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]
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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. [22,74-77].
- 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. [8,21-24].
- 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. [22,73].
- 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]