Gastrointestinal Perforation

What is gastrointestinal perforation?

Key points

  1. Gastrointestinal perforation is a medical emergency that requires immediate medical care.
  2. Symptoms include severe stomach pain, vomiting, and fever.
  3. The chances of recovery improve with early diagnosis and treatment.

Gastrointestinal perforation (GP) occurs when a hole forms all the way through the stomach, large bowel, or small intestine. It can be due to a number of different diseases, including appendicitis and diverticulitis. It can also be the result of trauma, such as a knife wound or gunshot wound. A perforation may also occur in the gallbladder. This can have symptoms that are similar to the symptoms of a gastrointestinal perforation.

A hole in your gastrointestinal system or gallbladder can lead to peritonitis. Peritonitis is inflammation of the membrane that lines the abdominal cavity.

It occurs when any of the following enters the abdominal cavity:

  • bacteria
  • bile
  • stomach acid
  • partially digested food
  • stool

GP is a medical emergency that requires immediate medical care. The condition is life-threatening. Chances of recovery improve with early diagnosis and treatment.

This condition is also known as intestinal perforation or perforation of the intestines.



What are the symptoms of gastrointestinal perforation?

Symptoms of GP may include:

  • severe stomach pain
  • chills
  • fever
  • nausea
  • vomiting

When you’ve had a gastrointestinal perforation and peritonitis occurs, the abdomen feels very tender. Pain often worsens when someone touches or palpates the area or when the patient moves. Pain is generally better when lying still. The abdomen may stick outward farther than normal and feel hard.

In addition to the general symptoms of perforation, symptoms of peritonitis may include:

  • fatigue
  • passing less urine, stools, or gas
  • shortness of breath
  • a fast heartbeat
  • dizziness


What are the causes of gastrointestinal perforation?

Illnesses can cause GP, including:

  • appendicitis, which is more common among older persons
  • diverticulitis, which is a digestive disease
  • a stomach ulcer
  • gallstones
  • gallbladder infection
  • inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis, which is less common
  • inflamed Meckel’s diverticulum, which is a congenital abnormality of the small intestine that’s similar to the appendix
  • cancer in the gastrointestinal tract

The condition may also be due to:

  • blunt trauma to the abdomen
  • a knife or gunshot wound to the abdomen
  • abdominal surgery
  • stomach ulcers due to taking aspirin, nonsteroidal anti-inflammatory drugs, and steroids (more common in older adults)
  • ingestion of foreign objects or caustic substances

Smoking and excessive use of alcohol increase your risk of GP.

Rarely, the condition may occur due to bowel injuries from an endoscopy or colonoscopy.



How is gastrointestinal perforation diagnosed?

To diagnose GP, your doctor will likely take X-rays of your chest or abdomen to check for air in the abdominal cavity. They may also perform a CT scan to get a better idea where the perforation might be. They’ll also order lab work to:

  • look for signs of infection, such as a high white blood cell count
  • evaluate your hemoglobin level, which can indicate if you have blood loss
  • evaluate electrolytes
  • evaluate acid level in the blood
  • assess kidney function
  • assess liver function


What are the treatment options for gastrointestinal perforation?

In most cases, surgery is necessary to close the hole and treat the condition. The goals of the surgery are to:

  • fix the anatomical problem
  • fix the cause of peritonitis
  • remove any foreign material in the abdominal cavity that might cause problems, such as feces, bile, and food

In rare cases, your doctor may forgo surgery and prescribe antibiotics alone if the hole closed on its own.

Sometimes, a piece of the intestine will need removal. The removal of a portion of either the small or large intestine may result in a colostomy or ileostomy, which allows intestinal contents to drain or empty into a bag attached to your abdominal wall.



What are the complications associated with gastrointestinal perforation?

Complications associated with GP include:

  • bleeding
  • sepsis, which is a life-threatening bacterial infection
  • abscesses in the belly
  • a wound infection
  • a bowel infarction, which is the death of part of the bowel
  • a permanent ileostomy or colostomy

Wound failure may occur in some cases. “Wound failure” means the wound can’t or doesn’t heal. Factors that increase the risk of this include:

  • malnutrition, or poor diet
  • smoking
  • excessive alcohol use
  • drug abuse
  • poor hygiene
  • sepsis
  • uremia, which is an illness caused by kidney failure
  • obesity
  • hematoma, which occurs when blood collects outside the blood vessels
  • type 2 diabetes
  • steroid therapy or the use of corticosteroids, which are anti-inflammatory drugs that suppress the immune system and can mask an ongoing infection and delay diagnosis
  • the use of biologic agents for conditions such as Crohn’s disease, ulcerative colitis, rheumatoid arthritis


What is the long-term outlook?

The success of surgery to repair a perforation depends on the size of the perforation or hole and the length of time before treatment. The chances of recovery improve with early diagnosis and treatment. Factors that can hinder treatment include:

  • advanced age
  • existing bowel disease
  • bleeding complications
  • malnutrition
  • the nature of the original cause of the condition
  • smoking
  • alcohol or drug abuse
  • active treatment for cancer
  • conditions requiring steroids or biologic agents including lupus, rheumatoid arthritis, and similar conditions.
  • other medical conditions such as heart disease, kidney or liver problems, and emphysema

If you experience pain or fever and you’re at risk of having a GP, you should see your doctor. The sooner you see your doctor, the better your outlook will be.



How can I prevent gastrointestinal perforation?

There are many causes of GP. For example, an underlying gastrointestinal disease can increase your risk for perforation. Get to know your medical history and seek information on the current conditions that might increase your risk.

Speak to a doctor if you experience any significant change from your normal state, especially if you have abdominal pain and fever.

  • What are some lifestyle changes a person could make that would help them avoid a gastrointestinal perforation?
  • Certain lifestyle changes can reduce the risk for developing GP. These include smoking cessation, reducing or stopping alcohol use, and limiting the use of drugs such as aspirin, NSAID’s (ibuprofen, naproxen, etc.), and steroids.

    If you have a history of diverticulosis or have ever had diverticulitis, a low-residue diet will decrease the risk of developing diverticulitis. You may consult a dietician for information on a low-residue diet.

    Additionally, keeping your other medical conditions under good control will decrease the risk of GP. Exercise, a healthy diet, and regular follow-up visits to your family physician are all important for controlling your chronic medical conditions.

    - Graham Rogers, MD
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