Bowel Perforation - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

The bowel (intestine) is an integral part of our body, absorbing essential nutrients from our food. It is a hollow tube that extends from the stomach like a large bowel, follows a small bowel, and ends in the anus. The whole intestine is lined by the mucosa that provides blood and nerve supply and contains glands that secrete digestive juices. In addition, several muscles and tissues in the intestine aid in contraction. Therefore, any trauma or injury to the bowel mucosa results in several complications. Read this article to know more.

What Is Bowel Perforation?

Bowel perforation is characterized by a hole developed in the intestinal walls due to trauma. It results in the leakage of the bowel contents into the abdominal cavity, thus causing infection.

What Causes Bowel Perforation?

The main factors that lead to bowel perforation are listed below:

1) Small Bowel Perforation -

• A severe ulcer that erodes the mucosa.

• Merkel’s diverticulum is a congenital disability that causes bulging out of the small bowel.

• Mesenteric ischemia is a condition that hinders blood flow to the part of the bowel.

• Specific medications involved in chemotherapy (treats cancer) are found to cause bowel perforations.

• Foreign body obstruction - Several studies show that certain ingested sharp foods (fishbone, chicken bone, etc.) may lead to narrowing and perforation of the intestine.

2) Large Bowel Perforation -

• Abdominal trauma or blunt injury is the leading cause of large bowel perforation.

• Colitis (the large intestine inflammation).

• Tumors may develop over the intestinal walls, which leads to its perforation.

• Obstruction of the bowel hinders the blood supply and thus leads to bowel defects.

Is Bowel Perforation Common?

Bowel perforation affects both children and adults. Abdominal trauma remains the primary causative factor of bowel perforation in children. In contrast, bowel perforation most commonly arises due to ulcerative diseases in adults. Diverticular conditions also predispose to bowel perforation in a few adults.

In the older age group, bowel perforation mainly occurs due to perforated appendicitis (a hole in the appendix that causes the spread of infection to other abdominal organs). Reports also show the occurrence of bowel perforation due to a colonoscopy procedure (which involves the insertion of a tube in the rectum to view the intestinal changes).

What Are the Signs and Symptoms?

Due to the hole in the intestine, its contents might leak into the abdominal cavity, leading to an infectious condition called peritonitis. It is the inflammation of the inner abdominal wall, and it causes the following symptoms:

• Severe abdominal pain.

• Abdominal swelling.

• Nausea.

• Vomiting.

• The patient may feel difficulty localizing the pain as the intestinal contents diffusely leak into the abdominal cavity.

• A certain pain-free period is also felt.

• At the early stage, vital signs like heart rate and breathing remain normal. However, as the disease progresses, the following clinical features appear-

• Fever.

• Increase in heart rate.

• Rapid breathing.

• Other signs of infection also develop.

How Is Bowel Perforation Diagnosed?

1) Physical Examination: The doctor inquires about previous abdominal surgeries, procedures, or any pain during such procedures, trauma, accidental ingestion of a foreign body, and medication history.

2) Laboratory Investigation: The doctor orders the following test to diagnose the appropriate condition by differentiating other diseases that cause abdominal pain, and it includes:

• Complete blood count.

• Liver function test.

• Inflammatory markers.

3) Chest X-ray: The radiologist asks the affected individual to sit upright for 15 minutes before the radiographic imaging. It helps visualize the air in the abdominal cavity leaking from the bowel. The radiograph is 50 % to 70 % effective in diagnosing bowel perforation.

4) Computed Tomography (CT) Scan: It is the most preferred diagnostic method as it aids in determining the following -

• Any abscess (pus) formation.

• Free air in the abdominal cavity.

• Localizes the perforated area.

• Inflammation of the surrounding structures.

5) Ultrasonography (USG): Utilizes high-frequency sound waves to provide a clear image of the target organs. In addition, in bowel perforation, the USG aids in localizing the free air.

What Is the Differential Diagnosis?

• Appendicitis - The pouch-like structure (appendix) attached to the large bowel gets inflamed and is referred to as appendicitis. It may mimic a bowel perforation.

• Crohn's Disease: Crohn’s disease is characterized by inflammation of the digestive tract. Therefore, symptoms like diarrhea, fever, and abdominal pain may occur suddenly and disappear

• Acute Cholecystitis - The gallbladder swells, causing severe abdominal pain, nausea, and vomiting. It usually occurs as a result of gallbladder stones.

• Acute Gastritis is a common condition that causes swelling of the abdominal lining due to infection.

How Is Bowel Perforation Treated?

• Broad-Spectrum Antibiotics - The specialist suggests antibiotics that target anaerobic organisms to prevent infection from worsening. However, they are not recommended for immunocompromised individuals and older age groups.

• Laparoscopy - The surgeon uses a laparoscope (device) to visualize and localize the perforated area in the bowel. Then, it is surgically repaired. It has been widely used in diagnosing and treating bowel perforation.

• It is essential to monitor several parameters like heart rate, blood pressure, if affected individuals have signs of infection.

What Are the Complications of Bowel Perforation?

Bowel perforation is a serious medical condition where a hole forms in the wall of the gastrointestinal tract, leading to the leakage of intestinal contents into the abdominal cavity. This can result in peritonitis, an infection, and inflammation of the peritoneum, which is the lining of the abdominal cavity. Peritonitis can rapidly lead to sepsis, a life-threatening systemic infection, causing multiple organ failure if not promptly treated. Additionally, abscesses may form, and there can be a significant risk of shock due to fluid loss and infection. Immediate surgical intervention is typically required to repair the perforation and manage these severe complications.

Is Bowel Perforation Life-Threatening?

The untreated bowel perforation leads to the following complications:

• Sepsis - The infection in the intestine spreads to other organs and causes life-threatening disease.

• Multi-System Organ Failure - Several body organs like the heart and kidney may function abnormally due to poor blood supply and the spread of infection.

• Bowel obstruction.

• Hernia - The tissues of the weakened intestine may bulge out and cause various complications.

Conclusion:

The prognosis of bowel perforation depends on the patient's age, time of diagnosis, and extent of perforation. When bowel perforation is small, the individual may recover with antibiotic treatment and surgical management. However, factors like increased age and other medical conditions hinder the success of the treatment. Therefore, it is crucial to diagnose bowel perforation early to avoid complications.