Bowel Perforation

Signs and Symptoms of Bowel Perforation

Bowel perforation refers to a hole in the gastrointestinal (GI) tract, which can occur anywhere from the top to the bottom, including the stomach, small or large intestine, including the rectum. It may occur as a result of an abnormal growth or tumor in any of these organs that erodes through its wall, or from lack of blood supply to the wall of the organ, known as ischemia, or from a bad infection like diverticulitis in the colon. Whatever the cause, the patient may have had symptoms of the primary process leading up to the perforation before it happens, or not. Sudden abdominal pain and bloating, or distention of the abdomen, are common symptoms of perforation. Other times, ongoing pain may actually be relieved when the bowel that has been stretching and “blowing up” finally “pops open.” The pain may be felt in the upper abdomen, if a stomach ulcer causes a hole with leakage of stomach and intestinal fluid. It may be in the left lower quadrant, related to diverticulitis, or it may be all over the abdomen, especially when intestinal contents are leaking out of the bowels. Sometimes, vomiting or diarrhea are associated with the primary disease process, or patients may have been constipated or not passing stool or gas from a bowel obstruction that goes on to perforate.

Once intestinal contents leak into the abdomen, patients may feel hot and develop fever with temperatures higher than normal. Some patients experience chills instead, and feel cold or have shivers, when others around them do not. Sometimes, it is possible to feel chilled and have a fever at the same time. Shoulder pain can be present, if blood leaks out and irritates the diaphragm muscle between the chest and abdomen, which sends its pain signals to the shoulders. The leakage of stool and intestinal contents leads to inflammation and infection in the abdomen and/or pelvis called peritonitis, and can also cause sepsis—a very serious illness with bacteria that get into the bloodstream and can even lead to death. A patient with peritonitis will have severe pain in the abdomen, especially with bumping or jarring of the body, and may appear very sick. As the illness progresses, they will be weak, feverish, and may not respond normally to conversation or stimulation.

Diagnosis of Bowel Perforation

The doctor will take a careful history, asking about when and how your symptoms started, like pain, fever, bloating, diarrhea or vomiting, and whether there have been changes since they started. A physical examination enables your doctor to evaluate for presence, location and degree of tenderness; and blood is drawn to check labs related to infection, dehydration and other factors. Imaging will be performed, either X-rays or a CT scan, which can show the doctor if air is present outside of the GI tract. Tiny bubbles of air confined to an affected area of diverticulitis, for instance, may be present, but if there is “free air” identified signifying perforation, surgery will likely be required emergently. In some cases, the site of perforation may be suspected based on the imaging, which can help the surgeon plan the operative approach. The cause may be related to an ulcer in the stomach or first segment of the small intestine, another abnormality in the small intestine, or a colon problem like diverticulitis or a tumor, among other possibilities.

Treatment for Bowel Perforation

Intravenous fluids, antibiotics, pain medication and bowel rest are all parts of treatment for bowel perforation, but this is considered a surgical emergency in almost all cases, and the patient will require an operation to find and fix the hole.

When surgery is performed, the affected area of the intestine is usually removed. If the perforation is from an ulcer near the end of the stomach, the hole is patched instead with fat from inside the abdomen. An anesthesiologist puts the patient to sleep for the operation, and wakes them up afterward. An incision is made in the abdomen for the surgeon to look inside. Once the hole is identified, the affected portion of intestine is removed, and all of the infected fluid and any stool contamination is washed out. If the hole is in the stomach or just past it, the perforated ulcer is “patched” instead, by sewing a portion of abdominal fat called omentum over the hole. If the hole is in the small intestine, the two ends are reconnected, and the abdomen is closed. A nasogastric tube (small-caliber tube inserted through the nose that goes down the esophagus into the stomach) will be left in place to drain the stomach of fluid until the area is healed enough to allow the patient to take fluids or food by mouth again. If the hole is in the large intestine, in most cases, because of the contamination, the two ends of the colon cannot be reconnected during this operation and expected to heal without falling apart. The surgeon will then create an ostomy (colostomy or ileostomy, depending on the location), or an opening in the abdominal wall, where the free upper end of the intestine is brought through and sutured to the skin. A special bag is placed over the opening, or stoma, for stool to collect in. In any case, the abdominal incision may be left open or partly open, with gauze packing tucked into the wound, which will be changed daily. This is because the wound is likely to get infected if it is closed up tightly; the open areas will heal over time, from the inside out, with dressing changes. The patient will learn how to care for the ostomy, if they have one, and a visiting nurse may come to the patient’s home to help with wound and/or ostomy care.

Once the patient has recovered from their operation, an ostomy may be reversed at some point in the future, depending on that patient’s individual circumstances and operative risks. Most surgeons will wait at least 3 months to allow healing inside the abdomen before considering reversal, but each patient’s case is unique. This requires another operation to reconnect the ends of the bowel, and a period of time in the hospital for recovery. At that time, the surgeon will leave open a smaller wound, where the ostomy was, to heal with dressing changes. This time, though, the main incision will be closed, and the surgeon might even be able to revise the old scar, leaving less of a scar in its place.

If the patient had a perforation in the colon, in most cases, a colonoscopy should be performed after recovery, regardless of the patient’s age, to check for any abnormalities.