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
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No funding was received for this study.
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The authors declare that they have no conflict of interest.
This article does not contain any studies with human participants or animals performed by any of the authors.
Statement of informed consent was not applicable since the manuscript does not contain any patient data.
Bielecki K, Kamiński P, Klukowski M (2002) Large bowel perforation: morbidity and mortality. Tech Coloproctol 6(3):177–182CrossRefPubMedGoogle Scholar
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
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
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
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
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
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
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
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
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
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
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
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
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
Gayer Gabriela, Petrovitch I, Brooke Jeffrey R (2011) Foreign objects encountered in the abdominal cavity at CT. Radiographics 31(2):409–428CrossRefPubMedGoogle Scholar
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
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
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
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
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
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
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
Levy AD, Mortele KJ, Yeh BM (2015) Infectious colitis. Gastrointestinal imaging. USA: Oxford University Press, p 236CrossRefGoogle Scholar
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
Kirkpatrick ID, Greenberg HM (2003) Gastrointestinal complications in the neutropenic patient: characterization and differentiation with abdominal CT 1. Radiology 226(3):668–674CrossRefPubMedGoogle Scholar
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
Khan AA, Davenport K (2006) A reminder of the association between Clostridium septicum and colonic adenocarcinoma. Int Semin Surg Oncol 1(3):12CrossRefGoogle Scholar
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
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
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
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
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
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
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
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
Dachman AH (2006) Advice for optimizing colonic distention and minimizing risk of perforation during CT colonography. Radiology 239(2):317–321CrossRefPubMedGoogle Scholar
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
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