Bowel Perforation

Excerpt

Bowel perforation is a serious and potentially life-threatening disease process that can affect a wide range of patient populations and present with varying severity, from minimally symptomatic microperforated diverticulitis to fulminant septic shock secondary to gastric perforation. The bowel functions as a closed system, and violation of this system can result in consequences that range from minor leakage of intraluminal gas to gross feculent peritonitis. Perforation represents a full-thickness disruption of the bowel wall, which can arise from diverse etiologies including inflammation, infection, obstruction, trauma, ischemia, neoplasia, or iatrogenic injury. Patients presenting with abdominal pain and distension, particularly in the appropriate clinical context, must be promptly evaluated for this entity, as delayed diagnosis significantly increases the risk of severe infection, peritonitis, sepsis, and death.

The clinical spectrum of bowel perforation reflects its complex pathophysiology and varied etiologies. Outcomes are heavily dependent on the timeliness of recognition and intervention. Diagnostic evaluation has advanced with the use of cross-sectional imaging, particularly computed tomography, which accurately identifies free air, free fluid, and the underlying source of perforation. Management requires an integrated approach, with initial resuscitation, broad-spectrum antibiotics, and urgent surgical consultation remaining cornerstones of therapy. While some carefully selected cases may be managed nonoperatively, hemodynamically unstable individuals, those with peritonitis, or those demonstrating persistent tachycardia or sepsis require prompt surgical exploration. Even when appropriately treated, bowel perforation carries a high risk of morbidity and mortality, with postrepair complications such as adhesions, intra-abdominal abscesses, anastomotic leaks, and fistula formation contributing to long-term sequelae. Despite advances in critical care and surgical techniques, bowel perforation remains a substantial clinical burden, underscoring the need for rapid recognition, multidisciplinary management, and ongoing research into improving patient outcomes.