- 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 may also be divided by anatomy.
- Small bowel
- 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
- Injured in 20% of penetrating abdominal trauma
- Injured in 7% of transpelvic gunshot wounds
- Small bowel
- 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
- 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
- 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
Collagen vascular diseases such as Ehlers-Danlos syndrome and osteogenesis imperfecta are associated with higher rates of bowel perforation.
- Trauma: both penetrating and blunt
- Iatrogenic: open, laparoscopic, or endoscopic procedures
- Peptic ulcer disease
- Diverticular disease
- Malignancies, especially colon cancer
- Inflammatory bowel disease
- Parasitic infestation
- Acute and chronic mesenteric ischemia
- Foreign body
- Hernia, intestinal volvulus, obstruction
- Pseudo-obstruction (Ogilvie syndrome)
- 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.
- Diet modification and high-fiber diet
- 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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Domino, Frank J., et al., editors. "Ruptured Bowel." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2020. www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/1688801/all/Ruptured_Bowel.
Ruptured Bowel. In: Domino FJF, Baldor RAR, Golding JJ, et al, eds. 5-Minute Clinical Consult. Wolters Kluwer; 2020. https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/1688801/all/Ruptured_Bowel. Accessed June 5, 2023.
Ruptured Bowel. (2020). In Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (Eds.), 5-Minute Clinical Consult (27th ed.). Wolters Kluwer. https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/1688801/all/Ruptured_Bowel
Ruptured Bowel [Internet]. In: Domino FJF, Baldor RAR, Golding JJ, Stephens MBM, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2020. [cited 2023 June 05]. Available from: https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/1688801/all/Ruptured_Bowel.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Ruptured Bowel ID - 1688801 ED - Domino,Frank J, ED - Baldor,Robert A, ED - Golding,Jeremy, ED - Stephens,Mark B, BT - 5-Minute Clinical Consult, Updating UR - https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/1688801/all/Ruptured_Bowel PB - Wolters Kluwer ET - 27 DB - 5-Minute Clinical Consult DP - Unbound Medicine ER -