Gastrointestinal perforation causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]

Overview

Causes of gastrointestinal perforation in adults

Instrumentation

• Instrumentation of the gastrointestinal tract includes upper endoscopy, sigmoidoscopy, colonoscopy [10,11], stent placement [10,11], endoscopic sclerotherapy [12], nasogastric intubation [13], esophageal dilation, and surgery.
• The area of the esophagus at most risk for instrumental perforation is Killian's triangle [18], which is the part of the pharynx formed by the inferior pharyngeal constrictor and cricopharyngeus muscle.
• Gastrointestinal leakage can also occur postoperatively as a result of anastomotic breakdown. [24-31].
• Immunosuppressed individuals may be at increased risk for dehiscence and deep organ space infection following surgery. [32]

Other causes

• Medications: Aspirin, potassium supplements, disease-modifying antirheumatic drugs (DMARDs), and nonsteroidal anti-inflammatory drug (NSAID) use has been associated with perforation of colonic diverticula, with diclofenac and ibuprofen being the most commonly implicated drugs. 43 48, 44
• Foreign bodies such as sharp objects, food with sharp surfaces, or gastric bezoar. 34-37

• Violent retching can lead to spontaneous esophageal perforation, known as Boerhaave syndrome due to increased intraesophageal pressure in the lower esophagus. [51]

Gastric causes

• Peptic ulcer disease is the most common cause of stomach and duodenal perforation.
• Marginal ulcers may complicate procedures involving a gastrojejunostomy.
• Perforated gastric ulcer is associated with a higher mortality, possibly related to delays in diagnosis [121].

Small intestine causes

• Perforation of the small intestine can be related to bowel obstruction, acute mesenteric ischemia, inflammatory bowel disease [53], or due to iatrogenic or noniatrogenic traumatic mechanisms.
• Abdominal wall, groin, diaphragmatic, internal hernia, paraesophageal hernia, and volvulus can all lead to perforation either related to bowel wall ischemia from strangulation, or pressure necrosis.
• Injuries to the small intestine during laparoscopic procedures are often not recognized during the procedure. [22]
• Croh'n disease has a propensity to perforate slowly, leading to formation of entero-enteric or enterocutaneous fistula formation. [52,53]

• Diseases such as typhoid, tuberculosis, or schistosomiasis can perforate the small intestine. The perforations usually occur in the ileum at necrotic Peyer's patches. A reperforation rate of 21.3 percent has been reported for typhoid perforation closure. [136] [61]

Large intestine causes

• Colonic diverticulosis is common in the developed world. These diverticula can become inflamed and perforate and may lead to abscess formation.

• Mesenteric ischemia increases the risk for perforation. Embolism, mesenteric occlusive disease, and heart failure lead to gastrointestinal ischemia. [59]
• Neoplasms can perforate by direct penetration and necrosis, or by producing obstruction. [64-66

Causes of spontaneous intestinal perforation in adults:

• Crohn’s disease
• Celiac disease
• Graft-vs-host disease
• Infections:
• Viral: Cytomegalovirus
• Bacteria: Salmonella paratyphi, mycobacterium tuberculosis
• Parasites: Ascaris lumbricoides
• Protozoa: Entameba histolytica
• Drugs: NSAIDs and indomethacin
• Enteric-coated potassium chloride
• Monoclonal antibodies: Bevicuzimab
• Meckel’s diverticulum
• Radiation-induced vascular injury
• Atherosclerotic vascular occlusion
• Buerger’s disease
• Giant cell arteritis
• Wegener’s granulomatosis
• Henoch-schonlein purpura
• Allergic granulomatous arteritis

Causes of intestinal perforation in neonates

• Necrotising enterocolitis
• Spontaneous
• Iatrogenic
• Umbilical catheterisation
• Umbilical cord clamping
• Nasogastric tube
• Obstruction
• Ileal atresia
• Gastric volvulus
• Gastroschisis
• Perforated inguinal hernia
• Malrotation/midgut volvulus
• Congenital band