Gastrointestinal perforation risk factors

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

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Overview

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]
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.
  • 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

References