Gastrointestinal perforation classification

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

Gastrointestinal perforation may be classified based upon the etiology into instrumental perforation, perforation due to systemic diseases, perforation due to inflammatory causes, medications and neoplasms. Gastrointestinal perforation may also be divided based on age of the patient into adult type and neonatal type perforation.

Gastrointestinal perforation classification

There is no specific classification for gastrointestinal perforation but it can be classified by cause and by age of the patients.

Gastrointestinal perforation can be classified by causes into:

Instrumental:

• Instrumentation of the gastrointestinal tract includes upper endoscopy, sigmoidoscopy, colonoscopy, stent placement, endoscopic sclerotherapy, nasogastric intubation, esophageal dilation, and surgery.
• 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.
• Immunosuppressed individuals may be at increased risk for perforation and deep organ space infection following surgery.

Systemic:

• 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
• Enteric-coated potassium chloride
• Monoclonal antibodies: Bevacizumab
• Meckel’s diverticulum

Inflammatory

• 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.

Medication

• Aspirin, potassium, disease-modifying antirheumatic drugs, and non-steroidal anti-inflammatory drug use have been associated with perforation.

Neoplasm

• Neoplasms can perforate by direct penetration and necrosis, or by producing obstruction.

Gastrointestinal perforation can be classified by age into:

• Adult-type gastrointestinal perforation
• Neonatal gastrointestinal perforation:
  • Necrotising enterocolitis
  • Spontaneous
  • Iatrogenic
  • Umbilical catheterization
  • Umbilical cord clamping
  • Nasogastric tube
  • Obstruction
  • Ileal atresia
  • Gastric volvulus
  • Gastroschisis
  • Perforated inguinal hernia