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Table 3 Presenting symptoms, imaging and clinical considerations in relation to site and causes of large bowel perforation

From: Gastrointestinal perforation: clinical and MDCT clues for identification of aetiology

Site Presentation CT findings Causes Cause-specific findings Considerations
Colorectal Abdominal pain, nausea, anorexia, vomiting, fever, sepsis IP gas (cecum, transverse, sigmoid, upper 2/3 of rectum), EP gas (ascending, descending colon, lower 1/3 rectum), extraluminal faecal contents, oral/rectal contrast leakage, wall defect, faecal material protruding through wall/lying within abdominal cavity, bowel wall thickening (> 5 mm), fat stranding, abnormal wall enhancement, abscess, inflammatory mass adjacent to colon, free fluid Tumour Wall thickness > 1.39 cm, irregular wall configuration, lymphadenopathy, metastatic disease, free gas, minimal in tumour necrosis, free gas massive following obstruction Tumour necrosis/following obstruction
   Iatrogenic Disproportionate amount of extraluminal gas, stent extending through wall defect History of instrumentation, opioids, radiation therapy, NSAIDs, chemotherapeutic regimens, corticosteroids
   Spontaneous Caecal diameter > 14 cm, diffuse bowel dilatation without transition point Severely ill, postoperative patients
   Diverticulae Inflamed diverticulum, pneumoretroperitoneum  
   Trauma
Foreign body
Foreign body, colovesical fistula, inflammatory mass
   Stercoral Faecal impaction with wall thickening,
Faecaloma protruding through colonic wall/in abdominal cavity
Elderly, chronic costipation, scleroderma, bedridden patients
   Infectious   Salmonella, yersinia, tuberculosis, amoebiasis, Cl. difficile, E. coli, schistosomiasis, shigellosis, herpes, gonorrhoea, syphilis, LGV, CMV
   Ischemia Poor/absent mural enhancement, pneumatosis intestinalis, vascular occlusion, portomesenteric gas Low-flow states, vascular occlusion
   IBD Skip lesions, intramural fat, fistula formation, marked colonic dilatation in UC Free perforation rare
  1. EP extraperitoneal perforation, IP intraperitoneal perforation, NSAIDs non-steroid anti-inflammatory drugs, LGV lymphogranuloma venereum, CMV cytomegalovirus, IBD inflammatory bowel disease, UC ulcerative colitis