Abdominal Radiology

, Volume 42, Issue 11, pp 2597–2608 | Cite as

Nontraumatic large bowel perforation: spectrum of etiologies and CT findings

  • Kunal KothariEmail author
  • Barak Friedman
  • Gregory M. Grimaldi
  • John J. Hines
Pictorial Essay


Large bowel perforation is an abdominal emergency that results from a wide range of etiologies. Computed tomography is the most reliable modality in detecting the site of large bowel perforation. The diagnosis is made by identifying direct CT findings such as extraluminal gas or contrast and discontinuity along the bowel wall. Indirect CT findings can help support the diagnosis, and include bowel wall thickening, pericolic fat stranding, abnormal bowel wall enhancement, abscess, and a feculent collection adjacent to the bowel. Common etiologies that cause large bowel perforation are colon cancer, foreign body aspiration, stercoral colitis, diverticulitis, ischemia, inflammatory and infectious colitides, and various iatrogenic causes. Recognizing a large bowel perforation on CT can be difficult at times, and there are various entities that may be misinterpreted as a colonic perforation. The purpose of this article is to outline the MDCT technique used for evaluation of suspected colorectal perforation, discuss relevant imaging findings, review common etiologies, and point out potential pitfalls in making the diagnosis of large bowel perforation.


Large bowel perforation Gastrointestinal perforation Computed tomography 


Compliance with ethical standards


No funding was received for this study.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Statement of informed consent was not applicable since the manuscript does not contain any patient data.


  1. 1.
    Bielecki K, Kamiński P, Klukowski M (2002) Large bowel perforation: morbidity and mortality. Tech Coloproctol 6(3):177–182CrossRefPubMedGoogle Scholar
  2. 2.
    Kriwanek S, Armbruster C, Beckerhinn P, Ditrich K (1994) Prognostic factors for survival in colonic perforation. Int J Colorectal Dis 9(3):158–162CrossRefPubMedGoogle Scholar
  3. 3.
    Furukawa A, Sakoda M, Yamasaki M, et al. (2005) Gastrointestinal tract perforation: CT diagnosis of presence, site, and cause. Abdom Imaging 30(5):524–534CrossRefPubMedGoogle Scholar
  4. 4.
    Singh JP, Steward MJ, Booth TC, Mukhtar H, Murray D (2010) Evolution of imaging for abdominal perforation. Ann R Coll Surg Engl 92(3):182–188CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Kim SH, Shin SS, Jeong YY, et al. (2009) Gastrointestinal tract perforation: MDCT findings according to the perforation sites. Korean J Radiol 10(1):63–70CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Levenson RB, Camacho MA, Horn E, et al. (2012) Eliminating routine oral contrast use for CT in the emergency department: impact on patient throughput and diagnosis. Emerg Radiol 19(6):513–517CrossRefPubMedGoogle Scholar
  7. 7.
    Lee CH, Haaland B, Earnest A, Tan CH (2013) Use of positive oral contrast agents in abdominopelvic computed tomography for blunt abdominal injury: meta-analysis and systematic review. Eur Radiol 23(9):2513–2521CrossRefPubMedGoogle Scholar
  8. 8.
    Maniatis V, Chryssikopoulos H, Roussakis A, et al. (2000) Perforation of the alimentary tract: evaluation with computed tomography. Abdom Imaging 25(4):373–379CrossRefPubMedGoogle Scholar
  9. 9.
    Hainaux B, Agneessens E, Bertinotti R, et al. (2006) Accuracy of MDCT in predicting site of gastrointestinal tract perforation. Am J Roentgenol 187(5):1179–1183CrossRefGoogle Scholar
  10. 10.
    Zissin R, Hertz M, Osadchy A, Even-Sapir E, Gayer G (2008) Abdominal CT findings in nontraumatic colorectal perforation. Eur J Radiol 65(1):125–132CrossRefPubMedGoogle Scholar
  11. 11.
    Iacobellis F, Berritto D, Grassi R (2015) Diagnostic approach to alimentary tract perforations. Imaging of alimentary tract perforation. Switzerland: Springer International Publishing, p 4Google Scholar
  12. 12.
    Kim SW, Kim HC, Yang DM (1017) Perforated tumours in the gastrointestinal tract: CT findings and clinical implications. Br J Radiol 2012(85):1307–1313Google Scholar
  13. 13.
    Imuta M, Awai K, Nakayama Y, et al. (2007) Multidetector CT findings suggesting a perforation site in the gastrointestinal tract: analysis in surgically confirmed 155 patients. Radiat Med 25(3):113–118CrossRefPubMedGoogle Scholar
  14. 14.
    Saeki M, Hoshikawa Y, Miyazaki O, et al. (1998) Computed tomographic analysis of colonic perforation:“dirty mass”, a new computed tomographic finding. Emerg Radiol 5(3):140–145CrossRefGoogle Scholar
  15. 15.
    Xiong L, Chintapalli KN, Dodd GD III, et al. (2004) Frequency and CT patterns of bowel wall thickening proximal to cancer of the colon. AJR 182:905–909CrossRefPubMedGoogle Scholar
  16. 16.
    Goh BK, Chow PK, Quah HM, et al. (2006) Perforation of the gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg 30(3):372–377CrossRefPubMedGoogle Scholar
  17. 17.
    Gayer Gabriela, Petrovitch I, Brooke Jeffrey R (2011) Foreign objects encountered in the abdominal cavity at CT. Radiographics 31(2):409–428CrossRefPubMedGoogle Scholar
  18. 18.
    Cianci R, Bianco V, Esposito G, Pizzi AD, Fillippone A. MDCT Imaging of Gastrointestinal Tract Perforation Due to Foreign Body Ingestion. In: Imaging of Alimentary Tract Perforation. Switzerland: Springer International Publishing, 2015; 79–84.Google Scholar
  19. 19.
    Goh BK, Tan YM, Lin SE, et al. (2006) CT in the preoperative diagnosis of fish bone perforation of the gastrointestinal tract. Am J Roentgenol 187(3):710–714CrossRefGoogle Scholar
  20. 20.
    Heffernan C, Pachter HL, Megibow AJ, Macari M (2005) Stercoral colitis leading to fatal peritonitis: CT findings. Am J Roentgenol 184(4):1189–1193CrossRefGoogle Scholar
  21. 21.
    Facy O, Radais F, Chalumeau C, et al. (2007) Stercoral perforation of the colon. Physiopathology and treatment strategy. Gastroenterol Clin Biol 31(12):1069–1070CrossRefPubMedGoogle Scholar
  22. 22.
    Balthazar EJ, Yen BC, Gordon RB (1999) Ischemic colitis: CT evaluation of 54 cases 1. Radiology 211(2):381–388CrossRefPubMedGoogle Scholar
  23. 23.
    Cruz C, Abujudeh HH, Nazarian RM, Thrall JH (2015) Ischemic colitis: spectrum of CT findings, sites of involvement and severity. Emerg Radiol 22(4):357–365CrossRefPubMedGoogle Scholar
  24. 24.
    Ho LM, Paulson EK, Thompson WM (2007) Pneumatosis intestinalis in the adult: benign to life-threatening causes. Am J Roentgenol 188(6):1604–1613CrossRefGoogle Scholar
  25. 25.
    Lee KS, Hwang S, Rúa SM, et al. (2013) Distinguishing benign and life-threatening pneumatosis intestinalis in patients with cancer by CT imaging features. Am J Roentgenol 200(5):1042–1047CrossRefGoogle Scholar
  26. 26.
    Azzaroli F, Turco L, Ceroni L, et al. (2011) Pneumatosis cystoides intestinalis. World J Gastroenterol 17(44):4932–4936CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Kaiser AM, Jiang JK, Lake JP, et al. (2005) The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol 100(4):910–917CrossRefPubMedGoogle Scholar
  28. 28.
    Chapman J, Davies M, Wolff B, et al. (2005) Complicated diverticulitis: is it time to rethink the rules? Ann Surg 242(4):576–583PubMedPubMedCentralGoogle Scholar
  29. 29.
    Ritz JP, et al. (2011) Outcome of patients with acute sigmoid diverticulitis: multivariate analysis of risk factors for free perforation. Surgery 149(5):606–613CrossRefPubMedGoogle Scholar
  30. 30.
    Berg DF, Bahadursingh AM, Kaminski DL, Longo WE (2002) Acute surgical emergencies in inflammatory bowel disease. Am J Surg 184(1):45–51CrossRefPubMedGoogle Scholar
  31. 31.
    Moulin V, Dellon P, Laurent O, et al. (2011) Toxic megacolon in patients with severe acute colitis: computed tomographic features. Clin Imaging 35(6):431–436CrossRefPubMedGoogle Scholar
  32. 32.
    Imbriaco M, Balthazar EJ (2001) Toxic megacolon: role of CT in evaluation and detection of complications. Clin Imaging 25(5):349–354CrossRefPubMedGoogle Scholar
  33. 33.
    Thoeni RF, Cello JP (2006) CT imaging of colitis. Radiology 240(3):623–638CrossRefPubMedGoogle Scholar
  34. 34.
    Levy AD, Mortele KJ, Yeh BM (2015) Infectious colitis. Gastrointestinal imaging. USA: Oxford University Press, p 236CrossRefGoogle Scholar
  35. 35.
    Ash L, Baker ME, O’Malley CM Jr, et al. (2006) Colonic abnormalities on CT in adult hospitalized patients with Clostridium difficile colitis: prevalence and significance of findings. Am J Roentgenol 186(5):1393–1400CrossRefGoogle Scholar
  36. 36.
    Kirkpatrick ID, Greenberg HM (2003) Gastrointestinal complications in the neutropenic patient: characterization and differentiation with abdominal CT 1. Radiology 226(3):668–674CrossRefPubMedGoogle Scholar
  37. 37.
    Kennedy CL, Krejany EO, Young LF, et al. (2005) The α-toxin of Clostridium septicum is essential for virulence. Mol Microbiol 57(5):1357–1366CrossRefPubMedGoogle Scholar
  38. 38.
    Khan AA, Davenport K (2006) A reminder of the association between Clostridium septicum and colonic adenocarcinoma. Int Semin Surg Oncol 1(3):12CrossRefGoogle Scholar
  39. 39.
    Kolbeinsson ME, Holder WD, Aziz S (1991) Recognition, management, and prevention of Clostridium septicum abscess in immunosuppressed patients. Arch Surg 126(5):642–645CrossRefPubMedGoogle Scholar
  40. 40.
    Urban BA, McCormick R, Fishman EK, Lillemoe KD, Petty BG (2000) Fulminant Clostridium septicum infection of hepatic metastases presenting as pneumoperitoneum. Am J Roentgenol 174(4):962–964CrossRefGoogle Scholar
  41. 41.
    Cappell MS, Batke M (2008) Mechanical obstruction of the small bowel and colon. Med Clin North Am 92(3):575–597CrossRefPubMedGoogle Scholar
  42. 42.
    Ponec RJ, Saunders MD, Kimmey MB (1999) Neostigmine for the treatment of acute colonic pseudo-obstruction. N Engl J Med 341:137–141CrossRefPubMedGoogle Scholar
  43. 43.
    Vanek VW, Al-Salti M (1986) Acute pseudo-obstruction of the colon (Ogilvie’s syndrome): an analysis of 400 cases. Dis Colon Rectum 29:203–210CrossRefPubMedGoogle Scholar
  44. 44.
    Geller A, Petersen BT, Gostout CJ (1996) Endoscopic decompression for acute colonic pseudo-obstruction. Gastrointest Endosc 44(2):144–150CrossRefPubMedGoogle Scholar
  45. 45.
    Maloney N, Vargas HD (2005) Acute intestinal pseudo-obstruction (Ogilvie’s syndrome). Clin Colon Rectal Surg 18(02):96–101CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Hapani S, Chu D, Wu S (2009) Risk of gastrointestinal perforation in patients with cancer treated with bevacizumab: a meta-analysis. Lancet Oncol 10(6):559–568CrossRefPubMedGoogle Scholar
  47. 47.
    Thornton E, Howard SA, Jagannathan J, et al. (1018) Imaging features of bowel toxicities in the setting of molecular targeted therapies in cancer patients. Br J Radiol 2012(85):1420–1426Google Scholar
  48. 48.
    Qi WX, Sun YJ, Tang LN, Shen Z, Yao Y (2014) Risk of gastrointestinal perforation in cancer patients treated with vascular endothelial growth factor receptor tyrosine kinase inhibitors: a systematic review and meta-analysis. Crit Rev Oncol/Hematol 89(3):394–403CrossRefGoogle Scholar
  49. 49.
    Iqbal CW, Cullinane DC, Schiller HJ, et al. (2008) Surgical management and outcomes of 165 colonoscopic perforations from a single institution. Arch Surg 143(7):701–707CrossRefPubMedGoogle Scholar
  50. 50.
    Ponticiello G, Di Nuzzo L, Saturnino PP. Colorectal perforation: assessment with MDCT. In: Imaging of alimentary tract perforation. Switzerland: Springer International Publishing, 2015; 59–60.Google Scholar
  51. 51.
    Sosna J, Blachar A, Amitai M, et al. (2006) Colonic perforation at CT colonography: assessment of risk in a multicenter large cohort. Radiology 239(2):457–463CrossRefPubMedGoogle Scholar
  52. 52.
    Dachman AH (2006) Advice for optimizing colonic distention and minimizing risk of perforation during CT colonography. Radiology 239(2):317–321CrossRefPubMedGoogle Scholar
  53. 53.
    Bellini D, Rengo M, De Cecco CN, et al. (2014) Perforation rate in CT colonography: a systematic review of the literature and meta-analysis. Eur Radiol 24(7):1487–1496CrossRefPubMedGoogle Scholar
  54. 54.
    Weinstein S, Osei-Bonsu S, Aslam R, Yee J (2013) Multidetector CT of the postoperative colon: review of normal appearances and common complications. Radiographics 33(2):515–532CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.Department of Radiology, Northwell Health SystemHofstra Northwell School of MedicineManhassetUSA

Personalised recommendations