Perforated bowel

What is a perforated bowel?

A perforated bowel is a hole or split in the wall of your bowel, part of the digestive tract that runs from your stomach to your rectum. This allows the contents of your bowel to leak into your abdomen and can quickly cause a serious infection, so it is treated as a medical emergency.

What are the symptoms of a perforated bowel?

The main symptoms of a perforated bowel include:

• sudden, severe abdominal pain that does not go away
• swelling or bloating of the abdomen
• fever or chills
• nausea and vomiting
• pain or tenderness when your abdomen is touched
• a change in your bowel movements, such as constipation, diarrhoea, or blood in your stool.

If you already have a bowel condition, symptoms may build up gradually beforehand, then suddenly worsen once the perforation happens. Watch for signs of sepsis, a life-threatening reaction to infection, including:

• a high or very low body temperature
• a rapid pulse or rapid breathing
• passing much less urine than usual
• confusion or a change in mental state
• patches of discoloured skin
• difficulty breathing.

Sepsis can be fatal. If you have several of these symptoms at once, especially alongside recent abdominal surgery or a diagnosis of diverticulitis, seek emergency medical help immediately.

What causes a perforated bowel, and who is at risk?

A perforated bowel can happen when an existing condition weakens the bowel wall, or when the bowel is directly injured. Conditions that can lead to a perforation include:

• diverticulitis, where small pouches in the bowel wall become inflamed or infected
• inflammatory bowel disease, including Crohn's disease and ulcerative colitis
• appendicitis, if a severely inflamed appendix ruptures
• peptic ulcer disease, where an ulcer gradually erodes through the full thickness of the stomach or intestine wall
• a bowel obstruction or blockage of hardened stool
• cancers affecting the digestive system
• toxic megacolon, a rare but serious swelling of the colon.

A perforation can also be caused by injury, including:

• a crushing injury to the abdomen, such as in a car accident
• a knife or gunshot wound
• accidental damage during abdominal surgery, or a leak where bowel was surgically rejoined
• a complication of a colonoscopy or similar procedure
• swallowing a harmful object or a corrosive substance
• forceful vomiting.

Risk factors for diverticulitis, one of the more common underlying causes, include a low-fibre diet, chronic constipation, older age, obesity and low physical activity. Having one of these conditions does not mean you will definitely develop a perforated bowel, but it does raise your risk.

Are there different types of bowel perforation?

A bowel perforation can occur in different parts of the digestive tract, including the stomach, small intestine, or large intestine (bowel or colon), and symptoms can vary depending on the location.

Doctors also distinguish between:

• a contained perforation, where the bowel contents have not spilled into the abdominal cavity because the tear is sealed off, which can sometimes be treated without immediate major surgery
• a "free" perforation, where the contents spill freely into the abdominal cavity, which needs emergency surgery.

How is a perforated bowel diagnosed?

A doctor will examine your abdomen and check measurements such as your blood pressure, temperature, pulse and breathing rate. They will also ask about your symptoms, any other health conditions, and whether you have recently had any medical procedures or surgery.

Tests used to confirm a perforated bowel include:

• blood tests, to check for infection and assess your kidney and liver function
• an X-ray, which can show air in the abdomen, a sign of a tear
• a CT scan, to produce detailed images and help pinpoint the location of the perforation
• in some cases, a colonoscopy or upper endoscopy, to look directly inside your bowel or stomach.

How is a perforated bowel treated?

Non-surgical treatment

A contained perforation can often be treated with drainage through the skin to remove any infected fluid, combined with intravenous (IV) antibiotics. The tear may then heal on its own once the infection is under control.

However, you cannot know whether your perforation is small enough to heal this way without an urgent diagnosis, so it is important to seek medical care right away rather than wait to see if it settles.

Surgical treatment

A "free" perforation, where bowel contents have spilled into the abdomen, needs emergency surgery. Depending on the location and severity, this may involve:

• an endoscopic procedure, using a camera to guide repair through your intestines, which usually does not require incisions
• laparoscopic (keyhole) surgery, using a camera and small incisions
• traditional open surgery, using larger incisions, for more complex cases
• removing the damaged section of bowel.

In some cases, you may need a temporary stoma. This is an opening created in your abdomen, with a colostomy or ileostomy bag attached to collect waste while the rest of your bowel heals. This is usually temporary, and a second surgery can later reconnect your bowel so you no longer need the bag.

You will also usually need IV antibiotics for several weeks, whether or not you have surgery, to help prevent or treat infection.

Recovery after surgery can take several weeks, and many people who receive prompt treatment make a full recovery.

When should I see a doctor?

A perforated bowel is a medical emergency. Seek emergency medical care immediately if you have sudden, severe abdominal pain, especially alongside fever, abdominal swelling, or vomiting, and particularly if you have a diagnosed digestive condition or have recently had abdominal surgery or a colonoscopy.

Do not wait to see if the symptoms go away on their own, and do not try to manage this condition at home.