Description

• 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 are generally divided into iatrogenic, pathologic (foreign body, malignancy), traumatic (blunt or penetrating), congenital (Meckel diverticulum), or spontaneous categories (1)[A].
• Perforations may also be divided by anatomy.
  • Esophageal
  • Gastric/duodenal
  • Small bowel
  • Appendiceal
  • Colonic

Epidemiology

• 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
  • Colon
    • Injured in 20% of penetrating abdominal trauma
    • Injured in 7% of transpelvic gunshot wounds
• 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

Incidence

• 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
• Iatrogenic
  • 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

Genetics
Collagen vascular diseases such as Ehlers-Danlos syndrome and osteogenesis imperfecta are associated with higher rates of bowel perforation.

Risk Factors

• Trauma: both penetrating and blunt
• Iatrogenic: open, laparoscopic, or endoscopic procedures
• Peptic ulcer disease
• Diverticular disease
• Appendicitis
• Malignancies, especially colon cancer
• Inflammatory bowel disease
• Parasitic infestation
• Cholecystitis
• Acute and chronic mesenteric ischemia
• Foreign body
• Hernia, intestinal volvulus, obstruction
• Pseudo-obstruction (Ogilvie syndrome)

General Prevention

• 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.
• Diverticulitis
  • Diet modification and high-fiber diet
• Iatrogenic
  • 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.