What is Intestinal Perforation?
Intestinal perforation is a serious problem where the wall of the intestine develops a hole. This can result from various conditions like physical trauma, medical device usage, inflammation, infection, cancer, lack of blood supply, or blockage. It’s crucial to spot this condition quickly and start treatment as soon as possible in order to stay ahead of the risk of potentially life-threatening infections and other complications that might be caused by the leakage of intestinal substances into the body.
Detecting this condition involves gathering a detailed patient history and conducting a thorough physical exam. Additional tests and studies can assist in confirming the diagnosis quickly and in guiding the treatment process more effectively.
What Causes Intestinal Perforation?
There are four main ways in which the wall of the intestine can develop a hole or tear, also known as a perforation.
First, a lack of enough blood supply to the intestines might cause this. This can occur due to a blockage in the bowel or death of the tissue, a condition also known as necrosis.
Second, infections can lead to intestinal perforation. These infections could be due to conditions like appendicitis (an inflamed appendix) or diverticulitis (inflammation of small pouches called diverticula in the digestive system).
Third, gradual wear and tear or erosion can also cause a hole in the intestine. This may be due to serious illnesses, like cancer, or due to ulcerative diseases where sores or ulcers form on the inner lining of the intestines.
Finally, physical harm to the intestine, either due to an injury or a medical procedure gone wrong (also known as iatrogenic injury), can lead to a perforation in the intestinal tract.
Risk Factors and Frequency for Intestinal Perforation
The reasons for a ruptured internal organ can depend on a person’s age and location. For example, in premature babies, necrotizing enterocolitis is often the main cause, while in kids and teenagers, appendicitis is more commonly the cause. In adults, there are many possible causes, and they don’t prefer one gender over another. This article specifically looks at the causes in adults from developed countries.
Signs and Symptoms of Intestinal Perforation
A comprehensive medical history and physical exam is crucial in identifying the cause of a perforation in the body. Most patients will experience abdominal pain, nausea, vomiting, reduced bowel movement, or fever. Understanding details about these symptoms—such as when they started, any previous similar episodes, recent medical procedures, and what makes them better or worse—can help determine the cause of the perforation. It’s also important to know about a family history of cancer and any personal history of procedures like a colonoscopy, as this information could indicate the presence of hidden cancer or inflammatory bowel disease.
On arrival for assessment, a patient’s vital signs should be quickly checked. Any signs of severe inflammatory response syndrome (SIRS) or septic shock may indicate the need for immediate resuscitation and treatment. A physical exam includes looking at the abdomen for surgical scars, visible hernias or injuries, and bloating. Feeling the abdomen can often cause discomfort, and if there are signs of inflammation in the peritoneum – the thin layer of tissue that covers the abdomen and most of the organs in the abdomen – it could suggest a perforation, inflammation, or a localized abscess.
Testing for Intestinal Perforation
If doctors suspect a hollow organ has a hole or “perforation,” they have multiple methods to diagnose and figure out the cause. Simple and inexpensive tests like abdominal and chest x-rays can be done quickly and help find even tiny amounts of air that have leaked from the inside of the organ into the stomach area, also known as “pneumoperitoneum.” X-rays can also visualize blockages in the small and large intestines.
However, a more detailed test known as a CT (Computed Tomography) scan of the abdomen and pelvis is the best way to confirm a perforation and identify the cause. Diseases like diverticulitis (inflammation of pouches in the wall of the colon), appendicitis (inflammation of the appendix), and bowel obstructions can be clearly seen on a CT scan. Doctors usually use intravenous contrast, which is a special dye that can help better visualize potential areas of weak blood supply. CT scans can also help spot complications from a perforation, like an abscess (a pocket of pus) or secondary bowel obstruction, which can guide the doctor in planning the right treatment.
In children, ultrasound is usually the first choice because it’s straightforward to perform and doesn’t involve radiation exposure. If necessary, other tests such as x-rays, MRI (Magnetic Resonance Imaging), and CT scans can be done.
Treatment Options for Intestinal Perforation
If a doctor suspects that there may be a hole in the intestines, also known as an intestinal perforation, they will typically do a thorough assessment and may call in a surgeon for further evaluation. Not every case of intestinal perforation needs to be fixed with surgery, but all of them need to be checked by a surgeon to help decide the best course of action.
Regardless of whether the patient needs surgery, their initial treatment often includes resting their digestive system, getting fluids via an intravenous (IV) tube, receiving broad-spectrum antibiotics that can kill a wide range of bacteria, and having their abdomen checked frequently by a doctor.
Given the seriousness of these cases, if the patient also has sepsis (the body’s extreme response to an infection) and peritonitis (inflammation of the inner wall of the abdomen), they are more likely to need surgery. However, some cases might be treated conservatively, meaning without surgery, if the condition is not as severe.
If the perforation is contained or controlled, meaning the leakage is not spreading, doctors might manage the situation non-surgically. They can use a technique called radiology guided drainage to remove fluid collections that have built up due to the perforation. But if non-surgical techniques are not working, and the patient’s symptoms continue or they develop sepsis, then surgery is usually needed.
In the past, a type of surgery called a laparotomy, which involves a large incision in the abdomen, was commonly performed for this condition. However, these days, laparoscopic surgery is often a potential option. This surgical technique involves using a small camera and special instruments inserted through small incisions, to identify and treat the source of the perforation.
In some cases, a doctor might have to cut out or repair the perforated section of the intestines and perform drainage and diversion procedures. An omental patch repair, which involves using a part of the large apron-like layer of fatty tissue inside the abdomen to seal the hole, is usually performed for perforations in the duodenum, the first part of the small intestine.
Doctors have to be careful to consider the risks and benefits of the surgery, particularly in elderly patients and those with other health conditions. Before the surgery is chosen as the best way forward, these considerations need to be thoroughly discussed with the patient and their family.
What else can Intestinal Perforation be?
Identifying where in the digestive system an intestinal rupture has occurred relies on a few factors. Doctors use a detailed health history and a physical examination to help pinpoint whether the disease is recent or chronic, and where the rupture likely is. The specific location of the rupture helps guide the kind of treatment needed.
If the rupture is in the upper GI tract (stomach and starting portion of small intestine), the main cause is usually peptic ulcer disease, which might trigger severe pains in the mid-upper abdomen or back that come on suddenly. The patient may have experienced long-term symptoms before the rupture, like indigestion, bloating, feeling nauseated, and feeling full quickly. Other causes can be cancer or trauma. Medical imaging usually shows air in the upper abdomen and possible leakage of stomach contents into the abdominal cavity. If patients ingest contrast materials, it can be seen leaking out soon after. Sudden pain around the belly button, vomiting, feeling nauseous, and reduced bowel activity might point to bowel obstruction. Medical images could show free air in the belly cavity with swollen small or large intestines, which could indicate a rupture.
If someone has a history of left lower abdominal pain or diverticulitis (a digestive condition where small pouches develop in the colon wall), a colonic rupture should be considered – especially if the person is also experiencing reduced bowel movements. Colonic rupture might also be a consideration if the patient hasn’t been screened for colon cancer. Medical imaging usually shows air near the point of rupture, and a possible infection caused by stool leaking into the abdominal cavity. In rare cases, the cause of free air in the belly cavity might be a non-serious condition called benign pneumatosis intestinalis, which isn’t related to reduced blood supply to the intestines and can be managed without surgery.
What to expect with Intestinal Perforation
The future health outcomes for a patient with a bowel perforation depend on several elements. These include the patient’s age, any current health conditions, whether the perforation is due to a benign (non-cancerous) or malignant (cancerous) issue, and the patient’s ability to handle treatment. Surgery is often needed for this condition, and therefore, those who cannot undergo or opt not to have the surgery when needed, might face worse health outcomes.
There can also be significant health risks, including the delayed risk of infection inside the abdomen and the development of hernias due to the healing process of the surgery. Risks of blood clots and heart or lung complications are higher in older patients, who may also experience a decrease in life quality. These elements should be openly discussed with patients and their families before surgery, especially in older individuals, to help them understand and decide what they expect and want from the treatment.
Possible Complications When Diagnosed with Intestinal Perforation
Complications can arise from an intestinal perforation (a hole in the intestine) due to the underlying illness causing it or the treatments used to address it. If the perforation isn’t dealt with promptly, leakage of intestinal substances can set off a severe, body-wide infection known as peritonitis and potentially even a more dangerous condition known as sepsis. Quick action in starting suitable treatment, including fluid replacement and antibiotics, is critical to reduce the harmful effects of the infection.
Surgery might be necessary to stop leakage. Before any procedure, it’s important to have a discussion with patients and their loved ones about potential surgery complications. This discussion should cover potential risks like infections, bleeding, leakage at joined sections of the intestine, and hernia formation. Other potential complications, such as lung-related issues, blood clots, heart problems, and extended need for a ventilator to assist breathing should also be discussed. Similarly, the expected recovery process and future level of functioning should be clarified.
Complications to Discuss:
- Infections
- Bleeding
- Leakage at the site in the intestine where two sections were joined
- Hernia formation
- Lung-related issues
- Blood clot events
- Heart problems
- Extended need for ventilator support
- Expected recovery process
- Possible future level of function
Preventing Intestinal Perforation
It’s vital for the doctor and patient to have an open conversation about the potential risks and complications of surgery. This discussion should consider the patient’s current health, what’s likely causing the blockage, and the possible results after surgery. Understanding what the patient hopes to achieve after recovery and their overall expectations is essential. It’s equally important for a patient to have a living will or other legal documents that clarify their wishes, especially if they are unable to talk with their healthcare team. Additionally, discussing how to manage pain after surgery matters a lot. It’s better to use multiple kinds of therapies, because this can help reduce the need for strong pain medications like opioids.
