Gastrointestinal perforation risk factors: Difference between revisions
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==Overview== | ==Overview== | ||
'''Instrumentation/surgery''' | |||
Instrumentation of the gastrointestinal tract is the main cause of iatrogenic perforation and may include upper endoscopy, sigmoidoscopy, colonoscopy [10,11], stent placement [10,11], endoscopic sclerotherapy [12], nasogastric intubation [13], esophageal dilation, and surgery. | |||
The incidence of perforation related to endoscopy increases with procedural complexity. | |||
Perforation is less common with diagnostic compared with therapeutic procedures [14]. | |||
A perforation rate of 0.11 percent for rigid endoscopy contrasts with a 0.03 percent rate for flexible endoscopy [15,16]. When iatrogenic perforation occurs, there is often significant associated pathology. As an example, in the esophagus, there may be stricture, severe esophagitis [17], or a diverticulum, and the presence of cervical osteophytes also increases the risk [16]. The area of the esophagus at most risk for instrumental perforation is Killian's triangle [18], which is the part of the pharynx formed by the inferior pharyngeal constrictor and cricopharyngeus muscle. During endoscopy, perforations are frequently recognized at the time of the procedure. At other times, the perforation remains occult for several days. | |||
Other procedures can also be complicated with perforation, such as chest tube insertion low in the chest [19], peritoneal dialysis catheter insertion, percutaneous gastrostomy [20], paracentesis, diagnostic peritoneal lavage, and percutaneous drainage of fluid collections or abscess. | |||
With surgery, perforation can occur during initial laparoscopic access, during mobilization of the organs or during the takedown of adhesions, or as a result of thermal injury from electrocautery devices [21-23]. Gastrointestinal leakage can also occur postoperatively as a result of anastomotic breakdown [24-31]. Immunosuppressed individuals may be at increased risk for dehiscence and deep organ space infection following surgery [32]. Medical illnesses such as diabetes, cirrhosis, and HIV are associated with an increased risk of anastomotic leak after colon resection for trauma [33 | |||
'''Penetrating or blunt trauma''' | |||
Traumatic perforation of the gastrointestinal tract is most likely a result of penetrating injury, although blunt perforation can occur with severe abdominal trauma acutely related to pressure effects or as a portion of the gastrointestinal tract is compressed against a fixed bony structure, or more slowly as a contusion develops into a full-thickness injury. (See "Overview of esophageal perforation due to blunt or penetrating trauma" and "Traumatic gastrointestinal injury in the adult patient".) | |||
'''Medications, other ingestions, foreign body''' | |||
Medications or other ingested substances (caustic injury) and foreign bodies (ingested or medical devices) can lead to gastrointestinal perforation. Foreign bodies, such as sharp objects (toothpicks), food with sharp surfaces (eg, chicken bones, fish), or gastric bezoar more commonly cause perforation, compared with dislodged medical implants [34-37]. Button batteries as an esophageal foreign body have a more pronounced perforation risk [38,39]. Surgically implanted foreign bodies such as hernia mesh [40] and artificial vascular grafts [41,42] can cause perforation with subsequent abscess and fistula formation or vasculoenteric fistulas. (See "Caustic esophageal injury in children" and "Caustic esophageal injury in adults" and "Foreign bodies of the esophagus and gastrointestinal tract in children" and "Ingested foreign bodies and food impactions in adults".) | |||
Aspirin and nonsteroidal anti-inflammatory drug (NSAID) use has been associated with perforation of colonic diverticula, with diclofenac and ibuprofen being the most commonly implicated drugs [43]. Some disease-modifying antirheumatic drugs (DMARDs) have been associated with lower intestinal perforations [44]. Rarely, NSAIDs have produced jejunal perforations [45]. Glucocorticoids, particularly in association with NSAIDs, are particularly problematic [46,47]. Further, because steroids suppress the inflammatory response, detection of a perforation can be delayed. | |||
NSAIDs, antibiotics, and potassium supplements are also common causative medications for pill-induced esophageal ulcers [48]. Other medication-induced injury leading to perforation has been reported for immunosuppressive therapies, cancer chemotherapy in patients with metastases, and for iron supplementation causing esophageal injury [2,49,50]. | |||
'''Violent retching/vomiting''' | |||
Violent retching/vomiting can lead to spontaneous esophageal perforation, known as Boerhaave syndrome. This occurs because of failure of the cricopharyngeal muscle to relax during vomiting or retching causing an increased intraesophageal pressure in the lower esophagus [51]. (See "Boerhaave syndrome: Effort rupture of the esophagus".) | |||
'''Hernia/intestinal volvulus/obstruction''' | |||
Abdominal wall, groin, diaphragmatic, internal hernia, paraesophageal hernia, and volvulus (gastric, cecal, sigmoid) can all lead to perforation either related to bowel wall ischemia from strangulation, or pressure necrosis. Perforation can also occur with afferent loop obstruction after Roux-en-Y reconstruction. (See "Overview of abdominal wall hernias in adults" and "Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults" and "Overview of treatment for inguinal and femoral hernia in adults" and "Surgical management of paraesophageal hernia" and "Gastric volvulus in adults" and "Postgastrectomy complications", section on 'Afferent and efferent loop syndrome'.) | |||
'''Inflammatory bowel disease''' | |||
Crohn disease has a propensity to perforate slowly, leading to formation of entero-enteric or enterocutaneous fistula formation [52,53]. (See "Operative management of Crohn disease of the small bowel, colon, and rectum"and "Surgical management of ulcerative colitis".) | |||
'''Appendicitis''' | |||
Overall in the United States in 2010, approximately 30 percent of hospital stays for appendicitis involved a perforated appendix [54-56]. Rates for perforated appendix in children have not significantly changed from 2001 to 2010 (approximately 300/1000 appendicitis discharges), whereas the rate has declined 12 percent for adults (from 307/1000 to 270/1000appendicitis discharges). (See "Acute appendicitis in children: Clinical manifestations and diagnosis" and "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".) | |||
'''Peptic ulcer disease''' | |||
Peptic ulcer disease (PUD) is the most common cause of stomach and duodenal perforation but occurs in less than 10 percent of patients with PUD. In spite of the introduction of proton pump inhibitors, the incidence of perforation from PUD has not changed appreciably [57]. Marginal ulceration leading to perforation may also complicate surgeries that create a gastrojejunostomy (eg, partial gastric resection, bariatric surgery). (See "Overview of the complications of peptic ulcer disease".) | |||
'''Diverticular disease''' | |||
Colonic diverticulosis is common in the developed world. All clinical cases of diverticulitis represent some degree of perforation of the thinned diverticular wall, leading to inflammation of the adjacent parietal peritoneum [58]. (See "Acute colonic diverticulitis: Surgical management" and "Overview of colon resection", section on 'Primary closure versus ostomy'.) | |||
Perforation can also occur with duodenal or small intestinal diverticula (jejunal, Meckel's). These diverticula can become inflamed, much as in colonic diverticulitis, and perforate, which may lead to abscess formation. (See "Meckel's diverticulum".) | |||
'''Cardiovascular disease''' | |||
Any process that reduces the blood flow to the intestines (occlusive or nonocclusive mesenteric ischemia) for an extended period of time increases the risk for perforation, including embolism, mesenteric occlusive disease, cardiopulmonary resuscitation, and heart failure that leads to gastrointestinal ischemia [59]. (See "Overview of intestinal ischemia in adults".) | |||
'''Infectious disease''' | |||
Typhoid, tuberculosis, and schistosomiasis can cause perforation of the small intestine [60,61]. With typhoid, the perforation is usually in a single location (ileum at necrotic Peyer's patches), but it can be multiple [62,63]. Typhoid perforation is more common in children, adolescents, or young adults. Cytomegalovirus, particularly in an immunosuppressed patient, can cause intestinal perforation. | |||
'''Neoplasms''' | |||
Neoplasms can perforate by direct penetration and necrosis, or by producing obstruction. Perforations related to tumor can also occur spontaneously, following chemotherapy, or as a result of radiation treatments when the tumor involves the wall of a hollow viscus organ [64-66]. Delayed perforations of the esophagus or duodenum in patients with malignancy can be related to stent placement for malignant obstruction. | |||
'''Connective tissue disease''' | |||
Spontaneous perforation of the small intestine or colon has been reported in patients with underlying connective tissue diseases (eg, Ehlers-Danlos syndrome), collagen vascular disease, and vasculitis [67-69]. (See "Clinical manifestations and diagnosis of Ehlers-Danlos syndromes" and "Genetics, clinical features, and diagnosis of Marfan syndrome and related disorders".) | |||
'''''causes''''' | |||
Perforation of the esophagus is more often iatrogenic (endoscopy or related to surgery), or due to noniatrogenic penetrating or blunt traumatic mechanisms [118]. | |||
Other causes include tumors, foreign body or caustic ingestion [34,35], pneumatic injury, peptic ulceration, intrinsic esophageal disease such as pill esophagitis [1,2], Crohn disease [3], eosinophilic esophagitis [4], foreign body ingestion, or, more rarely, it is spontaneous (Boerhaave's syndrome). During surgery, the esophagus can be injured during operations such as hiatal hernia repair, thyroidectomy, pulmonary procedures, and vagotomy. | |||
'''''causes''''' | |||
Peptic ulcer disease is the most common cause of stomach and duodenal perforation. | |||
Marginal ulcers may complicate procedures involving a gastrojejunostomy (eg, partial gastrectomy, bariatric surgery). | |||
Although the frequency of elective surgery for peptic ulcer disease has declined, the incidence of peptic perforation has remained the same or is increasing [57]. | |||
Perforated duodenal ulcers are located on the anterior or superior portions of the duodenum and typically rupture freely, causing severe acute abdominal pain. Perforated gastric ulcer is associated with a higher mortality, possibly related to delays in diagnosis [121]. | |||
Other causes include iatrogenic (endoscopy, surgery [open or laparoscopic]) or noniatrogenic trauma [14,19,59], ingested foreign bodies [36], neoplasm (particularly during chemotherapy) [64,65], tuberculosis [122], and perforated duodenal diverticulum. Gastric perforation during cardiopulmonary resuscitation can also occur [59]. | |||
'''''causes''''' | |||
Perforation of the small intestine can be related to bowel obstruction, acute mesenteric ischemia, inflammatory bowel disease [53], or due to iatrogenic (laparoscopic access, takedown of adhesions, endoscopy) or noniatrogenic traumatic mechanisms. Injuries to the small intestine during laparoscopic procedures are often not recognized during the procedure [22]. Severe pain or sepsis after a laparoscopic procedure should be investigated promptly [23]. Perforations caused by the tumor (eg, lymphoma [66]) can occur spontaneously or after chemotherapy. Further, because glucocorticoids suppress the inflammatory response, detection of a perforation can be delayed. Other causes of small intestinal perforation include foreign body ingestion, enteroliths/gallstones [5,6], or, more rarely, migrated stents (eg, esophageal, biliary). | |||
Perforation of a diverticulum of the small intestine, such as in perforated Meckel's diverticulum, can occur and may lead to abscess formation. Occasionally, jejunal diverticula can become inflamed and perforate [135]. These rare diverticula are located along the mesenteric aspect of the proximal jejunum and decrease in number with increasing distance from the duodenal-jejunal junction. Rarely, nonsteroidal anti-inflammatory drugs (NSAIDs) have produced jejunal perforations [45]. | |||
Occasionally, particularly in developing countries, diseases such as typhoid, tuberculosis [136], or schistosomiasis [61] can perforate the small intestine. In typhoid, the perforation is usually single but can be multiple 28 to 37 percent of the time [62,63]. The perforations usually occur in the ileum at necrotic Peyer's patches. Typhoid perforation is more common in children, adolescents, or young adults and has a high mortality (3 to 72 percent) reflecting, in part, the severity of the illness these patients have in addition to the effects of the perforation. A reperforation rate of 21.3 percent has been reported for typhoid perforation closure. Cytomegalovirus, particularly in an immunosuppressed patient, can also cause intestinal perforation. | |||
Colon and rectal perforation is more commonly due to diverticulitis, neoplasm, and iatrogenic and noniatrogenic traumatic mechanisms, including surgery (eg, anastomotic leak). Colonic diverticulosis is common in the developed world, affecting up to 50 percent of adults in Western countries. A younger age group is affected in left-sided diverticulitis, and it is more common in men. With increasing age, the number of diverticuli, which predominate in the sigmoid and left colon, increases with the disease moving more proximally. In Asian countries, the most common cause of right-sided colonic perforation is diverticulitis [138]. | |||
==References== | ==References== | ||
Revision as of 00:00, 27 December 2017
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
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Overview
Instrumentation/surgery
Instrumentation of the gastrointestinal tract is the main cause of iatrogenic perforation and may include upper endoscopy, sigmoidoscopy, colonoscopy [10,11], stent placement [10,11], endoscopic sclerotherapy [12], nasogastric intubation [13], esophageal dilation, and surgery.
The incidence of perforation related to endoscopy increases with procedural complexity.
Perforation is less common with diagnostic compared with therapeutic procedures [14].
A perforation rate of 0.11 percent for rigid endoscopy contrasts with a 0.03 percent rate for flexible endoscopy [15,16]. When iatrogenic perforation occurs, there is often significant associated pathology. As an example, in the esophagus, there may be stricture, severe esophagitis [17], or a diverticulum, and the presence of cervical osteophytes also increases the risk [16]. The area of the esophagus at most risk for instrumental perforation is Killian's triangle [18], which is the part of the pharynx formed by the inferior pharyngeal constrictor and cricopharyngeus muscle. During endoscopy, perforations are frequently recognized at the time of the procedure. At other times, the perforation remains occult for several days.
Other procedures can also be complicated with perforation, such as chest tube insertion low in the chest [19], peritoneal dialysis catheter insertion, percutaneous gastrostomy [20], paracentesis, diagnostic peritoneal lavage, and percutaneous drainage of fluid collections or abscess.
With surgery, perforation can occur during initial laparoscopic access, during mobilization of the organs or during the takedown of adhesions, or as a result of thermal injury from electrocautery devices [21-23]. Gastrointestinal leakage can also occur postoperatively as a result of anastomotic breakdown [24-31]. Immunosuppressed individuals may be at increased risk for dehiscence and deep organ space infection following surgery [32]. Medical illnesses such as diabetes, cirrhosis, and HIV are associated with an increased risk of anastomotic leak after colon resection for trauma [33
Penetrating or blunt trauma
Traumatic perforation of the gastrointestinal tract is most likely a result of penetrating injury, although blunt perforation can occur with severe abdominal trauma acutely related to pressure effects or as a portion of the gastrointestinal tract is compressed against a fixed bony structure, or more slowly as a contusion develops into a full-thickness injury. (See "Overview of esophageal perforation due to blunt or penetrating trauma" and "Traumatic gastrointestinal injury in the adult patient".)
Medications, other ingestions, foreign body
Medications or other ingested substances (caustic injury) and foreign bodies (ingested or medical devices) can lead to gastrointestinal perforation. Foreign bodies, such as sharp objects (toothpicks), food with sharp surfaces (eg, chicken bones, fish), or gastric bezoar more commonly cause perforation, compared with dislodged medical implants [34-37]. Button batteries as an esophageal foreign body have a more pronounced perforation risk [38,39]. Surgically implanted foreign bodies such as hernia mesh [40] and artificial vascular grafts [41,42] can cause perforation with subsequent abscess and fistula formation or vasculoenteric fistulas. (See "Caustic esophageal injury in children" and "Caustic esophageal injury in adults" and "Foreign bodies of the esophagus and gastrointestinal tract in children" and "Ingested foreign bodies and food impactions in adults".)
Aspirin and nonsteroidal anti-inflammatory drug (NSAID) use has been associated with perforation of colonic diverticula, with diclofenac and ibuprofen being the most commonly implicated drugs [43]. Some disease-modifying antirheumatic drugs (DMARDs) have been associated with lower intestinal perforations [44]. Rarely, NSAIDs have produced jejunal perforations [45]. Glucocorticoids, particularly in association with NSAIDs, are particularly problematic [46,47]. Further, because steroids suppress the inflammatory response, detection of a perforation can be delayed.
NSAIDs, antibiotics, and potassium supplements are also common causative medications for pill-induced esophageal ulcers [48]. Other medication-induced injury leading to perforation has been reported for immunosuppressive therapies, cancer chemotherapy in patients with metastases, and for iron supplementation causing esophageal injury [2,49,50].
Violent retching/vomiting
Violent retching/vomiting can lead to spontaneous esophageal perforation, known as Boerhaave syndrome. This occurs because of failure of the cricopharyngeal muscle to relax during vomiting or retching causing an increased intraesophageal pressure in the lower esophagus [51]. (See "Boerhaave syndrome: Effort rupture of the esophagus".)
Hernia/intestinal volvulus/obstruction
Abdominal wall, groin, diaphragmatic, internal hernia, paraesophageal hernia, and volvulus (gastric, cecal, sigmoid) can all lead to perforation either related to bowel wall ischemia from strangulation, or pressure necrosis. Perforation can also occur with afferent loop obstruction after Roux-en-Y reconstruction. (See "Overview of abdominal wall hernias in adults" and "Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults" and "Overview of treatment for inguinal and femoral hernia in adults" and "Surgical management of paraesophageal hernia" and "Gastric volvulus in adults" and "Postgastrectomy complications", section on 'Afferent and efferent loop syndrome'.)
Inflammatory bowel disease
Crohn disease has a propensity to perforate slowly, leading to formation of entero-enteric or enterocutaneous fistula formation [52,53]. (See "Operative management of Crohn disease of the small bowel, colon, and rectum"and "Surgical management of ulcerative colitis".)
Appendicitis
Overall in the United States in 2010, approximately 30 percent of hospital stays for appendicitis involved a perforated appendix [54-56]. Rates for perforated appendix in children have not significantly changed from 2001 to 2010 (approximately 300/1000 appendicitis discharges), whereas the rate has declined 12 percent for adults (from 307/1000 to 270/1000appendicitis discharges). (See "Acute appendicitis in children: Clinical manifestations and diagnosis" and "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)
Peptic ulcer disease
Peptic ulcer disease (PUD) is the most common cause of stomach and duodenal perforation but occurs in less than 10 percent of patients with PUD. In spite of the introduction of proton pump inhibitors, the incidence of perforation from PUD has not changed appreciably [57]. Marginal ulceration leading to perforation may also complicate surgeries that create a gastrojejunostomy (eg, partial gastric resection, bariatric surgery). (See "Overview of the complications of peptic ulcer disease".)
Diverticular disease
Colonic diverticulosis is common in the developed world. All clinical cases of diverticulitis represent some degree of perforation of the thinned diverticular wall, leading to inflammation of the adjacent parietal peritoneum [58]. (See "Acute colonic diverticulitis: Surgical management" and "Overview of colon resection", section on 'Primary closure versus ostomy'.)
Perforation can also occur with duodenal or small intestinal diverticula (jejunal, Meckel's). These diverticula can become inflamed, much as in colonic diverticulitis, and perforate, which may lead to abscess formation. (See "Meckel's diverticulum".)
Cardiovascular disease
Any process that reduces the blood flow to the intestines (occlusive or nonocclusive mesenteric ischemia) for an extended period of time increases the risk for perforation, including embolism, mesenteric occlusive disease, cardiopulmonary resuscitation, and heart failure that leads to gastrointestinal ischemia [59]. (See "Overview of intestinal ischemia in adults".)
Infectious disease
Typhoid, tuberculosis, and schistosomiasis can cause perforation of the small intestine [60,61]. With typhoid, the perforation is usually in a single location (ileum at necrotic Peyer's patches), but it can be multiple [62,63]. Typhoid perforation is more common in children, adolescents, or young adults. Cytomegalovirus, particularly in an immunosuppressed patient, can cause intestinal perforation.
Neoplasms
Neoplasms can perforate by direct penetration and necrosis, or by producing obstruction. Perforations related to tumor can also occur spontaneously, following chemotherapy, or as a result of radiation treatments when the tumor involves the wall of a hollow viscus organ [64-66]. Delayed perforations of the esophagus or duodenum in patients with malignancy can be related to stent placement for malignant obstruction.
Connective tissue disease
Spontaneous perforation of the small intestine or colon has been reported in patients with underlying connective tissue diseases (eg, Ehlers-Danlos syndrome), collagen vascular disease, and vasculitis [67-69]. (See "Clinical manifestations and diagnosis of Ehlers-Danlos syndromes" and "Genetics, clinical features, and diagnosis of Marfan syndrome and related disorders".)
causes
Perforation of the esophagus is more often iatrogenic (endoscopy or related to surgery), or due to noniatrogenic penetrating or blunt traumatic mechanisms [118].
Other causes include tumors, foreign body or caustic ingestion [34,35], pneumatic injury, peptic ulceration, intrinsic esophageal disease such as pill esophagitis [1,2], Crohn disease [3], eosinophilic esophagitis [4], foreign body ingestion, or, more rarely, it is spontaneous (Boerhaave's syndrome). During surgery, the esophagus can be injured during operations such as hiatal hernia repair, thyroidectomy, pulmonary procedures, and vagotomy.
causes
Peptic ulcer disease is the most common cause of stomach and duodenal perforation.
Marginal ulcers may complicate procedures involving a gastrojejunostomy (eg, partial gastrectomy, bariatric surgery).
Although the frequency of elective surgery for peptic ulcer disease has declined, the incidence of peptic perforation has remained the same or is increasing [57].
Perforated duodenal ulcers are located on the anterior or superior portions of the duodenum and typically rupture freely, causing severe acute abdominal pain. Perforated gastric ulcer is associated with a higher mortality, possibly related to delays in diagnosis [121].
Other causes include iatrogenic (endoscopy, surgery [open or laparoscopic]) or noniatrogenic trauma [14,19,59], ingested foreign bodies [36], neoplasm (particularly during chemotherapy) [64,65], tuberculosis [122], and perforated duodenal diverticulum. Gastric perforation during cardiopulmonary resuscitation can also occur [59].
causes
Perforation of the small intestine can be related to bowel obstruction, acute mesenteric ischemia, inflammatory bowel disease [53], or due to iatrogenic (laparoscopic access, takedown of adhesions, endoscopy) or noniatrogenic traumatic mechanisms. Injuries to the small intestine during laparoscopic procedures are often not recognized during the procedure [22]. Severe pain or sepsis after a laparoscopic procedure should be investigated promptly [23]. Perforations caused by the tumor (eg, lymphoma [66]) can occur spontaneously or after chemotherapy. Further, because glucocorticoids suppress the inflammatory response, detection of a perforation can be delayed. Other causes of small intestinal perforation include foreign body ingestion, enteroliths/gallstones [5,6], or, more rarely, migrated stents (eg, esophageal, biliary).
Perforation of a diverticulum of the small intestine, such as in perforated Meckel's diverticulum, can occur and may lead to abscess formation. Occasionally, jejunal diverticula can become inflamed and perforate [135]. These rare diverticula are located along the mesenteric aspect of the proximal jejunum and decrease in number with increasing distance from the duodenal-jejunal junction. Rarely, nonsteroidal anti-inflammatory drugs (NSAIDs) have produced jejunal perforations [45].
Occasionally, particularly in developing countries, diseases such as typhoid, tuberculosis [136], or schistosomiasis [61] can perforate the small intestine. In typhoid, the perforation is usually single but can be multiple 28 to 37 percent of the time [62,63]. The perforations usually occur in the ileum at necrotic Peyer's patches. Typhoid perforation is more common in children, adolescents, or young adults and has a high mortality (3 to 72 percent) reflecting, in part, the severity of the illness these patients have in addition to the effects of the perforation. A reperforation rate of 21.3 percent has been reported for typhoid perforation closure. Cytomegalovirus, particularly in an immunosuppressed patient, can also cause intestinal perforation.
Colon and rectal perforation is more commonly due to diverticulitis, neoplasm, and iatrogenic and noniatrogenic traumatic mechanisms, including surgery (eg, anastomotic leak). Colonic diverticulosis is common in the developed world, affecting up to 50 percent of adults in Western countries. A younger age group is affected in left-sided diverticulitis, and it is more common in men. With increasing age, the number of diverticuli, which predominate in the sigmoid and left colon, increases with the disease moving more proximally. In Asian countries, the most common cause of right-sided colonic perforation is diverticulitis [138].