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| ==Overview== | | ==Overview== |
| '''Instrumentation/surgery'''
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| * Instrumentation of the gastrointestinal tract is the main cause of iatrogenic perforation and may include upper endoscopy, sigmoidoscopy, colonoscopy [10,11], stent placement [10,11], endoscopic sclerotherapy [12], nasogastric intubation [13], esophageal dilation, and surgery.
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| * The incidence of perforation related to endoscopy increases with procedural complexity.[14].
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| * A perforation rate of 0.11 percent for rigid endoscopy contrasts with a 0.03 percent rate for flexible endoscopy [15,16].
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| * When iatrogenic perforation occurs, there is often significant associated pathology. As an example, in the esophagus, there may be stricture, severe esophagitis [17], or a diverticulum, and the presence of cervical osteophytes also increases the risk [16]. 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. During endoscopy, perforations are frequently recognized at the time of the procedure. At other times, the perforation remains occult for several days.
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| * Other procedures can also be complicated with perforation, such as chest tube insertion low in the chest [19], peritoneal dialysis catheter insertion, percutaneous gastrostomy [20], paracentesis, diagnostic peritoneal lavage, and percutaneous drainage of fluid collections or abscess.
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| * With surgery, perforation can occur during initial laparoscopic access, during mobilization of the organs or during the takedown of adhesions, or as a result of thermal injury from electrocautery devices [21-23].
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| * 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]. Medical illnesses such as diabetes, cirrhosis, and HIV are associated with an increased risk of anastomotic leak after colon resection for trauma [33
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| '''Medications, other ingestions, foreign body'''
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| * Medications or other ingested substances (caustic injury) and foreign bodies (ingested or medical devices) can lead to gastrointestinal perforation.
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| * Foreign bodies, such as sharp objects (toothpicks), food with sharp surfaces (eg, chicken bones, fish), or gastric bezoar more commonly cause perforation, compared with dislodged medical implants [34-37].
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| * Button batteries as an esophageal foreign body have a more pronounced perforation risk [38,39]. Surgically implanted foreign bodies such as hernia mesh [40] and artificial vascular grafts [41,42] can cause perforation with subsequent abscess and fistula formation or vasculoenteric fistulas.
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| * Aspirin 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]. Some disease-modifying antirheumatic drugs (DMARDs) have been associated with lower intestinal perforations [44]. Rarely, NSAIDs have produced jejunal perforations [45]. Glucocorticoids, particularly in association with NSAIDs, are particularly problematic [46,47]. Further, because steroids suppress the inflammatory response, detection of a perforation can be delayed.
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| * NSAIDs, antibiotics, and potassium supplements are also common causative medications for pill-induced esophageal ulcers [48]. Other medication-induced injury leading to perforation has been reported for immunosuppressive therapies, cancer chemotherapy in patients with metastases, and for iron supplementation causing esophageal injury [2,49,50].
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| '''Violent retching/vomiting'''
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| * Violent retching/vomiting can lead to spontaneous esophageal perforation, known as Boerhaave syndrome. This occurs because of failure of the cricopharyngeal muscle to relax during vomiting or retching causing an increased intraesophageal pressure in the lower esophagus [51]. (See "Boerhaave syndrome: Effort rupture of the esophagus".)
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| '''Hernia/intestinal volvulus/obstruction'''
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| * Abdominal wall, groin, diaphragmatic, internal hernia, paraesophageal hernia, and volvulus (gastric, cecal, sigmoid) can all lead to perforation either related to bowel wall ischemia from strangulation, or pressure necrosis. Perforation can also occur with afferent loop obstruction after Roux-en-Y reconstruction. (See "Overview of abdominal wall hernias in adults" and "Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults" and "Overview of treatment for inguinal and femoral hernia in adults" and "Surgical management of paraesophageal hernia" and "Gastric volvulus in adults" and "Postgastrectomy complications", section on 'Afferent and efferent loop syndrome'.)
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| '''Inflammatory bowel disease'''
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| * Crohn disease has a propensity to perforate slowly, leading to formation of entero-enteric or enterocutaneous fistula formation [52,53]. (See "Operative management of Crohn disease of the small bowel, colon, and rectum"and "Surgical management of ulcerative colitis".)
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| '''Appendicitis'''
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| * Overall in the United States in 2010, approximately 30 percent of hospital stays for appendicitis involved a perforated appendix [54-56]. Rates for perforated appendix in children have not significantly changed from 2001 to 2010 (approximately 300/1000 appendicitis discharges), whereas the rate has declined 12 percent for adults (from 307/1000 to 270/1000appendicitis discharges). (See "Acute appendicitis in children: Clinical manifestations and diagnosis" and "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)
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| '''Peptic ulcer disease'''
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| * Peptic ulcer disease (PUD) is the most common cause of stomach and duodenal perforation but occurs in less than 10 percent of patients with PUD. In spite of the introduction of proton pump inhibitors, the incidence of perforation from PUD has not changed appreciably [57]. Marginal ulceration leading to perforation may also complicate surgeries that create a gastrojejunostomy (eg, partial gastric resection, bariatric surgery). (See "Overview of the complications of peptic ulcer disease".)
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| '''Diverticular disease'''
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| Colonic diverticulosis is common in the developed world. All clinical cases of diverticulitis represent some degree of perforation of the thinned diverticular wall, leading to inflammation of the adjacent parietal peritoneum [58]. (See "Acute colonic diverticulitis: Surgical management" and "Overview of colon resection", section on 'Primary closure versus ostomy'.)
| | ===== '''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] |
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| Perforation can also occur with duodenal or small intestinal diverticula (jejunal, Meckel's). These diverticula can become inflamed, much as in colonic diverticulitis, and perforate, which may lead to abscess formation. (See "Meckel's diverticulum".)
| | ===== 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 |
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| '''Cardiovascular disease'''
| | * Violent retching can lead to spontaneous esophageal perforation, known as Boerhaave syndrome due to increased intraesophageal pressure in the lower esophagus. [51] |
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| Any process that reduces the blood flow to the intestines (occlusive or nonocclusive mesenteric ischemia) for an extended period of time increases the risk for perforation, including embolism, mesenteric occlusive disease, cardiopulmonary resuscitation, and heart failure that leads to gastrointestinal ischemia [59]. (See "Overview of intestinal ischemia in adults".)
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| '''Infectious disease'''
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| Typhoid, tuberculosis, and schistosomiasis can cause perforation of the small intestine [60,61]. With typhoid, the perforation is usually in a single location (ileum at necrotic Peyer's patches), but it can be multiple [62,63]. Typhoid perforation is more common in children, adolescents, or young adults. Cytomegalovirus, particularly in an immunosuppressed patient, can cause intestinal perforation.
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| '''Neoplasms'''
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| Neoplasms can perforate by direct penetration and necrosis, or by producing obstruction. Perforations related to tumor can also occur spontaneously, following chemotherapy, or as a result of radiation treatments when the tumor involves the wall of a hollow viscus organ [64-66]. Delayed perforations of the esophagus or duodenum in patients with malignancy can be related to stent placement for malignant obstruction.
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| '''Connective tissue disease'''
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| Spontaneous perforation of the small intestine or colon has been reported in patients with underlying connective tissue diseases (eg, Ehlers-Danlos syndrome), collagen vascular disease, and vasculitis [67-69].
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| '''Esophageal causes'''
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| * Perforation of the esophagus is more often iatrogenic (endoscopy or related to surgery), or due to noniatrogenic penetrating or blunt traumatic mechanisms [118].
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| * Other causes include tumors, foreign body or caustic ingestion [34,35], pneumatic injury, peptic ulceration, intrinsic esophageal disease such as pill esophagitis [1,2], Crohn disease [3], eosinophilic esophagitis [4], foreign body ingestion, or, more rarely, it is spontaneous (Boerhaave's syndrome). During surgery, the esophagus can be injured during operations such as hiatal hernia repair, thyroidectomy, pulmonary procedures, and vagotomy.
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| '''Gastric causes''' | | '''Gastric causes''' |
| * Peptic ulcer disease is the most common cause of stomach and duodenal perforation. | | * Peptic ulcer disease is the most common cause of stomach and duodenal perforation. |
| * Marginal ulcers may complicate procedures involving a gastrojejunostomy (eg, partial gastrectomy, bariatric surgery). | | * Marginal ulcers may complicate procedures involving a gastrojejunostomy. |
| * Although the frequency of elective surgery for peptic ulcer disease has declined, the incidence of peptic perforation has remained the same or is increasing [57]. | | * Perforated gastric ulcer is associated with a higher mortality, possibly related to delays in diagnosis [121]. |
| * Perforated duodenal ulcers are located on the anterior or superior portions of the duodenum and typically rupture freely, causing severe acute abdominal pain. Perforated gastric ulcer is associated with a higher mortality, possibly related to delays in diagnosis [121].
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| * Other causes include iatrogenic (endoscopy, surgery [open or laparoscopic]) or noniatrogenic trauma [14,19,59], ingested foreign bodies [36], neoplasm (particularly during chemotherapy) [64,65], tuberculosis [122], and perforated duodenal diverticulum. Gastric perforation during cardiopulmonary resuscitation can also occur [59].
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| '''Small intestine causes''' | | '''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 (laparoscopic access, takedown of adhesions, endoscopy) or noniatrogenic traumatic mechanisms. Injuries to the small intestine during laparoscopic procedures are often not recognized during the procedure [22]. | | * 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. |
| * Severe pain or sepsis after a laparoscopic procedure should be investigated promptly [23]. Perforations caused by the tumor (eg, lymphoma [66]) can occur spontaneously or after chemotherapy. Further, because glucocorticoids suppress the inflammatory response, detection of a perforation can be delayed. Other causes of small intestinal perforation include foreign body ingestion, enteroliths/gallstones [5,6], or, more rarely, migrated stents (eg, esophageal, biliary). | | * 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] |
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| * Perforation of a diverticulum of the small intestine, such as in perforated Meckel's diverticulum, can occur and may lead to abscess formation. Occasionally, jejunal diverticula can become inflamed and perforate [135]. These rare diverticula are located along the mesenteric aspect of the proximal jejunum and decrease in number with increasing distance from the duodenal-jejunal junction. Rarely, nonsteroidal anti-inflammatory drugs (NSAIDs) have produced jejunal perforations [45]. | | * 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] |
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| * Occasionally, particularly in developing countries, diseases such as typhoid, tuberculosis [136], or schistosomiasis [61] can perforate the small intestine. In typhoid, the perforation is usually single but can be multiple 28 to 37 percent of the time [62,63]. The perforations usually occur in the ileum at necrotic Peyer's patches. Typhoid perforation is more common in children, adolescents, or young adults and has a high mortality (3 to 72 percent) reflecting, in part, the severity of the illness these patients have in addition to the effects of the perforation. A reperforation rate of 21.3 percent has been reported for typhoid perforation closure. Cytomegalovirus, particularly in an immunosuppressed patient, can also cause intestinal perforation. | | ===== Colon and large intestine ===== |
| | * Colonic diverticulosis is common in the developed world. These diverticula can become inflamed and perforate and may lead to abscess formation. |
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| * Colon and rectal perforation is more commonly due to diverticulitis, neoplasm, and iatrogenic and noniatrogenic traumatic mechanisms, including surgery (eg, anastomotic leak). Colonic diverticulosis is common in the developed world, affecting up to 50 percent of adults in Western countries. A younger age group is affected in left-sided diverticulitis, and it is more common in men. With increasing age, the number of diverticuli, which predominate in the sigmoid and left colon, increases with the disease moving more proximally. In Asian countries, the most common cause of right-sided colonic perforation is diverticulitis [138]. | | * 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 |
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| ==References== | | ==References== |