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Small Bowel Perforation

Causes, Symptoms, and Treatment of Small Intestine Perforation

Jul 20, 2009 David Henry

Perforation of the small intestines is a rare but serious condition. The causes, signs and symptoms, and treatment options are discussed below.

Small bowel perforation is a serious condition in which a hole in the duodenum, jejunum, or ileum (3 parts of the small intestines), allows intestinal contents to leak out into the abdominal cavity. Bacteria from within the intestines can cause "peritonitis," or inflammation within the abdominal cavity. The patient can develop sepsis and possibly die. Thus, small bowel perforation must be corrected quickly.

Causes of Small Bowel Perforation

Perforation from a duodenal ulcer, prior to the 1980s, was the most common cause of small bowel perforation. Today, perforation that occurs during endoscopy* is the most common cause, specifically during a procedure called ERCP with endoscopic sphincterotomy. ERCP (endoscopic retrograde cholangiopancreatography) is a procedure that allows physicians to evaluate for disorders of the ducts from the liver and pancreas that carry bile and other substances. (*Endoscopy is the use of a video camera at the end of a long, thin tube to look at the inside of the esophagus, stomach, duodenum, or other orifice.) Other causes of perforation include infections (tuberculosis and cytomegalovirus), Crohn’s disease, ischemia, injury from radiation therapy, cancer (lymphoma, adenocarcinoma, etc.), and swallowed foreign bodies.

Symptoms of Small Bowel Perforation

Symptoms include abdominal pain, tenderness to palpation, distention, fever, and tachycardia. Symptoms can occur much more gradually with duodenal perforation, since most of the duodenum is retroperitoneal, and the intestinal contents, therefore, would not leak into the peritoneal cavity.

Diagnosis of Small Bowel Perforation

The best diagnostic tests are an upper GI study with water-soluble contrast (Gastrografin) or a CT scan. Free air in the peritoneal cavity and contrast extravasation may be seen. Abdominal X-ray may also show air underneath the diaphragm (air that has leaked from within the intestines, through the perforation, and into the peritoneal cavity).

Treatment of Small Bowel Perforation

Small intestinal perforations that leak into the peritoneal cavity require surgery. The perforated segment may be closed primarily with sutures or the segment may be resected. If the patient is unstable or if florid peritonitis is present, it may be best to create an “ostomy” (allowing the intestinal contents to empty into a bag attached to the skin) for several weeks while the intestines are healing. A duodenal perforation that is retroperitoneal may not need surgery. An injury to the Ampulla of Vater in the duodenum can be managed with a biliary stent. If the perforation occurs during an endoscopy, the physician can often repair the perforation immediately during the endoscopy. If the perforation is unable to be repaired endoscopically, the patient will likely need emergent surgery to repair the perforation.

References

Chapter 27: Small intestine. Brunicardi C et al., Eds. Schwartz’s Principles of Surgery. 4th ed. McGraw-Hill, 2005.

Azer, Samy A. eMedicine (General Surgery): Intestinal perforation

Wikipedia: Gastrointestinal perforation

Lambert, Allison et al. Small-bowel perforation after colonoscopy. Gastrointestinal Endoscopy 2007. 65(2): 352-3.

The copyright of the article Small Bowel Perforation in General Medicine is owned by David Henry. Permission to republish Small Bowel Perforation in print or online must be granted by the author in writing.

Small perforation (hole) in the small intestines