Intestinal Perforation

Intestinal perforation is a very dangerous condition that may be easily fatal. It is a feared risk of endoscopic procedures.


The most common cause is a rupture of the colon during colonoscopy. Higher risk is in elderly people with fragile intestinal wall, in patients with intestinal inflammations and in people with diverticulosis. Endoscopic therapeutic procedures (i.e. endoscopic polypectomy) also increase the risk of perforation. Carefully performed colonoscopy reduces the risk, but is never totally eliminated. Another cause of perforation may be a swallowed sharp object, which is rather a problem of children and mentally ill patients.


Spontaneous perforation of the intestinal wall occurs rarely. The highest risk is in patients, whose intestines are affected by a pathological process including inflammation (Crohn’s disease, ulcerative colitis, severe appendicitis, diverticulitis), or colon cancer.


In the first moment, the perforation of the intestinal wall is asymptomatic, or accompanied only with a mild abdominal pain. The main problem is that both the air and intestinal contents get into the abdominal cavity. This situation leads to restricted or diffuse peritonitis. Bacterial peritonitis is lethal as the bacterial toxins are well absorbed through the peritoneum (membrane covering the abdominal cavity) into local bloodstream causing sepsis (blood poisoning). The typical symptoms include abdominal pain, stiff abdomen, high fever and other general signs of infection. Untreated septic condition usually progresses into a fatal cardiovascular shock. Intestinal activity stops due to the inflammation causing emergence of so-called paralytic ileus.


The patient with acute abdominal pain should be cautiously examined by a doctor, in ideal case by a surgeon. The physical examination must be focused on the abdomen and symptoms of peritoneal signs (stiff abdomen, pain to the touch, etc.). X-ray of the abdomen is essential as it shows free air in the abdominal cavity and thus informs us about a very probable perforation of the gastrointestinal tract. Compute tomography of the abdomen can give us better and more precise information about the conditions in the abdominal cavity. In many cases, however, the diagnosis, the exact location and the cause of intestinal perforation are stated only during a therapeutic surgical intervention.


When the perforation is small and happens during a colonoscopy, the doctors can immediately close the hole by special clips. This procedure, however, requires an experienced endoscopist. The other option is a surgical intervention when the location of damaged intestine must be found and closed. The patient should not receive any food or fluids orally; the hydration and administration of antibiotics should be done intravenously.


Jiri Stefanek, MD  Author of texts: Jiri Stefanek, MD
 Sources: basic text sources