What are the etiologies of intestinal perforation?

Updated: Jul 24, 2020
  • Author: Samy A Azer, MD, PhD, MPH; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Causes of intestinal perforation include the following:

  • Penetrating injury to the lower chest or abdomen (eg, knife injuries) - In cases of penetrating trauma, the small bowel is the most commonly injured intra-abdominal viscus, because it is coiled in the abdomen and occupies most of the area of the peritoneal cavity; in addition, the small bowel is attached to a mesentery and is highly mobile
  • Blunt abdominal trauma to the stomach - Such injuries are more common in children than they are in adults and include vehicle-related trauma, bicycle handlebar injuries, and seatbelt syndrome
  • Ingestion of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), [3] and steroids - Intestinal perforation from such causes is particularly observed in elderly patients; prescribing NSAIDs to patients with diverticular disease carries an increased risk of colonic perforation
  • Presence of a predisposing condition - Predisposing conditions include peptic ulcer disease, acute appendicitis, acute diverticulitis, and inflamed Meckel diverticulum; indeed, acute appendicitis is still one of the common causes of bowel perforation in elderly patients and is associated with relatively poor outcomes [4]
  • Bowel injuries associated with endoscopy - Injuries can occur with endoscopic retrograde cholangiopancreatography (ERCP) and colonoscopy [5, 6, 7, 8]
  • Endoscopic biliary stent - Dislocation and migration of biliary stents to the intestine may cause bowel perforation [9]
  • Intestinal puncture as a complication of laparoscopy - Factors that may predispose patients to this complication are obesity, pregnancy, acute and chronic bowel inflammation, and bowel obstruction
  • Bacterial infections - Bacterial infections (eg, typhoid fever) may be complicated by intestinal perforation in about 5% of patients; perforation in these patients may unexpectedly occur after their condition has started to improve
  • Inflammatory bowel disease - Bowel perforation may occur in patients with acute ulcerative colitis, and perforation of the terminal ileum may occur in patients with Crohn disease (CD); the CD-associated gene SLCO3A1 has been shown to mediate inflammatory processes in intestinal epithelial cells and thereby result in a higher incidence of bowel perforation in CD patients [10]
  • Perforation secondary to intestinal ischemia (eg, ischemic colitis)
  • Bowel perforation by intra-abdominal malignancy, lymphoma, or metastatic renal carcinoma - Even benign tumours, such as desmoid tumours (eg, those originating from the fibrous tissues of the mesentery), may cause bowel perforation [11]
  • Radiotherapy of cervical carcinoma and other intra-abdominal malignancies - This may be associated with late complications, including bowel obstruction and bowel perforation [12]
  • Necrotizing vasculitis - Wegener granulomatosis affecting the viscera, though uncommon, may cause bowel ulcerations and perforations [13]
  • Kidney transplant - After a kidney transplant, gastrointestinal (GI) perforations may occur as a complication; in these cases, the perforation is usually related to the use of high doses of immunosuppressive medications, a treatment employed in the early postoperative period and in the management of acute rejection episodes [14]
  • Ingestion of caustic substances - Accidental or intentional ingestion of caustic substances may result in acute intestinal perforation and peritonitis; delayed perforation may occur up to 4 days after acid exposure
  • Foreign bodies (eg, toothpicks) - These may cause perforation of the esophagus, stomach, or small intestine, with intra-abdominal infection, peritonitis, and sepsis

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