Ruptured Bowel

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Basics

Description

  • A perforation of the GI endothelium extending through the visceral wall into the peritoneal cavity, allowing GI contents to enter the peritoneum. Leakage can result in bacterial and/or biochemical contamination of the peritoneal cavity with resultant inflammation, abscess, erosion, sepsis, and possible death.
  • A potentially catastrophic and fatal condition requiring prompt recognition and treatment
  • Perforations are generally divided into iatrogenic, pathologic (foreign body, malignancy), traumatic (blunt or penetrating), congenital (Meckel diverticulum), or spontaneous categories (1)[A].
  • Perforations may also be divided by anatomy.
    • Esophageal
    • Gastric/duodenal
    • Small bowel
    • Appendiceal
    • Colonic

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 from 14/1,000 to 8/1,000 person-years; perforated duodenal ulcer comprises 5% of all abdominal emergencies.
  • Perforated peptic ulcer disease
    • Short-term mortality of up to 30%; one of the most lethal emergencies worldwide (2)
  • Perforated appendicitis
    • Occurs in 4% of patients with appendicitis
  • Perforated colonic diverticulitis
    • 3.5 cases per 100,000 per year
  • Iatrogenic: varies by underlying disease and reason for surgical intervention
  • Infection-induced perforation: Typhoid is most common followed by HIV and tuberculosis.
  • Radiation-/medication induced
    • NSAIDs, steroids
    • Cancer chemotherapy, especially bevacizumab used in colorectal, ovarian, or breast cancer

Incidence
  • Decrease in incidence of perforated peptic ulcers due to use of proton pump inhibitors (PPIs) and treatment of Helicobacter pylori infection
  • Annual incidence estimated to be 10/100,000
  • Diverticular perforation 4/100,000; incidence is rising in younger patients.

Etiology and Pathophysiology

  • Any mechanism that increases intraluminal pressure can perforate the intestinal lumen according to the law of Laplace (high index of suspicion in blunt trauma).
  • In pediatrics: Necrotizing enterocolitis (NEC) is the most common cause of bowel perforation.
  • Peptic ulcer disease: H. pylori, NSAID use, smoking
  • Zollinger-Ellison syndrome: hyperacidity and gastric/duodenal mucosal erosion
  • Appendicitis: appendiceal occlusion with fecalith
  • Diverticulitis: constipation, low-fiber diet, NSAIDs
  • Malignancy: cancerous erosion of the bowel wall
  • Crohn disease: excessive transmural inflammation
  • Acute or chronic mesenteric ischemia: transmural infarction due to occlusive vascular disease
  • Iatrogenic
    • Greater risk of colonic perforation during colonoscopy in patients with diverticulitis, ischemic colitis, or toxic mega colon
    • Greater risk of bowel injury/perforation during reoperative surgery in patients with adhesions

Genetics
Collagen vascular diseases such as Ehlers-Danlos syndrome and osteogenesis imperfecta are associated with higher rates of bowel perforation.

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
  • Foreign body
  • Hernia, intestinal volvulus, obstruction
  • Pseudo-obstruction (Ogilvie syndrome)

General Prevention

  • Peptic ulcer disease
    • Eradicate H. pylori and/or use of PPIs in patients with peptic ulcer disease.
  • Crohn disease
    • Treat acute attacks with immunosuppressive agents to reduce inflammation.
  • Diverticulitis
    • Diet modification and high-fiber diet
  • Iatrogenic
    • Attention to surgical detail; gentle tissue handling

Commonly Associated Conditions

  • Consider underlying malignancy in elder patients.
  • 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 leakage of intestinal contents into the peritoneum can result in peritonitis.
    • If the diagnosis is suspected clinically, peritonitis is an indication for surgical intervention.

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