Spontaneous free perforation of the small intestine

In western cultures, spontaneous free perforation of the small intestine in adults is rare. The vast majority of published reports are of isolated cases. A review of 19 patients treated at the Lahey Clinic over the past 23 years is presented. All patients presented with an acute onset of peritoneal signs, and free perforation subsequently was documented at operation or at autopsy. Causes of the perforations were malignancy, six; inflammatory small bowel disease, four; combinations of radiotherapy, chemotherapy, or steroids, four; mechanical, three; and iatrogenic, two. Of the 19 patients, 15 had a history of previous abdominal surgery or recent steroid use, chemotherapy, or radiation therapy. Although the underlying disease may be of prime importance in causing perforation, these treatment modalities may be important factors in enhancing predisposition to perforation. Of the 16 patients operated on, ten had intestinal resection with primary anastomosis, and six had primary closure of the perforation. Four major complications included two deaths, and five minor complications occurred. In general, earlier operative intervention decreased mortality. A population of patients who may be at risk for small bowel perforations is identified. A review of the pertinent literature is presented.