Description

• Ruptured bowel: A perforation of the gastrointestinal endothelium extending through the full thickness of the entire visceral wall into the peritoneal cavity, resulting in a direct communication between the GI contents of the lumen and the peritoneum. Depending on the specific anatomic location, this leakage can result in bacterial and biochemical contamination of the peritoneal cavity leading to inflammation, erosion, and potentially sepsis. Clinically ruptured bowel is a potentially catastrophic and fatal complication of many underlying etiologies requiring prompt recognition by the clinician.
• A perforation of the alimentary canal resulting in spillage of intestinal contents; perforations are divided into iatrogenic, pathologic, and traumatic (1).
• Perforations may also be divided by anatomy:
  • Esophageal
  • Gastric/Duodenal
  • Small bowel
  • Appendix
  • Colon

Epidemiology

• Traumatic perforations
  • Small bowel:
    • Injured in 80% of abdominal gunshot wounds
    • Injured in 30% of abdominal stab wounds
    • Injured in 5% of blunt abdominal trauma
  • Colon:
    • Injured in 20% of penetrating abdominal trauma
    • Injured in 7% of transpelvic gunshot wounds
• Perforated duodenal ulcer:
  • Incidence has decreased, according to recent long-term studies, from 14/1,000–8/1,000 person-years; perforated duodenal ulcer comprises 5% of all abdominal emergencies.
• Perforated appendicitis:
  • Occurs in 4% of patients with appendicitis
• Perforated colonic diverticulitis:
  • 3.5 cases/100,000/year
• Iatrogenic: Varies by underlying disease and reason for intervention
• Infection-induced perforation: Typhoid is the most common etiological organism. Consider HIV- or tuberculosis-related bowel perforation.
• Radiation/Medication induced:
  • NSAIDs, steroids
  • Cancer chemotherapy, especially bevacizumab used in colorectal, ovarian, or breast cancer: Risk of duodenal ulcer perforation as well as small bowel and colonic perforation

• Rapid decrease in incidence of perforated peptic ulcer disease due to use of proton pump inhibitors and Helicobacter pylori eradication strategies
• Annual incidence estimated to be 10/100,000 individuals
• Diverticular perforation incidence of 4/100,000 population; incidence is rising among young patients

Risk Factors

• Trauma: Both penetrating and blunt
• Iatrogenic: Open, laparoscopic, or endoscopic procedures
• Peptic ulcer disease
• Diverticular disease
• Appendicitis
• Malignancies, especially colon cancer
• Inflammatory bowel disease
• Parasitic infestation
• Cholecystitis
• Acute and chronic mesenteric ischemia

Genetics
Collagen vascular diseases such as Ehlers-Danlos syndrome and osteogenesis imperfecta

General Prevention

• Peptic ulcer disease:
  • Eradication of H. pylori and/or the use of proton pump inhibitors in patients with peptic ulcer disease
• Crohn disease:
  • Immunosuppressive agents to reduce inflammatory component of underlying disease process
• Diverticulitis:
  • Diet modification and high-fiber diet
• Iatrogenic:
  • Meticulous attention to detail with gentle tissue handling

Pathophysiology

• Peptic ulcer disease: H. pylori, NSAID use
• Zollinger-Ellison syndrome: Hyperacidity and gastric/duodenal mucosal erosion
• Appendicitis: Appendiceal occlusion with fecalith
• Diverticulitis: Constipation, low-fiber diet
• Malignancy: Cancerous erosion of the bowel wall
• Crohn disease: Excessive and prolonged transmural inflammation of the bowel wall
• Any mechanism that results in the increase in intraluminal pressure can, by definition, perforate the lumen of the intestines according to the Law of La Place.
• Acute or chronic mesenteric ischemia: A transmural infarction due to an occlusive vascular disease process
• Iatrogenic:
  • Greater risk of colonic perforation during colonoscopy in patients with diverticulitis
  • Greater risk of bowel injury/perforation during reoperative surgery/in patients with adhesions

Commonly Associated Conditions

• One must remain vigilant for the possibility of an underlying malignancy that has eroded through the bowel wall, leading to perforation.
• Zollinger-Ellison syndrome in patients with treatment-resistant peptic ulcer disease
• Appendiceal carcinoid tumors
• Peritonitis: An inflammatory process of the abdominal peritoneum caused by any irritant:
  • Any interruption in the intestinal wall that results in leakage of intestinal contents into the peritoneum can result in peritonitis.
  • If the diagnosis is suspected clinically but cannot be confirmed, peritonitis is the indication to operate.