Gastrointestinal perforation: Causes of a perforated bowel and how to treat it

Gastrointestinal perforation, also known as a perforated bowel, is when there is a hole somewhere in the lower digestive tract. This can be in the stomach, small intestine, or large bowel. This condition leads to compromised intestinal contents, potentially leading to spillage into the peritoneal cavity. There are generally two types of bowel perforation:

Free perforation: Intestinal contents can spill and spread into the intraperitoneal cavity.

Contained perforation: The site of perforation is walled off by surrounding gut structures with little or no spillage.

While considered a rare occurrence, gastrointestinal perforation is a medical emergency that has a mortality rate of 20 to 40 percent. The spilling of contents into the peritoneal cavity causes inflammation of the membrane that lines the abdominal cavity, known as peritonitis, due to digestive enzymes, stomach acid, and gut bacteria invading a space they shouldn’t be.

What causes gastrointestinal perforation

There are multiple causes of bowel perforation, but they seldom result in the development of a hole and content spillage. Perforated bowel causes include:

• Trauma: Injury to the abdomen from a shape or blunt object can lead to a ruptured bowel. Knife stabbings are an example of a penetrating injury that can potentially cause bowel perforation. Blunt force trauma is seen more frequently in children but is the cause of less than 10 percent of severe abdominal injuries. Car accidents, sports injuries, and physical assault are commonly associated with bowel perforation development.
• Iatrogenic: This means that perforation was the result of a doctor’s actions, most likely during a diagnostic investigation such as an upper GI endoscopy, ERCP (endoscopic retrograde cholangiopancreatography), or colonoscopy. A perforation may also arise as a complication during certain abdominal procedures such as cholecystectomy, kidney transplantation, or radiation therapy, leading to gastrointestinal perforation symptoms.
• Bowel inflammation: Bowel perforation may arise from a number of acute or chronic inflammatory bowel conditions such as Crohn’s disease, ulcerative colitis, appendicitis, diverticulitis, and necrotizing vasculitis, leading to perforated bowel symptoms.
• Tumors: Malignant intra-abdominal cancers can lead to eventual perforation of the bowel. Benign tumors are less likely to cause perforation, but it is possible in certain cases.
• Other: Fecal impaction, acute cholecystitis, bowel strangulation, megacolon, spontaneous perforation are other causes.

Symptoms of a perforated bowel

The symptoms of gastrointestinal perforation include:

• Fever
• Chills
• Severe stomach pain
• Nausea
• Vomiting
• Swelling of the abdomen

Once peritonitis has settled in the entire abdomen, it will begin to feel tender to the touch and could hurt in response to movement. Patients who reach this stage often lie still to avoid unnecessary movement, leading pain. Peritonitis may include these additional symptoms:

• Fatigue
• Passing less urine, stools or gas
• Shortness of breath
• Fast heartbeat
• Dizziness

Diagnosis and treatment of gastrointestinal perforation

Since a perforated bowel is a medical emergency, time is of the essence. When you are brought into the emergency room, it will not be readily apparent what is causing the severe abdominal pain you are experiencing, therefore, imaging tests will need to be done to make a definite diagnosis and proceed with gastrointestinal perforation treatment.

Imaging tests typically consist of taking x-rays of the chest and abdomen to assess for air in the abdominal cavity. To get a more detailed look at where the perforation is, a computed tomography (CT) scan will be done. These tests are optimal, as they can be done very quickly. Blood work will most likely also be done to check for any preexisting infection and whether the abdominal organs are functioning properly

Treatment for a perforated bowel involves bowel rest, which restricts the consumption of food and drinks with all nutrients being delivered through an IV. Treatment may require surgery to fix the anatomical problem and remove any foreign material in the abdominal cavity, such as feces, bile, or food contents. Antibiotics may be used to treat or prevent infection. It can also be necessary to remove entire sections of the bowel, resulting in a colostomy or ileostomy. This procedure allows for intestinal contents to empty into a bag attached to your abdomen.

Perforated bowel diet

Some cases of perforated bowel may require the patient to eat a specific diet to promote recovery. The following are a few diet plans:

Clear liquids: This diet may be prescribed after surgery. When recovering from peritonitis, it is important to stay hydrated. This typically includes water, fat-free broth, fruit juices without pulp, fruit punch, clear soda, plain gelatin, ice pops, and plain coffee and tea.

Soft food: These types of food are thought to have less fiber and are easily broken down in the digestive tract. This diet typically consists of pureed foods, applesauce, ground meat, tofu, cooked or soft fruits, and cooked pasta. It is generally good to avoid food with a high fiber content such as whole grain cereals and raw vegetables.

Regular food: Once the bowel has regained most of its function and there is minimal to no pain as a result, regular food may be reintroduced. This includes foods that are simple to chew and digest like pancakes, scrambled eggs, and soft meats.

Solid food diet: With the guidance of the attending doctor, the reintroduction of solid foods may begin. It is generally recommended to avoid high fiber foods for the time being until a better assessment of your tolerance can be made. Gradually adding higher levels of fiber into the diet can give the digestive system a chance to make a full recovery.

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