Bowel Perforation and Inflammatory Bowel Disease
Inflammatory bowel disease can damage the bowel to such an extent that it perforates, meaning a small hole develops in the lining of the bowel wall. This is a medical emergency and must be treated without delay if life-threatening complications are to be prevented.
Causes of bowel perforation
The bowel can perforate, or rupture, in a variety of different ways. This includes the following:
1. Abdominal surgery
2. Blunt trauma to the abdomen – e.g. a car accident
3. Medication, including non-steroidal anti-inflammatory drugs (NSAIDs)
4. Ulcer
5. Inflammatory bowel disease
This article will focus upon bowel perforation due to inflammatory bowel disease.
Inflammatory bowel disease
The bowel can perforate due to chronic bowel diseases such as Crohn's disease, diverticulitis and ulcerative colitis. This happens because such conditions will place the bowel under constant strain, especially if flare-ups are regular. Eventually the wall of the bowel may become so weak that a small hole develops.
If a patient with an inflammatory bowel condition does suffer a perforated bowel, emergency surgery must be carried out. This should involve a washout of the abdominal cavity and a repair of the perforation. If a patient has severe Crohn's disease, part of the bowel may also need to be removed and an ileostomy fashion.
An ileostomy is when the end of small intestine is diverted through an opening in the abdomen. It is then attached to a stoma bag which sits on the surface of the skin. Faeces and waste products collect in the stoma bag, which will need to be emptied throughout the day.
An ileostomy will be necessary if part of the bowel needs to be removed, as a patient will no longer to pass faeces through the colon and the rectum.
Treatment of Crohn's disease after bowel perforation
At some point the patient may wish to consider either a reversal or removal of the remaining colon and rectum, in conjunction with a reconstruction of the abdominal wall. This would be a major operation and the surgery would be complex.
It would require a joint procedure between a colorectal surgeon and a plastic surgeon. The colorectal surgeon would perform the bowel surgery which would involve excision of the scar, division of adhesions and then either a re-anastomosis of the ileum to the remaining colon or excision of the remaining colon, rectum and anal canal.
This would then be followed by a plastic surgical reconstruction of the abdominal wall which would probably utilise a technique known as component separation. This would allow the musculature of the abdominal wall to be returned more to normal and would give a better function outcome.
Such surgery is complicated and there is a risk of further bowel injury. Additionally, if the bowel is re-joined it may leave a relatively short length of colon. This would increase the frequency of motions which may be difficult to control.
It is also highly likely that a patient will develop further Crohn's disease in the colon. In patients who have segmental resections for chronic Crohn's disease approximately 50% will require a completion colectomy at some point in the future, thus leaving a permanent ileostomy.
Permanent ileostomy
If a patient elects not to take the risk of recurrent disease, he/she may have the remaining colon removed and a permanent ileostomy fashioned. Again, this will be a formidable operation and would require a plastic surgeon to reconstruct the abdominal wall. There is a possibility that a patient will develop Crohn's disease in the small bowel.
Problems are particularly prevalent if there are dense adhesions in the abdominal cavity. Adhesions can cause complications, the most common of which is a small bowel obstruction. This is due to the small bowel loops becoming entrapped or caught round adhesions within the abdominal cavity.
An episode of bowel obstruction would cause sudden onset of severe colicky abdominal pain, vomiting, abdominal distension and cessation of bowel function. A patient would require admission to hospital, followed by administration of intravenous fluids, insertion of a nasogastric tube and regular, careful abdominal examination.
Adhesions
The majority of patients who develop small bowel obstruction due to adhesions will only need conservative treatment. However, studies have shown that between 10% and 20% of patients require a surgical laparotomy because of the obstruction not resolving, or because there is concern that the bowel will become ischaemic or strangulated internally (which will require a laparotomy and may require further small bowel resection.)
Should a patient suffer a recurrence of Crohn's disease, depending on the site, he/she would require further management under the care of a medical gastroenterologist, and it is possible that further surgical treatment will be required.
Delay in diagnosis
Such complications will of course be very upsetting, but there is a good chance that a patient will make a recovery.
However, a patient will be exposed to life-threatening complications if medical practitioners fail to notice the bowel perforation. Sadly this does happen as clinicians fail to understand the nature of a patient's symptoms.
This will be very problematic as a perforated bowel means that the contents of the bowel – namely faeces and waste products – leak into the abdominal cavity. This will infect the lining of the abdomen, resulting in an infection called peritonitis. Peritonitis is a serious condition that can lead to sepsis, multi-organ failure and death.
Bowel perforation and medical negligence
If there is a delay in diagnosis, the standard of care provided must be examined. Indeed, any reasonably competent medical practitioner should be able to diagnose a bowel perforation in a timely manner.
A diagnosis can be achieved through a clinical presentation, as a patient's symptoms should indicate a severe abdominal infection. This can be verified through simple tests such as a blood test, which will reveal high C-Reactive Proteins and a raised white cell count. Suspicions should be especially elevated if a patient has an inflammatory bowel condition, as this is associated with bowel perforation.
As soon as a perforated bowel is suspected, a patient should undergo an investigative laparotomy. This should be carried out on an emergency basis.
If this standard of care is not achieved, there may be grounds for a medical negligence compensation claim.
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If you suffered complications because your bowel perforation was not diagnosed and treated promptly, you need to talk to a solicitor about your options. Contact us today to find out more.
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