Gastrointestinal perforation risk factors

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]

Gastrointestinal perforation Microchapters
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Overview

Instrumentation

• Instrumentation of the gastrointestinal tract includes upper endoscopy, sigmoidoscopy, colonoscopy, stent placement, endoscopic sclerotherapy, nasogastric intubation, esophageal dilatation, and surgery. [10,11, 12, 13]
• The area of the esophagus at most risk for instrumental perforation is Killian's triangle, the part of the pharynx formed by the inferior pharyngeal constrictor and cricopharyngeus muscle.
• Immunosuppressed individuals may be at increased risk for dehiscence and deep organ space infection following surgery. [32]

Other causes

• Medications: Aspirin, potassium supplements, disease-modifying antirheumatic drugs (DMARDs), and nonsteroidal anti-inflammatory drug (NSAID) use has been associated with perforation of colonic diverticula. 43 48, 44
• Foreign bodies such as sharp objects, food with sharp surfaces, or gastric bezoar. 34-37

• Violent retching can lead to spontaneous esophageal perforation, known as Boerhaave syndrome due to increased intraesophageal pressure in the lower esophagus. [51]

Gastric causes

• Peptic ulcer disease is the most common cause of stomach and duodenal perforation.
• Marginal ulcers may complicate procedures involving a gastrojejunostomy.
• Perforated gastric ulcer is associated with a higher mortality, possibly related to delays in diagnosis. [121].

Small intestine causes

• Perforation of the small intestine can be related to bowel obstruction, acute mesenteric ischemia, inflammatory bowel disease, or due to iatrogenic or noniatrogenic traumatic mechanisms. [53]
• Abdominal wall, groin, diaphragmatic, internal hernia, paraesophageal hernia, and volvulus can all lead to perforation due to ischemia.
• Injuries to the small intestine during laparoscopic procedures are often not recognized during the procedure. [22]
• Crohn's disease has a propensity to perforate slowly, leading to formation of fistula. [52,53]

• Diseases such as typhoid, tuberculosis, or schistosomiasis can perforate the small intestine.
• The perforations usually occur in the ileum at necrotic Peyer's patches.
• A reperforation rate of 21.3 percent has been reported for typhoid perforation closure. [136] [61]

Large intestine causes

• Colonic diverticulosis is common in the developed world. These diverticula can become inflamed and perforate and may lead to abscess formation.

• Mesenteric ischemia increases the risk for perforation. Embolism, mesenteric occlusive disease, and heart failure lead to gastrointestinal ischemia. [59]
• Neoplasms can perforate by direct penetration and necrosis, or by producing obstruction. [64-66

Neonatal intestinal perforation risk factors

Risk factors for necrotizing enterocolitis (NEC):

• Ninety percent of NEC cases occur in preterm infants due to immaturity of the gastrointestinal tract. [7,8][39,40].
• Preterm infants have lower concentrations or more immature function of contributing mucosal defense factors than do term infants and adults [4].
• Preterm infants have high levels of cytokines such as tumor necrosis factor, IL-1, IL-6, IL-8, IL-10, IL-12, and IL-18 that increase vascular permeability and attract inflammatory cells.
• Human milk is more protective against NEC in preterm infants than formulas. The mucus coat of the intestine is less affected by human milk than formulas.
• Growth factors within human milk repair disturbed layers in intestine.
• Bacterial colonization is believed to play a pivotal role in the development of NEC.
• Rapid colonization of the intestinal tract by commensal bacteria from the maternal rectovaginal flora normally occurs.
• Ischemic insult to the GI tract has been proposed as a major contributor to NEC. [30,49,50]. Inflammatory mediators induced by ischemia, infectious agents, or mucosal irritants may cause mucosal injury.
• Events that have been implicated in the development of NEC include:
• perinatal asphyxia [51]
• Recurrent apnea
• Respiratory distress syndrome
• Hypotension
• Congenital heart disease [52,53]
• Patent ductus arteriosus
• Umbilical arterial catheterization
• Anemia
• Polycythemia [54,55][59]
• Medications such as theophylline or phenobarbital might irritate the intestinal mucosa. [70].

Risk factors for spontaneous intestinal perforation of the newborn:

• Placental chorioamnionitis appears to be an antenatal risk factor for SIP. [11].
• Antenatal administration of glucocorticoids, nonsteroidal antiinflammatory drugs, indomethacin, and magnesium sulfate had been initially reported to increase the risk of SIP. [13,15,16].
• Delayed onset of feeding
• Intraventricular hemorrhage of Grade III or higher [24,25]