Medscape is available in 5 Language Editions – Choose your Edition here.


Intestinal Perforation Workup

  • Author: Samy A Azer, MD, PhD, MPH; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
Updated: Dec 02, 2015

Laboratory Studies

A complete blood count (CBC) may reveal parameters suggestive of infection (eg, leukocytosis), though leukocytosis may be absent in elderly patients. Elevated packed blood cell volume suggests a shift of intravascular fluid. Blood culture for aerobic and anaerobic organisms is indicated. Findings from liver function and renal function tests may be within reference ranges (or nearly so) if no preexisting disorder is present.


Imaging Studies


Erect radiographs of the chest are recognized as the most appropriate first-line investigation when a perforated peptic ulcer is considered likely.[15] However, in approximately 30% of patients, no free gas can be identified. Thus, an erect posteroanterior chest radiograph is not sufficiently sensitive to rule out pneumoperitoneum in patients presenting with upper abdominal pain.

Plain supine and erect radiographs of the abdomen are the most common first steps in the diagnostic imaging evaluation of patients presenting with medical history and/or clinical signs suggestive of bowel perforation. Findings suggestive of perforation include the following:

  • Free air trapped in the subdiaphragmatic locations - If the quantity of free air is great enough, its presence can be visualized on the supine radiograph of the abdomen, allowing clear definition of the inner and outer surface of the wall of the bowel
  • Visible falciform ligament - The ligament may appear as an oblique structure extending from the right upper quadrant toward the umbilicus, particularly when large quantities of gas are present on either side of the ligament
  • Air-fluid level - This is indicated by the presence of hydropneumoperitoneum or pyopneumoperitoneum on erect radiographs of the abdomen

Water-soluble radiologic contrast media administered orally or through a nasogastric tube can be used as an adjunct diagnostic tool to detect any intraperitoneal leak.

The perforation has sealed at presentation in approximately 50% of patients. For those who favor a nonoperative approach, contrast radiology is routine in the management of these patients.


Localized gas collection related to bowel perforation may be detectable, particularly if it is associated with other ultrasonographic abnormalities (eg, thickened bowel loop). The site of bowel perforation can be detected by ultrasonography (eg, gastric vs duodenal perforation, perforated appendicitis vs perforated diverticulitis). Ultrasonograms of the abdomen can also provide rapid evaluation of the liver, spleen, pancreas, kidneys, ovaries, adrenals, and uterus.

Computed tomography

Computed tomography (CT) of the abdomen can be a valuable investigative tool, providing differential morphologic information not obtainable with plain radiography or ultrasonography.

CT scans may provide evidence of localized perforation (eg, perforated duodenal ulcer) with leakage in the area of the gallbladder and right flank with or without free air being apparent. They may show inflammatory changes in the pericolonic soft tissues and focal abscess due to diverticulitis (may mimic perforated colonic carcinoma). CT scans may not provide definitive radiographic evidence of perforated Meckel diverticulitis.


Diagnostic Procedures

Laparoscopy may significantly improve surgical decision making in patients with acute abdominal pain, particularly when the need for operation is uncertain.

Peritoneal diagnostic tap may be useful in determining the presence of intra-abdominal blood, fluid, and pus.

Peritoneal lavage is more valuable in the presence of a history of blunt abdominal trauma. The presence of blood or purulent material or the detection of bacteria on Gram stain suggests the need for early surgical exploration. Alkaline phosphatase concentration in the peritoneal lavage is a helpful and sensitive test that may be used to detect occult blunt intestinal injuries. A concentration greater than 10 IU/L has been shown to be a sensitive and reliable test in the detection of occult small bowel injuries.

Fine-catheter peritoneal cytology involves the insertion of a venous cannula into the peritoneal cavity, through which a fine umbilical catheter is inserted while the patient is under local anesthesia. Peritoneal fluid is aspirated, placed on a slide, and stained for examination under a light microscope for percentage of polymorphonuclear cells. A value greater than 50% suggests a significant underlying inflammatory process. This test, however, provides no clue as to the exact cause of inflammation.

Contributor Information and Disclosures

Samy A Azer, MD, PhD, MPH Professor of Medical Education, Chair of Medical Education Research and Development Unit, Faculty of Medicine, Universiti Teknologi MARA, Malaysia; Visiting Professor of Medical Education, Faculty of Medicine, University of Toyama, Japan; Former Senior Lecturer in Medical Education, Faculty Education Unit, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne and University of Sydney, Australia

Samy A Azer, MD, PhD, MPH is a member of the following medical societies: New York Academy of Sciences, Sigma Xi, Association for Psychological Science, Gastroenterological Society of Australia, American College of Gastroenterology, Royal Society of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.


Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

  1. Lau WY, Leow CK. History of perforated duodenal and gastric ulcers. World J Surg. 1997 Oct. 21(8):890-6. [Medline].

  2. Sarath Chandra S, Siva Kumar S. Definitive or conservative surgery for perforated gastric ulcer? - An unresolved problem. Int J Surg. 2008 Dec 25. [Medline].

  3. Goh H, Bourne R. Non-steroidal anti-inflammatory drugs and perforated diverticular disease: a case-control study. Ann R Coll Surg Engl. 2002 Mar. 84(2):93-6. [Medline]. [Full Text].

  4. Lee JF, Leow CK, Lau WY. Appendicitis in the elderly. Aust N Z J Surg. 2000 Aug. 70(8):593-6. [Medline].

  5. Stapfer M, Selby RR, Stain SC, et al. Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg. 2000 Aug. 232(2):191-8. [Medline]. [Full Text].

  6. Anderson ML, Pasha TM, Leighton JA. Endoscopic perforation of the colon: lessons from a 10-year study. Am J Gastroenterol. 2000 Dec. 95(12):3418-22. [Medline].

  7. Iqbal CW, Cullinane DC, Schiller HJ, et al. Surgical management and outcomes of 165 colonoscopic perforations from a single institution. Arch Surg. 2008 Jul. 143(7):701-6; discussion 706-7. [Medline].

  8. Teoh AY, Poon CM, Lee JF, et al. Outcomes and predictors of mortality and stoma formation in surgical management of colonoscopic perforations: a multicenter review. Arch Surg. 2009 Jan. 144(1):9-13. [Medline].

  9. Namdar T, Raffel AM, Topp SA, et al. Complications and treatment of migrated biliary endoprostheses: a review of the literature. World J Gastroenterol. 2007 Oct 28. 13(40):5397-9. [Medline].

  10. Wei SC, Tan YY, Weng MT, Lai LC, Hsiao JH, Chuang EY, et al. SLCO3A1, a Novel Crohn's Disease-Associated Gene, Regulates NF-?B Activity and Associates with Intestinal Perforation. PLoS One. 2014. 9(6):e100515. [Medline]. [Full Text].

  11. Kim JB, Kim SH, Cho YK, Ahn SB, Jo YJ, Park YS, et al. A case of colon perforation due to enteropathy-associated T-cell lymphoma. World J Gastroenterol. 2013 Mar 21. 19(11):1841-4. [Medline]. [Full Text].

  12. Cheung CP, Chiu HS, Chung CH. Small bowel perforation after radiotherapy for cervical carcinoma. Hong Kong Med J. 2003 Dec. 9(6):461-3. [Medline].

  13. Deniz K, Ozseker HS, Balas S, et al. Intestinal involvement in Wegener's granulomatosis. J Gastrointestin Liver Dis. 2007 Sep. 16(3):329-31. [Medline]. [Full Text].

  14. Catena F, Ansaloni L, Gazzotti F, et al. Gastrointestinal perforations following kidney transplantation. Transplant Proc. 2008 Jul-Aug. 40(6):1895-6. [Medline].

  15. Butler J, Martin B. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Detection of pneumoperitoneum on erect chest radiograph. Emerg Med J. 2002 Jan. 19(1):46-7. [Medline]. [Full Text].

  16. Langell JT, Mulvihill SJ. Gastrointestinal perforation and the acute abdomen. Med Clin North Am. 2008 May. 92(3):599-625, viii-ix. [Medline].

  17. Kim JH, Ahn HD, Kwon KA, Kim YJ, Chung JW, Park DK, et al. Spontaneous healing of gastric perforation after endoscopic ligation for gastric varices. J Korean Med Sci. 2013 Apr. 28(4):624-7. [Medline]. [Full Text].

  18. Crofts TJ, Park KG, Steele RJ. A randomized trial of nonoperative treatment for perforated peptic ulcer. N Engl J Med. 1989 Apr 13. 320(15):970-3. [Medline].

  19. Donovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer: an alternative therapeutic plan. Arch Surg. 1998 Nov. 133(11):1166-71. [Medline]. [Full Text].

  20. Kim J, Lee GJ, Baek JH, Lee WS. Comparison of the surgical outcomes of laparoscopic versus open surgery for colon perforation during colonoscopy. Ann Surg Treat Res. 2014 Sep. 87(3):139-43. [Medline]. [Full Text].

  21. Ritz JP, Lehmann KS, Frericks B, Stroux A, Buhr HJ, Holmer C. Outcome of patients with acute sigmoid diverticulitis: Multivariate analysis of risk factors for free perforation. Surgery. 2011 May. 149(5):606-13. [Medline].

  22. Cappendijk VC, Hazebroek FW. The impact of diagnostic delay on the course of acute appendicitis. Arch Dis Child. 2000 Jul. 83(1):64-6. [Medline]. [Full Text].

  23. De Blaky M. Acute perforated gastroduodenal ulceration; statistical analysis and review of the literature. Surgery. 1940. 8:850.

  24. Herrington JL Jr. Historical aspects of gastric surgery. Scott HW Jr, Sawyers JL, eds. Surgery of the Stomach, Duodenum and Small Intestine. Boston, Mass: Blackwell Scientific; 1992.

  25. Holland AJ, Cass DT, Glasson MJ, et al. Small bowel injuries in children. J Paediatr Child Health. 2000 Jun. 36(3):265-9. [Medline].

  26. Isaacman DJ, Scarfone RJ, Kost SI, et al. Utility of routine laboratory testing for detecting intra-abdominal injury in the pediatric trauma patient. Pediatrics. 1993 Nov. 92(5):691-4. [Medline].

  27. Lim JH. Ultrasound examination of gastrointestinal tract diseases. J Korean Med Sci. 2000 Aug. 15(4):371-9. [Medline].

  28. Putcha RV, Burdick JS. Management of iatrogenic perforation. Gastroenterol Clin North Am. 2003 Dec. 32(4):1289-309. [Medline].

  29. Saxe JM, Cropsey R. Is operative management effective in treatment of perforated typhoid?. Am J Surg. 2005 Mar. 189(3):342-4. [Medline].

  30. Saxena V, Basu S, Sharma CL. Perforation of the gall bladder following typhoid fever-induced ileal perforation. Hong Kong Med J. 2007 Dec. 13(6):475-7. [Medline].

  31. Schnoll-Sussman F, Kurtz RC. Gastrointestinal emergencies in the critically ill cancer patient. Semin Oncol. 2000 Jun. 27(3):270-83. [Medline].

  32. Shah M, Azam B. Case report of an intra-abdominal desmoid tumour presenting with bowel perforation. Mcgill J Med. 2007 Jul. 10(2):90-2. [Medline]. [Full Text].

  33. Velitchkov NG, Losanoff JE, Kjossev KT, et al. Delayed small bowel injury as a result of penetrating extraperitoneal high-velocity ballistic trauma to the abdomen. J Trauma. 2000 Jan. 48(1):169-70. [Medline].

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.