Gastrointestinal perforation causes
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 of the gastrointestinal tract includes upper endoscopy, sigmoidoscopy, colonoscopy, stent placement, endoscopic sclerotherapy, nasogastric intubation, esophageal dilation, and surgery is the commonest cause of gastrointestinal perforation. Other causes include medications, foreign bodies, violent retching, Peptic ulcer disease. Perforation of the small intestine can be related to bowel obstruction, acute mesenteric ischemia, inflammatory bowel disease. Colonic diverticulosis is common cause of perforation in large intestine. Causes of spontaneous intestinal perforation in adults include Crohn’s disease, Celiac disease, graft-vs-host disease, and infection. Causes of intestinal perforation in neonates include Necrotising enterocolitis, Iatrogenic, umbilical catheterization, umbilical cord clamping, nasogastric tube, Obstruction, and ileal atresia.
Gastrointestinal perforation causes
Causes of gastrointestinal perforation in adults
Instrumentation
- Instrumentation of the gastrointestinal tract includes upper endoscopy, sigmoidoscopy, colonoscopy, stent placement, endoscopic sclerotherapy, nasogastric intubation, esophageal dilation, and surgery.[1]
- The area of the esophagus at most risk for instrumental perforation is Killian's triangle, which is the part of the pharynx formed by the inferior pharyngeal constrictor and cricopharyngeus muscle.
- Gastrointestinal leakage can also occur postoperatively as a result of anastomotic breakdown.[2]
- Immunosuppressed individuals may be at increased risk for dehiscence and deep organ space infection following surgery.[3]
Other causes
- Medications: aspirin, potassium, disease-modifying antirheumatic drugs, and non-steroidal anti-inflammatory drug use has been associated with perforation.[4]
- Foreign bodies such as sharp objects, food with sharp surfaces, or gastric bezoar.[5]
- Violent retching can lead to spontaneous esophageal perforation, known as Boerhaave syndrome due to increased intraesophageal pressure in the lower esophagus.
- 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.[6]
Small intestine causes
- Perforation of the small intestine can be related to bowel obstruction, acute mesenteric ischemia, inflammatory bowel disease.[7]
- Abdominal wall, groin, diaphragmatic, internal hernia, paraesophageal hernia, and volvulus can all lead to perforation either related to bowel wall ischemia.
- Injuries to the small intestine during laparoscopic procedures are often not recognized during the procedure.
- Crohn's disease has a propensity to perforate slowly, leading to formation of entero-enteric or enterocutaneous fistula formation.
- Diseases such as typhoid, tuberculosis, or schistosomiasis can perforate the small intestine.
- The perforations usually occur in the ileum at necrotic Peyer's patches.[8]
Large intestine causes
- Colonic diverticulosis is common in the developed world. They 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.
- Neoplasms can perforate by direct penetration and necrosis, or by producing obstruction.[9]
Causes of spontaneous intestinal perforation in adults[10]
- Crohn’s disease
- Celiac disease
- Graft-vs-host disease
- Infections:
- Viral: Cytomegalovirus
- Bacteria: Salmonella paratyphi, mycobacterium tuberculosis
- Parasites: Ascaris lumbricoides
- Protozoa: Entameba histolytica
- Drugs: NSAIDs and indomethacin[11]
- Enteric-coated potassium chloride
- Monoclonal antibodies: Bevacizumab
- Meckel’s diverticulum
- Radiation-induced vascular injury
- Atherosclerotic vascular occlusion
- Buerger’s disease
- Giant cell arteritis
- Wegener’s granulomatosis
- Henoch-schonlein purpura
- Allergic granulomatous arteritis
Causes of intestinal perforation in neonates
- Necrotising enterocolitis
- Spontaneous
- Iatrogenic
- Umbilical catheterization
- Umbilical cord clamping
- Nasogastric tube
- Obstruction
- Ileal atresia
- Gastric volvulus
- Gastroschisis
- Perforated inguinal hernia
- Malrotation/midgut volvulus
- Congenital band
References
- ↑ Akbulut S, Cakabay B, Ozmen CA, Sezgin A, Sevinc MM (2009). "An unusual cause of ileal perforation: report of a case and literature review". World J Gastroenterol. 15 (21): 2672–4. PMC 2691502. PMID 19496201.
- ↑ Rickles AS, Iannuzzi JC, Kelly KN, Cooney RN, Brown DA, Davidson M; et al. (2013). "Anastomotic leak or organ space surgical site infection: What are we missing in our quality improvement programs?". Surgery. 154 (4): 680–7, discussion 687-9. doi:10.1016/j.surg.2013.06.035. PMID 24074406.
- ↑ Ismael H, Horst M, Farooq M, Jordon J, Patton JH, Rubinfeld IS (2011). "Adverse effects of preoperative steroid use on surgical outcomes". Am J Surg. 201 (3): 305–8, discussion 308-9. doi:10.1016/j.amjsurg.2010.09.018. PMID 21367368.
- ↑ Morris CR, Harvey IM, Stebbings WS, Speakman CT, Kennedy HJ, Hart AR (2003). "Anti-inflammatory drugs, analgesics and the risk of perforated colonic diverticular disease". Br J Surg. 90 (10): 1267–72. doi:10.1002/bjs.4221. PMID 14515298.
- ↑ Strangfeld A, Richter A, Siegmund B, Herzer P, Rockwitz K, Demary W; et al. (2017). "Risk for lower intestinal perforations in patients with rheumatoid arthritis treated with tocilizumab in comparison to treatment with other biologic or conventional synthetic DMARDs". Ann Rheum Dis. 76 (3): 504–510. doi:10.1136/annrheumdis-2016-209773. PMC 5445993. PMID 27405509.
- ↑ Wu JT, Mattox KL, Wall MJ (2007). "Esophageal perforations: new perspectives and treatment paradigms". J Trauma. 63 (5): 1173–84. doi:10.1097/TA.0b013e31805c0dd4. PMID 17993968.
- ↑ Werbin N, Haddad R, Greenberg R, Karin E, Skornick Y (2003). "Free perforation in Crohn's disease". Isr Med Assoc J. 5 (3): 175–7. PMID 12725136.
- ↑ Singh NG, Mannan AA, Kahvic M, Alanzi FM (2010). "Jejunal perforation caused by schistosomiasis". Trop Doct. 40 (3): 191–2. doi:10.1258/td.2010.090352. PMID 20555055.
- ↑ Ara C, Coban S, Kayaalp C, Yilmaz S, Kirimlioglu V (2007). "Spontaneous intestinal perforation due to non-Hodgkin's lymphoma: evaluation of eight cases". Dig Dis Sci. 52 (8): 1752–6. doi:10.1007/s10620-006-9279-x. PMID 17420936.
- ↑ Gordon PV, Young ML, Marshall DD (2001). "Focal small bowel perforation: an adverse effect of early postnatal dexamethasone therapy in extremely low birth weight infants". J Perinatol. 21 (3): 156–60. doi:10.1038/sj.jp.7200520. PMID 11503101.
- ↑ Stavel M, Wong J, Cieslak Z, Sherlock R, Claveau M, Shah PS (2017). "Effect of prophylactic indomethacin administration and early feeding on spontaneous intestinal perforation in extremely low-birth-weight infants". J Perinatol. 37 (2): 188–193. doi:10.1038/jp.2016.196. PMID 27763630.