What is Bowel Perforation?
Bowel perforation happens when the inside lining of the bowel wall is damaged or harmed, usually by some sort of infection, inflammation, blockage, accident, or intrusive treatment. This can cause the contents of the bowel to spill into the abdomen. If someone has symptoms like abdominal pain and swelling, particularly if they have a history of such problems, they need to be checked for bowel perforation right away. If not treated immediately, it can be very dangerous as it increases the risk of serious infections like peritonitis. Treatment typically includes stabilizing the patient and consulting with a surgeon. Even with appropriate treatment, bowel perforation can lead to complications like adhesions (scar tissues) and fistulas (abnormal connections between organs), which can increase the risk of illness and death.
What Causes Bowel Perforation?
Perforations in the bowel can happen in different areas, and there can be multiple overlapping reasons causing them.
For the small bowel, these causes might include erosion due to an ulcer (a sore in the stomach), tumours, infection or abscess (a collection of pus), Meckel’s diverticulum (a pouch on the wall of the lower part of the intestine that is present at birth), hernia with strangulation (when an organ or tissue squeezes through a weak spot in surrounding muscles or tissue and its blood supply gets cut off), inflammatory bowel disease, like colitis (inflammation of the inner lining of the colon), mesenteric ischemia (poor blood supply to the intestines), a foreign body, blockage, injuries caused by medicine or radiation, procedures performed by a doctor, or physical trauma, such as a punch to the abdomen.
In the case of the large bowel, the causes can be a tumour, diverticulitis (inflammation or infection in one or more small pouches in the digestive tract), infection or abscess, colitis, a foreign body, blockage, volvulus (twisting of the bowel that causes a blockage), injuries caused by a doctor during a procedure, or physical trauma.
Risk Factors and Frequency for Bowel Perforation
Bowel perforation, or a hole in the bowel, can occur due to different reasons in children and adults. In kids, it’s commonly caused by a blow to the stomach, while in adults, it most often results from ulcerative disease. Moreover, the condition can also develop due to a colonoscopy procedure.
- In children, bowel perforation occurs in 1% to 7% of those who have had a stomach injury.
- In adults, bowel perforation is most often caused by duodenal ulcers, which are 2 to 3 times more likely to cause perforation than stomach ulcers.
- Perforation can also occur due to diverticular disease in up to 15% of cases.
- In older adults, the most common cause of perforation is perforated appendicitis.
- The overall incidence of bowel perforation due to a colonoscopy procedure is about 2%, with higher rates seen with colonoscopies that require therapeutic interventions.
Signs and Symptoms of Bowel Perforation
If someone has recently had endoscopic procedures, surgeries, or any trauma in the abdominal area and then experiences pain in the lower chest or abdomen, this could indicate bowel perforation. Also, a history of conditions such as hernias, bowel obstructions, suspected or known cancers, consumption of certain regular medications like NSAIDs, corticosteroids, and chemotherapy drugs, or insertion or ingestion of a foreign object increases the likelihood of a bowel perforation. Patients often report a growing feeling of pain and fullness in their belly. Sometimes, the pain may briefly go away before it comes back worse, which can happen when an inflamed area decompresses right after the perforation happens.
However, it might be challenging to pinpoint where the pain is coming from due to the widespread dispersal of air and intestinal contents. During a physical examination, touching the belly may reveal tenderness. Patients may feel nauseous and vomit quite often. As the condition worsens, the belly might tense up defensively and become rigid. Initially, patients might not display any abnormal vital signs. Still, as the condition progresses, rapid heartbeat and breathing, fever, and other symptoms of a severe body-wide inflammation known as sepsis are expected to occur.
- Recent procedures or traumas in the abdominal area
- Increasing pain and fullness in the belly
- Previous health issues including hernias, bowel obstructions, and cancers
- Regular use of NSAIDs, corticosteroids, or chemotherapy drugs
- Insertion or ingestion of a foreign object
- Tenderness in the belly
- Nausea and vomiting
- Rigid abdomen
- Rapid heart rate and breath rate
- Fever
- Potential signs of sepsis
Testing for Bowel Perforation
If you think you might have a bowel perforation, your doctor will first do a thorough examination and ask about your medical history. They will also carry out several laboratory and imaging tests, similar to those given to any patient with abdominal pain. This could involve checking your blood count, kidney function, liver function, and levels of certain enzymes and inflammation markers like C-reactive protein. However, common test results like increased white blood cell count or enzyme levels do not definitively confirm bowel perforation.
An upright chest x-ray, which is correct about half to two-thirds of the time, can help identify any free air inside your abdomen. This would point to a possible bowel perforation. The chances of spotting this free air go up if you have been sitting upright for at least 15 minutes before getting the x-ray. If you can’t sit upright, a side-lying film can be used.
After undergoing a laparoscopy, which is a minimally invasive surgical procedure, up to 40% of patients will show more than 2 cm of free gas even up to 24 hours later, without having a bowel perforation. If more invasive surgery has been carried out, free gas might be seen for up to a week, but it should be decreasing gradually.
A CT scan, which provides detailed cross-sectional images of your body, is the preferred method for not only spotting free air but also for finding out exactly where the potential perforation is. It can also tell if the affected area has self-sealed, if an abscess has formed (pocket of pus), or if the surrounding structures are inflamed.
While an ultrasound can be used to pinpoint areas of gas that suggest perforation, its accuracy significantly depends on the operating technician’s level of skill and experience.
It’s important to get a surgical consultation early if you have abdominal pain and any signs of getting worse.
Treatment Options for Bowel Perforation
If a person is suspected to have a hole in their bowel, the first step in treatment is to stabilize the patient, especially if they are showing signs of infection or shock. This usually involves giving them fluids through a vein (intravenous or IV). They’re also started on antibiotics that help fight a variety of bacteria, especially those that don’t need air to survive (anaerobic) and others called gram-negative bacteria.
If the doctors think the hole is in the lower part of the intestine, the patient might get a tube through their nose and into their stomach to help relieve pressure and fluid build-up. Also, they will be instructed not to eat or drink anything.
When a patient’s appendix has burst or has a localized collection of pus (abscess), it is usually considered a low-risk case. However, doctors also consider other factors that might make the antibiotic treatment less effective or cause the patient to be more resistant to the antibiotics. Such factors include recent travel to places where antibiotic-resistant bacteria are common, immune system problems, old age, and whether the patient is known to already have antibiotic-resistant bacteria in their body.
If the patient is stable and there are no signs of inflammation of the tissues that line the inner wall of the abdomen (peritonitis), they might avoid surgery. Instead, they may be given antibiotics and monitored closely. This decision would be made together with the surgical team.
For patients with a localized abscess, it might be possible to drain it. This procedure is typically performed by a radiologist – a doctor who specializes in using imaging techniques like X-rays and ultrasound.
Most of the time, however, doctors will need to look directly at the bowel with laparoscopic tools or through an open procedure. This exploration can allow for repair of the bowel and give doctors a chance to control an existing infection. These procedures are less invasive, but if the patient’s symptoms worsen or they become unstable, they may need to undergo a more comprehensive surgical exploration of the abdomen, known as an exploratory laparotomy.
What else can Bowel Perforation be?
- Inflammation of the Gallbladder (Cholecystitis) and Biliary Colic (pain due to gallstones)
- Acute Gastritis (sudden inflammation or swelling in the lining of the stomach)
- Pancreatitis (inflammation of the pancreas)
- Appendicitis (inflammation of the appendix)
- Constipation (difficulty in passing stool)
- Crohn’s disease (a type of Inflammatory bowel disease that affects the lining of the digestive tract)
- Endometriosis (a disorder where tissue that normally lines the uterus grows outside the uterus)
- Fallopian tube disorders (issues with the tubes that connect the ovaries to the uterus)
- Inflammatory bowel disease (an umbrella term used to describe disorders that involve chronic inflammation of your digestive tract)
- Meckel’s Diverticulum Surgery (surgical procedure to remove a small pouch in the digestive tract that is present at birth)
What to expect with Bowel Perforation
The patient’s overall health before a perforation happens is the best indicator of what their recovery might look like. Patients without several existing health issues generally have better outcomes. Dealing with the root cause is crucial in preventing more incidents in the future.
Possible Complications When Diagnosed with Bowel Perforation
There are different complications that can happen after a surgery. Some of these can happen early after the procedure, while others might show up later.
Early complications after surgery can include:
- Problems with blood flow leading to shock and multiple organ failure
- Infections, either at the site of surgery, in the abdomen, or spread throughout the body
Late complications after surgery can include:
- Problems with wound healing
- Sticky bands of tissue called adhesions, which can cause the intestines to become blocked
- Fistula (an abnormal connection between two parts inside your body) formation
- Hernias
Recovery from Bowel Perforation
After-surgery care should pay continued attention to stabilizing the patient’s blood flow and keeping a check on the expected urine production. Also important are replenishing electrolytes, monitoring for any signs of infection and taking steps to control it, managing pain, and considering nutritional needs.