Gastrointestinal perforation

Perforation of an organ can be caused by a variety of factors. These include:

• Appendicitis
• Cancer (all types)
• Crohn disease
• Diverticulitis
• Gallbladder disease
• Peptic ulcer disease
• Ulcerative colitis
• Bowel blockage
• Chemotherapy agents
• Increased pressure in the esophagus caused by forceful vomiting
• Ingestion of caustic substances

It may also be caused by surgery in the abdomen or procedures such as colonoscopy or upper endoscopy.

Perforation of the intestine or other organs causes the contents to leak into the abdomen. This causes a severe infection called peritonitis.

Symptoms may include:

• Severe abdominal pain
• Chills
• Fever
• Nausea
• Vomiting
• Shock

X-rays of the chest or abdomen may show air in the abdominal cavity. This is called free air. It is a sign of a perforation. If the esophagus is perforated, free air can be seen in the mediastinum (around the heart) and in the chest. A CT scan is more effective than x-rays in detecting free air.

A CT scan of the abdomen often shows where the hole is located. The white blood cell count is often higher than normal.

Treatment most often involves emergency surgery to repair the hole.

• Sometimes, a small part of the intestine must be removed. One end of the intestine may be brought out through an opening (stoma) made in the abdominal wall. This is called a colostomy or ileostomy.
• A drain from the abdomen or other organ may also be needed.

In rare cases, people can be treated with antibiotics alone if the perforation has closed. Patients who are the best candidates for healing without surgery include those with a contained perforation, hemodynamic stability, and absence of diffuse peritonitis. This can be confirmed by a physical exam, blood tests, CT scan, and x-rays.

A perforation from a colonoscopy may sometimes be closed during the procedure thus avoiding the need for surgery.

Surgery is successful most of the time. However, the outcome will depend on how severe the perforation is and for how long it was present before treatment. The presence of other illnesses or septic shock can also affect how well a person will do after treatment.

Even with surgery, infection is the most common complication of the condition. Infections can be either inside the abdomen (abdominal abscess or peritonitis), or throughout the whole body. Bodywide infection is called sepsis. Sepsis can be very serious and can lead to death.

Contact your health care provider if you have:

• Blood in your stool
• Changes in bowel habits
• Fever
• Nausea
• Severe abdominal pain
• Vomiting

Call 911 or the local emergency number, or the local poison control center emergency number at 1-800-222-1222 if you or someone else has ingested a caustic substance.

DO NOT wait until the person has symptoms before you call for help.

People will often have a few days of abdominal pain before the intestinal perforation occurs. If you have pain in the abdomen, see your provider right away. Treatment is much simpler and safer when it is started before the perforation occurs.

Intestinal perforation; Perforation of the intestines; Gastric perforation; Esophageal perforation

Brakenridge S, Thompson A. Abdominal sepsis. In: Vincent J-L, Moore FA, Bellomo R, Marini JJ, eds. Textbook of Critical Care. 8th ed. Philadelphia, PA: Elsevier; 2024:chap 90.

Matthews JB, Turaga K. Surgical peritonitis and other diseases of the peritoneum, mesentery, omentum, and diaphragm. In: Chung RT, Rubin DT, Wilcox CM, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 12th ed. Philadelphia, PA: Elsevier; 2026:chap 37.

Ritter KA, Junak MI, Scarborough JE, Ho VP. The acute abdomen. In: Tyler DS, Hayes-Dixon A, Hines OJ, et al, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 22nd ed. Philadelphia, PA: Elsevier; 2026:chap 85.

Updated by: Todd Eisner, MD, Private practice specializing in Gastroenterology in Boca Raton and Delray Beach, Florida at Gastroenterology Consultants of Boca Raton. Affiliate Assistant Professor, Florida Atlantic University School of Medicine. Review provided by VeriMed Healthcare Network. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.