Gastrointestinal perforation

Last updated: September 11, 2023

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Summarytoggle arrow icon

Gastrointestinal perforation is a full-thickness loss of bowel wall integrity that results in perforation peritonitis. Perforation of a duodenal ulcer is the most common cause of perforation peritonitis. Patients typically present with an acute onset of severe abdominal pain associated with nausea, vomiting, and fever. Signs of peritoneal irritation are evident on examination and include decreased bowel sounds and diffuse or localized abdominal guarding and rebound tenderness. CT abdomen with IV contrast is the preferred imaging modality to confirm the presence of free air within the peritoneal cavity (pneumoperitoneum) and localize the site of the perforated viscus. Most patients will require an emergency exploratory laparotomy. Patients with evidence of a well-contained perforation (e.g., a small localized appendicular or diverticular perforation) and no signs of sepsis may be given a trial of conservative management with antibiotics, bowel rest, close monitoring of vital signs, and serial abdominal examination. The prognosis depends on the etiology, degree of intraabdominal contamination, and other comorbidities.

See also esophageal perforation.

Etiologytoggle arrow icon

Clinical featurestoggle arrow icon

Bowel perforation is a surgical emergency. In some cases, clinical features alone are sufficient to warrant emergency explorative laparotomy.

Diagnosticstoggle arrow icon

Laboratory analysis

Imaging [6][7]

Immediate studies

Before an upright x-ray, patients must be sitting up for at least 10 minutes in order to allow free air to move upward and collect under the diaphragm. [8]

Confirmatory studies

IV contrast is preferred if bowel perforation is suspected. If oral contrast must be used, a water-soluble contrast agent is preferred.

Differential diagnosestoggle arrow icon

See “Differential diagnoses” in “Acute abdomen”.

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Initial management

Supportive care

Ketorolac is contraindicated in patients with suspected bowel perforation.

Opioids are contraindicated in patients with suspected bowel obstruction.

Surgical management [13]

Most patients with GI tract perforation should be managed with urgent explorative laparotomy.

Conservative management [11][15]

Patients with only localized peritonitis and no signs of sepsis may be candidates for conservative (nonsurgical) management.

Traumatic hollow viscus injurytoggle arrow icon

See “Primary survey” for the general approach to trauma patients; see also “Blunt abdominal trauma” (BAT) and “Penetrating abdominal trauma.”

Diagnosis [17][18]

  • Emergency surgery consult (prior to imaging) in patients with :
  • Maintain high index of suspicion: Clinical features may be subtle.
    • Patients with BAT are at elevated risk, especially if they also have : [18]
      • High-energy injury: e.g., resulting from high-speed motor vehicle collision
      • Seat belt sign (typical injury after a vehicle collision with ecchymoses on the neck or on the flank caused by the seat belt strap) with pain and guarding
      • Other injuries associated with hollow viscus injury: e.g., abdominal aortic injury, L-spine transverse fracture
    • Iatrogenic injury: Suspect in patients with clinical features of GI perforation following recent liver biopsy, paracentesis, peritoneal dialysis or lavage, or GI endoscopy.
  • CT abdomen: test of choice for all stable patients
    • In patients with BAT, evidence of hollow viscus injury may be absent on the initial CT abdomen.
    • Consider repeat imaging in at-risk patients with BAT, especially if they have:

Maintain a high index of suspicion for hollow viscus injury in patients with blunt abdominal trauma as clinical features may initially be very subtle. [18]


Acute management checklisttoggle arrow icon

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

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  8. $Contributor Disclosures - Gastrointestinal perforation. All of the relevant financial relationships listed for the following individuals have been mitigated: Jan Schlebes (medical editor, is a shareholder in Fresenius SE & Co KGaA). None of the other individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  9. $Bowel Perforation.
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