Understanding a Bowel Perforation

What is a bowel perforation or hole in your colon and what are the symptoms? Who is at risk? And how is a perforation treated?

Your colon is composed of layers of smooth muscle and mucous membranes. The innermost layer, called the mucosa, is soft and pliant—similar to the tissues in your mouth. Bowel perforations occur when a hole is made in this lining, often as a result of colon surgery or serious bowel disease. A hole in the colon then allows the contents of the colon to leak into the usually sterile contents of your abdominal cavity.

The symptoms of a bowel perforation can vary and may come on slowly or rapidly depending on the underlying cause. Symptoms may include:

• Abdominal pain (often severe and diffuse)
• Severe abdominal cramping
• Bloating
• Nausea and vomiting
• A change in your bowel movements or habits.
• Rectal bleeding
• Fever (usually not immediately)
• Chills
• Fatigue

Scientists have found that a number of factors may increase your risk of developing a bowel perforation. These include both factors involved in surgery or a procedure (iatrogenic causes) and bowel diseases characterized by inflammation. Risk factors may include:

• Recent or prior abdominal.
• Recent or prior pelvic surgery.
• Age greater than 75.
• History of multiple medical problems.
• Trauma to the abdomen or pelvis (such as in an automobile accident.)
• A history of diverticular disease.
• A history of inflammatory bowel disease.
• Colon cancer
• Use of the monoclonal antibody immunotherapy drug ipilimumab.
• Pelvic adhesions (scar tissue, usually related to previous surgeries.)
• Female gender (women typically have a more flexible colon, which can lead to accidental perforation during medical procedures, including a colonoscopy.)
• Diagnostic and surgical procedures involving the digestive tract, abdomen, or pelvis. Risk factors for a perforation during a colonoscopy include being female, older age, a history of diverticular disease, and bowel obstructions.

Bowel perforations may occur spontaneously (unexpectedly) as a result of a medical condition or instead be a complication of various diagnostic and surgical procedures which accidentally create a hole in the colon. Trauma, especially blunt trauma to the abdomen, is also an important cause of bowel perforations.

Procedure associated causes include:

• Enema – An improperly or forcefully inserted rectal tube for an enema can rip or push through the colon lining.
• Bowel preparation for colonoscopy - Rarely, the bowel preparation for a colonoscopy can result in a perforation. This is more common in people with a history of constipation.
•  Sigmoidoscopy – Although the endoscope for a flexible sigmoidoscopy is flexible, perforation remains a risk, but a rare one.
• Colonoscopy – The tip of the endoscope has the potential to push through the inner lining of the colon, although this is a rare complication of the procedure and is not seen in the virtual colonoscopy. Perforation of the bowel associated with a colonoscopy is more common in those who have the severe acute disease of the bowel as well as those who are on steroid medications. The colonoscopy perforation rate appears to be around 1 in 1400 people who have screening colonoscopies and 1 of 1000 people who have a therapeutic colonoscopy (for example, to remove a polyp.)
• Abdominal or pelvic surgery, particularly colon surgery as for colon cancer.

Causes of spontaneous bowel perforation (those unrelated to surgery or procedures) include:

• Inflammatory bowel disease/colitis such as Crohn's disease and ulcerative colitis. The lifetime risk of a bowel perforation with Crohn's disease is between one and three percent, making this a very common cause.
• Severe bowel obstruction, especially when the colon is "weakened" by diverticular disease, another process, or cancer.
• Trauma.
• Ischemic bowel disease (when the blood supply to the colon is compromised.)
• Colon cancer.
• Foreign body ingestion - Most commonly due to the ingestion of fish bones, and bone fragments, as well as non-food items.
• Severe bowel impaction.

If your doctor suspects a bowel perforation, she can order tests to confirm her suspicion. A simple abdominal x-ray may show gas outside the colon but is not often diagnostic. A CT scan of your abdomen with or without contrast or a barium enema or swallow may be needed. A complete blood count may show an elevation of your white blood cell count if the perforation has been present for a while, or evidence of anemia due to bleeding. Small perforations may sometimes take several imaging studies and time to accurately diagnose.

Perforation of the bowel is considered a medical emergency and requires immediate treatment. Left untreated, the contents of the bowel can leak out and cause inflammation, infection and even abscesses in your abdomen. The technical name for this is peritonitis, which is a painful precursor to sepsis—or a body-wide infection.

The majority of perforations are surgically repaired. Depending on the location and size of the tear, the doctor might be able to fix it through an endoscope, similar to the one used during a colonoscopy—but this is not an option for everyone. Open bowel surgery may or may not result in a stoma and colostomy: an artificial opening outside of your stomach where stool drains into a small bag until the bowel is healed.

Complications of untreated perforation may include:

• Bleeding
• Infection (peritonitis and sepsis)
• Death

Complications depend on a person's general health, as well as the amount of time it has taken to diagnose and treat the perforation.

During your initial recovery period, you will not be able to drink or eat anything by mouth. This is called resting the bowels and allows the inner lining 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. Although you may be anxious to return to your normal routine, it's important that you give your colon time to heal properly, and follow your doctor's orders.

The Bottom Line

Bowel perforation may occur spontaneously, such as with inflammatory bowel disease, or during surgery or diagnostic tests. Symptoms may come on rapidly, or instead slowly, and should be considered in anyone who has risk factors for a perforation combined with risk factors for the condition.

When caught early, there are different treatment options available, but even with surgery (which is most often required) the bowel can often be preserved and repaired without a colostomy. Recovery can take time, both for healing, and to correct and risk factors which led to the perforation.