Gastrointestinal perforation epidemiology and demographics
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
Colonic perforation
The incidence of Colonic perforation (CP) could be as low as 0.016% of all diagnostic colonoscopy procedures[6] and may be seen in up to 5% of therapeutic colonoscopies[7,8].
the incidence of CP following flexible sigmoidoscopy varies from 0.027% to 0.088%. [1,9-12]
Rectal perforation during colonoscopic retroflexion was reported to be around 0.01%. [13]
Peptic perforation
There is lower incidence of peptic ulcer complications during the later years.
Incidence rates varied from 1.5 to 7.8/100000 per year regarding perforated peptic ulcers and from 5.2 to 40.2 regarding peptic ulcer bleeding.
Esophageal perforation
Seventeen esophageal perforations (1.7%) occurred in the course of 1011 procedures. Four perforations resulted from balloon dilatation, and 13 were secondary to bougienage. Six patients were managed surgically (35%), all of them recovering uneventfully. Eleven patients were managed conservatively, mainly because they were unfit for surgery. Survival rate in this group was 82%; only two patients died, both of whom had underlying malignant diseas
We recently reported a 9% incidence of bowel perforation in our cohort of 1062 patients with biopsy-proven GI involvement with lymphoma [1]. Among the 100 perforation events, the small bowel was the most common site of perforation and diffuse large B-cell lymphoma (DLBCL) was the most common histology. The risk of perforation seems to vary by both the site of involvement as well as the type of lymphoma. Herein, we report additional data from the same cohort of patients regarding site-specific incidence of perforation, stratified by lymphoma histology (Table 1). Among the 1062 GI lymphomas in our series, the stomach was the most frequent site of involvement (44%), followed by the colon/rectum (25%), small bowel (24%) and duodenum (7%). The esophagus was the least frequently involved (<1%). Overall, DLBCL was the most frequent histology (39%) and was associated with the highest frequency of perforations (13.2%), whereas mucosa-associated lymphoid tissue (MALT) lymphoma, the next most frequent histology (21%), was associated with a much lower risk of perforation (1.8%). In general, low-grade lymphomas perforated less frequently than their high-grade counterparts, irrespective of the site of involvement
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.
Upper endoscopy:
●Diagnostic endoscopy with a flexible endoscope: 0.03 percent
●Diagnostic endoscopy with a rigid endoscope: 0.11 percent
●Stricture dilation: 0.09 to 2.2 percent
●Sclerotherapy: 1 to 5 percent
● Pneumatic dilation for achalasia: 2 to 6 percent
The major complication of esophageal dilation is esophageal perforation, which is associated with a mortality rate of approximately 20 percent [2].
The incidence of perforation is influenced by the etiology of the stricture, the experience of the endoscopist, and the techniques and equipment used. In general, perforation rates associated with esophageal stricture dilation are low, unlike procedures such as pneumatic dilation for achalasia, where perforations are estimated to complicate three to five percent of procedures
The perforation rate was 0.1 percent per session in a report from 1999 that looked at 1043 dilation sessions using Eder-Puestow or Savary dilators in 153 patients (over half of whom had peptic strictures) [4].
Colonoscopy:
●Screening colonoscopy: 0.01 to 0.1 percent
●Anastomotic stricture dilation: 0 to 6 percent
●Crohn disease stricture dilation: 0 to 18 percent
●Stent placement: 4 percent
●Colonic decompression tube placement: 2 percent
●Colonic endoscopic mucosal resection 0 to 5 percent
Mortality rates from iatrogenic colonic perforation range from 0 to 0.65 percent [60].
The incidence of perforation during colonoscopy increases as the complexity of the procedure increases and is estimated at 1:1000 for therapeutic colonoscopy and 1:1400 for overall colonoscopies.
The presence of collagenous colitis appears to predispose to perforation during colonoscopy [140].
the rectosigmoid area was most commonly perforated (53 percent),
followed by the cecum (24 percent) [141]
most perforations were due to blunt injury, 27 percent of perforations occurred with polypectomy, and 18 percent of perforations were produced by thermal injury. Almost 25 percent of patients presented in a delayed fashion.
In general, perforation rates greater than 1 in 1000 screening colonoscopies or 1 in 500 for all colonoscopies should initiate evaluation of the endoscopist's technique
In the late 1970s, it was estimated that 164,000 cases of sepsis occurred in the United States (US) each year [1].
●One national database analysis of discharge records from hospitals in the US estimated an annual rate of more than 1,665,000 cases of sepsis between 1979 and 2000 [2].
a global incidence of 437 per 100,000 person-years for sepsis between the years 1995 and 2015, although this rate was not reflective of contributions from low- and middle-income countries [6].
between 2005 and 2014 rates of septic shock determined by clinical criteria increased from 12.8 to 18.6 per 1000 hospital admissions and mortality decreased from 55 to 51 percent [7].
Rates increased with age, and were approximately twice as high in men than in women.