Perforated bowel, or intestinal perforation, occurs when a hole forms in the wall of the small intestine or colon (large intestine). This allows the contents of the intestine to leak into the abdominal cavity. Common symptoms include sudden, intense stomach pain, nausea, vomiting, and fever.
Abdominal injuries, infections, or chronic diseases such as inflammatory bowel disease (IBD) can cause intestinal perforation. Other causes include loss of intestinal blood flow or blockages, such as impacted stool or tumors, that put pressure on the intestinal wall.
A perforated bowel is a medical emergency that requires immediate surgery. Without treatment, it can cause severe infections, including sepsis, a life-threatening response to infection.
Healthcare professionals classify types of intestinal perforation based on the location of the hole in the intestinal wall.
Bowel perforation can occur in the small or large intestine (large intestine). Because the small and large intestines have different structures and functions, the location of the perforation helps healthcare professionals determine the underlying cause and appropriate treatment.
Perforation of the small intestine
The small intestine absorbs water and nutrients from the food you eat and moves digestive waste into the large intestine.
Small bowel perforations are rare and affect 1 in 350,000 people each year. The most common causes include medical procedures (such as abdominal surgery), injuries, infections, and diverticulitis (inflammation or infection of abnormal pouches in the intestines).
Perforation of the colon (colon).
The large intestine processes digestive waste, which consists of undigested food, fluid and old cells from the lining of the gastrointestinal tract. It absorbs water and turns this waste into solid stool. Muscle movements push the stool toward the rectum for elimination.
Bowel obstruction (such as loose stools), diverticulitis, and IBD (Crohn’s disease or ulcerative colitis) are the most common causes of colon perforation.
Trauma or injury to the colon during medical procedures, such as a colonoscopy, can also cause perforations.
A perforated bowel causes sudden and severe abdominal pain. People with an underlying gastrointestinal condition or bowel obstruction may experience worsening symptoms leading to perforation, including:
- Stomach discomfort
- Flatulence
- Nausea
- Loss of appetite
- Difficulty passing gas or bowel movements
When perforation occurs, symptoms develop suddenly and escalate rapidly. These symptoms may include:
- Severe abdominal pain that occurs suddenly and does not go away
- Fever or chills
- Nausea and vomiting
- Abdominal swelling or tenderness
- Inability to pass gas or stool
Perforated bowel occurs when a hole forms in the inner wall of the large or small intestine, allowing its contents to leak into the abdominal cavity. This leakage can lead to a serious infection, such as peritonitis (inflammation of the lining of the abdominal cavity), and can quickly become life-threatening.
Underlying conditions that weaken or inflame the intestinal wall can cause intestinal perforation. This includes:
- Diverticulitis (inflammation or infection of abnormal pouches in the intestines)
- Appendicitis (inflammation of the appendix, pouch on the large intestine)
- Inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis
- Toxic megacolon (a rare but life-threatening inflammation and swelling of the colon)
- Bowel impaction (impacted stool or ingestion of non-food items)
- Colon cancer
Perforation can also occur due to physical trauma to the abdomen from an accident or medical procedure, such as:
- Abdominal surgery if the surgeon accidentally damages the intestine
- Stitches or staples that are pulled out after bowel surgery
- Colonoscopy
- Abdominal injury from a blunt object, for example during a car accident or fall
- A knife or bullet wound
Lack of blood flow or poor blood flow to the intestines can also lead to perforation. Reduced blood flow can be caused by a strangulated hernia (when tissue pushes through a weak muscle wall and becomes trapped, cutting off blood supply) or a blockage (such as a blood clot) in an artery that supplies blood to the intestines.
Risk factors
Anyone can experience a perforated bowel, although certain factors can increase the risk, including:
- Age: Older adults are at greater risk of intestinal perforation due to age-related changes in the gastrointestinal system, such as weakened intestinal tissues.
- Lifestyle: Smoking and a diet low in fiber increase the risk of diverticulitis, the main cause of bowel perforation.
- Basic conditions: Diverticulitis and IBD make the intestines more susceptible to perforation. Conditions that affect blood flow to the intestines, such as diabetes or a history of blood clots, can also increase the risk.
- Certain medications: Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids (steroid hormones), and some cancer treatments (such as chemotherapy drugs) can increase the risk of bowel perforation.
The goal of diagnosing perforated bowel is to confirm the diagnosis quickly so that treatment can begin as soon as possible to avoid serious complications.
Your healthcare provider will ask about your symptoms and review your medical history. He will then perform a physical examination, checking for tenderness and swelling of the abdomen. They will also check for temperature and rapid heart rate, which are signs of peritonitis (abdominal infection).
Diagnostic tests can help confirm the diagnosis and identify the location and severity of bowel perforation. Your healthcare provider may order:
- x-rays: X-rays can help identify air in the abdominal cavity, which is a sign of intestinal perforation.
- Computed tomography (CT) scan: This imaging test takes detailed pictures of the internal organs in the abdomen, including the small and large intestines. It can confirm the diagnosis and assess the location and severity of the perforation.
- Blood tests: Taking blood samples can help detect signs of infection, such as an elevated white blood cell count. Blood tests can also measure the number of red blood cells to diagnose anemia, a sign of internal bleeding from a perforation.
A perforated bowel is a medical emergency that requires immediate medical attention and immediate treatment to prevent life-threatening complications. Treatment goals include repairing the hole in the intestinal wall and preventing or treating infection.
Surgery
Most perforated bowels require emergency surgery to repair the hole. If the perforation is small, healthcare providers may take a “watch and wait” approach to see if the hole will repair itself, but this is rare.
In most cases, surgery takes place shortly after diagnosis. Health professionals can perform the surgery laparoscopically. This involves making small incisions in the abdomen and, using a small camera, inserting surgical tools through the incisions to repair the hole and drain any intestinal contents inside the abdominal cavity.
In some cases, the surgeon may need to remove damaged parts of the intestine and create a colostomy or ileostomy. This procedure involves creating a stoma, or opening, in the abdomen through which waste is diverted into an outer bag. Bypassing the normal digestive tract helps protect the gut for healing.
A colostomy or ileostomy may be temporary, giving the intestines time to heal. Another operation can help reconnect the bowel and remove the stoma. Extensive bowel damage may require a permanent stoma to eliminate waste.
Antibiotics
Your doctor will prescribe broad-spectrum antibiotics to prevent or treat infections that develop when intestinal contents leak into the abdominal cavity. You can receive them intravenously (IV) before and after surgery to eliminate infection or reduce the risk of developing one.
Supportive Care
After surgery, you will stay in the hospital to recover and receive supportive care to promote healing. This may include:
- Nutritional support: Instead of eating by mouth, you may need a nasogastric tube (a tube that goes through your nose and down into your stomach) to deliver nutrients while your intestines heal.
- Liquids: Intravenous fluids delivered through a tube into a vein can help keep you hydrated while you heal.
It is not always possible to prevent intestinal perforation, but many people experience abdominal pain for several days before intestinal perforation develops. If you notice persistent stomach discomfort, make an appointment with your doctor as soon as possible. Treating the underlying cause can help prevent perforation before it occurs.
If you have certain risk factors, such as IBD, diverticulitis, or chronic constipation, certain lifestyle habits can help reduce your risk of bowel perforation:
- Routine screenings: Regular colonoscopies can detect conditions that can cause bowel perforation, such as diverticulitis or colorectal cancer, early.
- Manage basic conditions: Following your treatment plan for underlying conditions such as IBD can reduce the risk of perforation.
- Increasing fiber intake: A high-fiber diet with fruits, vegetables, and whole grains can support healthy bowel habits and reduce the risk of constipation, which can sometimes cause bowel obstruction and perforation.
A perforated bowel is a medical emergency and requires immediate medical treatment to prevent complications. Possible complications include:
- peritonitis: An infection that develops when intestinal contents spill into the abdominal cavity, leading to severe inflammation.
- sepsis: Systemic (body) response to infection that occurs when bacteria from intestinal perforation enter the bloodstream. Causes severe pain, fever, chills, high heart rate or weak pulse, and confusion or disorientation. If left untreated, sepsis is life-threatening.
- Abscess formation: Localized pockets of pus that may form in the abdominal cavity due to infection, which may require surgical drainage to remove.
- Multiple organ cancellation: An untreated infection can damage the organs in the abdomen, causing them to shut down. Without timely treatment, multiple organ failure is often fatal.
A perforated bowel is a serious medical emergency that occurs when a hole forms in the intestinal wall, allowing contents to leak into the stomach.
Symptoms include sudden and severe stomach pain, nausea and vomiting. If intestinal contents leak into the abdominal cavity and cause infection, fever may develop.
Emergency surgery to repair a hole in the bowel wall is the most common treatment for a perforated bowel. If left untreated, bowel perforation can lead to life-threatening complications, including sepsis and organ failure.