Understanding a Bowel Perforation

Your colon is the final part of your digestive tract, before it reaches the anus and stool passes from the body. It is made of layers of smooth muscle and mucous membranes that line the twisting, tube-like colon.

Bowel perforations occur when a hole is made in the mucosa, the most inner layer of this lining. Whether from a surgical procedure or a serious bowel disease, this is a true medical emergency. It requires immediate medical attention.

This article explains how such a hole in the colon tissues can cause its contents to leak out into the space in your abdomen. It details the causes, risks, symptoms, and treatment of a perforated bowel.

Bowel Perforation Symptoms

The symptoms of a bowel perforation can vary. They may start slowly or be quite fast, depending on the cause. Symptoms may include:

• Pain, often severe and spread across your abdomen
• Severe cramps in the stomach region
• Bloating, or a feeling of tightness or swelling
• Nausea and vomiting
• A change in your bowel movements or habits
• Bleeding from the rectum
• Fever, which is usually delayed
• Body chills
• Fatigue, or feeling tired

Complications

The contents of the bowel can leak out through the hole in the colon wall. Gastric acids, bacteria, and food particles can leak into the abdominal cavity that contains many of your internal organs. It is normally sterile, meaning it is free from such contamination.

The leaked bowel contents can lead to infection and inflammation. It also can cause an abscess, or pus-filled space, to form in your abdomen. Usually, this will cause a great deal of pain.

When this happens, it is called peritonitis. This painful infection can lead to a body-wide infection called sepsis. These conditions are life-threatening and often fatal when they are left untreated.

Complications of an untreated perforation may include:

• Bleeding
• Infection leading to sepsis
• Death

Factors that affect the severity of a bowel perforation include your overall age and health. The outcome also may depend on how much time it takes to diagnose and treat the problem. This is why it's so important to act quickly if you experience any symptoms.

Causes

You can have a hole in your colon that happens by itself. This spontaneous type of perforation is usually due to a medical condition, such as inflammatory bowel disease (IBD).

Bowel perforations also can be caused by a medical procedure that's done in or near your digestive tract. Some procedures rely on instruments that can create a hole in the colon by accident.

Trauma, caused by some type of accident or force, also can cause a bowel perforation. This is especially true of blunt trauma to the abdomen, such as occurs with a direct kick or a long fall.

Causes Linked to a Procedure

Several medical procedures can lead to a bowel perforation. These causes may include:

• Enema: Most enemas use a tube that's inserted into the rectum. If this is done with too much force, or done the wrong way, it can rip or push through the colon lining.
• Bowel preparation for colonoscopy: It's rare, but the bowel cleansing that you do before a colonoscopy can create a hole. This is more common in people with a history of constipation.
• Sigmoidoscopy: The endoscope is a tool used to perform a flexible sigmoidoscopy. It's also used safely for other procedures. But perforation remains a risk, even if it is rare.
• Colonoscopy: It's possible for the tip of the endoscope to push through the inner lining of the colon. This is a rare complication and is not seen in a virtual colonoscopy. A hole created by a colonoscopy is more common when polyps are removed during the procedure.
• Abdominal or pelvic surgery: Surgery, especially for colon cancer, may create the risk of a perforation.

Spontaneous Causes

Other causes of a bowel perforation are not linked to a medical procedure. They may include:

• IBD conditions such as Crohn's disease and ulcerative colitis. The lifetime risk of bowel perforation with Crohn's disease is between 1% and 3%, making this a very common cause.
• Severe bowel obstruction, especially when the colon is "weakened." This can be due to a diverticular disease, cancer, or another underlying health condition.
• Trauma or injury to the bowel
• Ischemic bowel disease, with some type of interference in the blood supply to the colon
• Colon cancer
• A foreign object, such as a fish bone, bone fragments, or other non-food item
• Bowel impaction, with feces you can't pass because of severe constipation

Risk Factors

Several factors may raise your risk of a bowel perforation including:

• Recent or prior abdominal surgery
• Recent or prior pelvic surgery
• Age greater than 75
• History of more than one medical problem
• Trauma to the abdomen or pelvis, as with an accident
• History of diverticular disease
• History of IBD
• Colon cancer
• Taking Yervoy (ipilimumab) as part of cancer treatment
• Scar tissue in the pelvis, usually from a previous surgery
• Being assigned female at birth, because the colon is more easily injured during a procedure

Diagnosis

If your healthcare provider thinks you have a bowel perforation, they likely will order some tests. A simple X-ray may show that you have gas outside of your colon but usually is not enough for a diagnosis.

Often, you'll need to have a computed tomography (CT) scan of your abdomen. A barium enema may be needed, but this procedure to introduce a contrast liquid for better imaging may itself be a risk for bowel perforation.

A complete blood count may reveal that your level of white blood cells is high. This is common with infection and suggests a hole in your colon wall may have been there for a while. Your blood tests also may show signs of anemia due to bleeding.

Smaller perforations may be harder to diagnose, and that may mean more time and imaging tests.

Treatment

In most cases, you'll need surgery to repair a bowel perforation. This depends on the size and the site of the tear. A gastroenterologist or colorectal surgery specialist may be able to fix it through an endoscope. However, this is not an option for everyone.

Open bowel surgery is more complicated. In some cases, it may result in a stoma and colostomy. A procedure is done to create the stoma, an intentional opening outside of your stomach. Your stool then drains into a small bag until the colon is healed.

Recovery

At the start of your recovery, you will not be able to drink or eat anything by mouth. This is called resting the bowels. It gives the inner lining of the colon the time to heal properly.

You will also have a nasogastric tube in place to drain the contents of your stomach for a period of time. You may receive intravenous antibiotics and nutrition for a few days if you're in the hospital.

You'll want to get back to your normal routine, to be sure. But it's important to give your colon the time to heal properly and follow your healthcare provider's orders.

Summary

A bowel perforation is a hole in the lining of your colon. It can happen for a variety of reasons, some of them related to medical conditions that people already have, such as IBD or colon cancer. These holes also can be caused by injury, including the rare perforation that happens during a medical procedure like a colonoscopy.

The contents in your colon can leak out through the hole caused by a perforated bowel. This can cause bleeding, as well as a painful and serious infection. A bowel perforation usually can be treated with surgery. If left untreated, though, the infection it causes can lead to death and disability.

If you think you have symptoms of bowel perforation, don't wait. Seek medical care immediately.

A Word From Verywell

People who have chronic digestive disorders may not think that a symptom like constipation is all that serious. It can be, and it can even lead to a bowel perforation. Be sure to keep your healthcare provider up-to-date on what you're experiencing.