): p. 66. doi: 10.1186/1757-7241-19-66.
  • Kang O, Morgan M. Bowel perforation. https://radiopaedia.org/articles/bowel-perforation-1. Accessed November 25, 2019.
  • Mavroudis CD, Kucharczuk JC. Acute Management of Esophageal Perforation. Current Surgery Reports. 2013; 2(1). doi: 10.1007/s40137-013-0034-x.
  • Kaman L. Management of Esophageal Perforation in Adults. Gastroenterology Research. 2011. doi: 10.4021/gr263w.
  • Sartelli M, Viale P, Catena F, et al. 2013 WSES guidelines for management of intra-abdominal infections. World Journal of Emergency Surgery. 2013; 8(1): p. 3. doi: 10.1186/1749-7922-8-3.
  • Sepesi B, Raymond DP, Peters JH. Esophageal perforation: surgical, endoscopic and medical management strategies. Curr Opin Gastroenterol. 2010; 26(4): pp. 379–383. doi: 10.1097/mog.0b013e32833ae2d7.
last updated 01/31/2020
{{uncollapseSections(['7U14eT0', 'HU1KeT0', 'sU1teT0', 'GU1BeT0', 'tU1XUT0', 'FU1gUT0', 'YS1nyT0', '8U1OUT0'])}}