Bowel Perforation

A Bowel Perforation Is Rare With IBD -- But It Is Serious

Bowel perforation
The severe ulceration that can occur in the colon because of IBD could -- rarely -- lead to a perforation. Image © A.D.A.M.

Perforation of the small intestine or the large intestine is a serious and potentially fatal complication of inflammatory bowel disease (IBD). A bowel perforation is a surgical emergency, and needs immediate treatment to prevent further complications such as infection or even death.

If you are concerned you have symptoms of a bowel perforation, contact your doctor right away. If you have symptoms such as heavy bleeding and severe abdominal pain, you may need to get to your local emergency department or call an ambulance.

How Common Is Bowel Perforation?

A perforation due to IBD is thankfully considered a rare event. Perforation due to Crohn's disease is estimated to be between 1 and 3 percent over the course of the disease. Perforations are more common, however, during the first flare-up of ulcerative colitis. The risk increases in particular when that first flare-up is extremely severe in nature. A perforation may also occur when long standing disease (such as after about 8 to 10 years after diagnosis) causes the wall of the intestine to become very weak because of deep ulcerations. The weakened intestinal walls are more susceptible to developing a tear.

Symptoms of an Intestinal Perforation

The symptoms of a perforation can include:

  • Severe abdominal pain
  • Fever
  • Chills
  • Nausea
  • Rectal bleeding, sometimes heavy
  • Vomiting

Diagnosing a Bowel Perforation

A perforation is often diagnosed based on the history and a physical examination of the patient.

Having many of the above symptoms may lead a physician to suspect a perforation, especially for those with Crohn's disease, or long-standing inflammation from IBD.

Some of the tests done to diagnose and find a perforation include radiology tests such as a CT scan or an x-ray of the abdomen. In some cases, a perforation might not be found until exploratory abdominal surgery is done.

An x-ray may show abnormalities in the abdomen, such as air under the diaphragm, which is a result of the perforation. A CT scan may be performed because it could show the actual location of the perforation, which will help in devising a treatment plan. If the abdomen is palpated (felt by a physician), it may feel very rigid.

How a Perforation is Treated

In some cases, a perforation may be treated with antibiotics to counter any potential infection, placement of a nasogastric tube, and bowel rest (nothing to eat or drink).

More often, surgery is needed to repair the perforation and remove any waste material that has leaked from the intestine into the abdominal cavity. If the contents of the bowel have entered the abdominal cavity, the bacteria that are present in fecal matter may travel through the body and cause a massive and potentially fatal infection (peritonitis).

The type and extent of surgery needed will depend on the severity of the perforation and the condition of the patient. In some cases a portion of the intestine will need to be removed.

A temporary ileostomy or colostomy may also be needed to allow the intestine some time to heal.

Sources:

Langell JT, Mulvihill SJ. "Gastrointestinal perforation and the acute abdomen." Med Clin North Am May 2008;92: 599-625, viii-ix. 19 Nov 2013.

Sachar DB, Walfish AE. "Ulcerative colitis." The Merck Manual Dec 2012. 19 Nov 2013.

Tomaszczyk M, Zwemer DA. "Spontaneous free perforation of the distal ileum in Crohn's disease: case study." Int Surg 2005 Jul-Aug;90(3 Suppl):S45-S47. 19 Nov 2013.

Werbin N, Haddad R, Greenberg R, Karin E, Skornick Y. "Free perforation in Crohn's disease." Isr Med Assoc J 2003 Mar;5:175-177. 19 Nov 2013.

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