Your colon is composed of layers of smooth muscle and mucous membranes.

The innermost
layer, called the mucosa, is soft and pliant—similar to the tissues in your mouth. Bowel
perforations occur when a hole is made in this lining, often as a result of colon surgery or serious
bowel disease. A hole in the colon then allows the contents of the colon to leak into the usually
sterile contents of your abdominal cavity.

Symptoms

The symptoms of a bowel perforation can vary and may come on slowly or rapidly depending on
the underlying cause. Symptoms may include:

 Abdominal pain1 (often severe and diffuse)

 Severe abdominal cramping
 Bloating
 Nausea and vomiting2
 A change in your bowel movements or habits
 Rectal bleeding
 Fever (usually not immediately)
 Chills
 Fatigue

Risk Factors

Scientists have found that a number of factors may increase your risk of developing a bowel
perforation. These include both factors involved in surgery or a procedure (iatrogenic causes)
and bowel diseases characterized by inflammation.2 Risk factors may include:

 Recent or prior abdominal

 Recent or prior pelvic surgery
 Age greater than 75
 History of multiple medical problems
 Trauma to the abdomen or pelvis (such as in an automobile accident)3
 A history of diverticular disease
 A history of inflammatory bowel disease
 Colon cancer4
 Use of the monoclonal antibody immunotherapy drug ipilimumab
 Pelvic adhesions (scar tissue, usually related to previous surgeries)
 Female gender (women typically have a more flexible colon, which can lead to accidental
perforation during medical procedures, including a colonoscopy)
 Diagnostic and surgical procedures involving the digestive tract, abdomen, or pelvis. Risk
factors for a perforation during a colonoscopy include being female, older age, a history
of diverticular disease, and bowel obstructions.5

Causes
Bowel perforations may occur spontaneously (unexpectedly) as a result of a medical condition or
instead be a complication of various diagnostic and surgical procedures which accidentally create
a hole in the colon. Trauma, especially blunt trauma to the abdomen, is also an important cause
of bowel perforations.

Procedure associated causes include:

 Enema – An improperly or forcefully inserted rectal tube for an enema can rip or push
through the colon lining.
 Bowel preparation for colonoscopy - Rarely, the bowel preparation for a colonoscopy can
result in a perforation. This is more common in people with a history of constipation.6
 Sigmoidoscopy – Although the endoscope for a flexible sigmoidoscopy is flexible,
perforation remains a risk, but a rare one.
 Colonoscopy – The tip of the endoscope has the potential to push through the inner lining
of the colon, although this is a rare complication of the procedure and is not seen in the
virtual colonoscopy. Perforation of the bowel associated with a colonoscopy is more
common in those who have the severe acute disease of the bowel as well as those who are
on steroid medications. The colonoscopy perforation rate appears to be around 1 in 1400
people who have screening colonoscopies and 1 of 1000 people who have a therapeutic
colonoscopy (for example, to remove a polyp).
 Abdominal or pelvic surgery, particularly colon surgery as for colon cancer4.

Causes of spontaneous bowel perforation (those unrelated to surgery or procedures) include:

 Inflammatory bowel disease/colitis such as Crohn's disease and ulcerative colitis. The
lifetime risk of a bowel perforation with Crohn's disease is between one and three
percent, making this a very common cause.
 Severe bowel obstruction, especially when the colon is "weakened" by diverticular
disease, another process, or cancer
 Trauma
 Ischemic bowel disease (when the blood supply to the colon is compromised)
 Colon cancer
 Foreign body ingestion - Most commonly due to the ingestion of fish bones, and bone
fragments, as well as non-food items
 Severe bowel impaction

Diagnosis

If your doctor suspects a bowel perforation, she can order tests to confirm her suspicion. A
simple abdominal x-ray may show gas outside the colon but is not often diagnostic. A CT scan of
your abdomen with or without contrast or a barium enema or swallow may be needed. A
complete blood count may show an elevation of your white blood cell count if the perforation
has been present for a while, or evidence of anemia due to bleeding. Small perforations may
sometimes take several imaging studies and time to accurately diagnose.

Treatment
Perforation of the bowel is considered a medical emergency and requires immediate treatment.
Left untreated, the contents of the bowel can leak out and cause inflammation, infection and even
abscesses in your abdomen. The technical name for this is peritonitis, which is a painful
precursor to sepsis—or a body-wide infection.

The majority of perforations are surgically repaired. Depending on the location and size of the
tear, the doctor might be able to fix it through an endoscope, similar to the one used during a
colonoscopy—but this is not an option for everyone. Open bowel surgery may or may not result
in a stoma and colostomy: an artificial opening outside of your stomach where stool drains into a
small bag until the bowel is healed.

Complications

Complications of untreated perforation may include:

 Bleeding
 Infection (peritonitis and sepsis)
 Death

Complications depend on a person's general health, as well as the amount of time it has taken to
diagnose and treat the perforation.

Recovery

During your initial recovery period, you will not be able to drink or eat anything by mouth. This
is called resting the bowels and allows the inner lining time to heal properly. You will also have
a nasogastric tube in place to drain the contents of your stomach for a period of time. You may
receive intravenous antibiotics and nutrition for a few days if you're in the hospital. Although
you may be anxious to return to your normal routine, it's important that you give your colon time
to heal properly, and follow your doctor's orders.

A Word From Verywell

Bowel perforation may occur spontaneously, such as with inflammatory bowel disease, or during
surgery or diagnostic tests. Symptoms may come on rapidly, or instead slowly, and should be
considered in anyone who has risk factors for a perforation combined with risk factors for the
condition.

When caught early, there are different treatment options available, but even with surgery (which
is most often required) the bowel can often be preserved and repaired without a colostomy.
Recovery can take time, both for healing, and to correct and risk factors which led to the
perforation.

1. Jones MW, Zabbo CP. Bowel Perforation. StatPearls Publishing. February 2019.
https://www.ncbi.nlm.nih.gov/books/NBK537224/. Accessed June 19, 2019.
2. Jones MW, Zabbo CP. Bowel Perforation. StatPearls Publishing. February 2019.
https://www.ncbi.nlm.nih.gov/books/NBK537224/.
3. Mukhopadhyay M. Intestinal injury from blunt abdominal trauma: a study of 47 cases.
Oman Med J. 2009;24(4):256-9. doi:10.5001/omj.2009.52
4. Banaszkiewicz Z, Woda Ł, Tojek K, Jarmocik P, Jawień A. Colorectal cancer with
intestinal perforation - a retrospective analysis of treatment outcomes. Contemp Oncol
(Pozn). 2014;18(6):414-8. doi:10.5114/wo.2014.46362
5. Lohsiriwat V. Colonoscopic perforation: incidence, risk factors, management and
outcome. World J Gastroenterol. 2010;16(4):425-30. doi:10.3748/wjg.v16.i4.425
6. Yamauchi A, Kudo SE, Mori Y, et al. Retrospective analysis of large bowel obstruction
or perforation caused by oral preparation for colonoscopy. Endosc Int Open.
2017;5(6):E471-E476. doi:10.1055/s-0043-106200