Perforated bowel or stomach (perforated viscus): symptoms and emergency treatment

Viscus (plural viscera) is the medical word for an internal organ, and a perforated viscus usually means a hole in the wall of a hollow organ of the digestive tract such as the stomach, small intestine or large bowel. When the wall gives way, stomach acid, food and bowel contents can spill into the abdominal cavity.

The NHS explains that the lining of the tummy, the peritoneum, covers internal organs like the kidneys, liver and bowel, and that if the lining becomes infected, causing peritonitis, the organs it covers can be damaged. A perforation is one of the main routes by which this happens, and it is treated as a surgical emergency in most cases.

The NHS peritonitis page lists a burst stomach ulcer, a burst appendix, digestive problems such as Crohn's disease or diverticulitis, pancreatitis, surgery, injury to the stomach, pelvic inflammatory disease and cirrhosis among causes.

Individual causes are described on other NHS pages. A stomach ulcer, the NHS says, can lead to a hole in the stomach that can cause peritonitis, and the main causes of stomach ulcers are infection with Helicobacter pylori bacteria and regular use of anti-inflammatory painkillers, with smoking and increasing age also raising risk. Appendicitis, says the NHS, can cause the appendix to burst if not treated quickly. Diverticulitis can rarely lead to a hole in the bowel, which can cause a severe infection called peritonitis.

• Peptic (stomach or duodenal) ulcer that has eaten through the wall.

• Appendicitis that has progressed to a burst appendix.

• Diverticulitis, where a pouch in the bowel wall becomes inflamed and gives way.

• Injury or complications of surgery.

• Other bowel disease such as Crohn's disease.

The NHS lists tummy pain, a very high temperature or feeling hot, cold or shivery, a rapid heartbeat, and not being able to pee or peeing much less than normal as symptoms of peritonitis, with loss of appetite, feeling or being sick and a swollen tummy also possible.

For a burst appendix, the NHS says the pain may suddenly get better for a short time and then usually becomes severe and spreads to the whole abdomen, which may be very painful to move. For a stomach ulcer, severe tummy pain that is painful to touch, vomiting bright red blood or coffee-ground vomit, black sticky poo, or sudden chest pain are emergency signs. For diverticulitis, the NHS lists severe tummy pain with vomiting, a swollen tummy or being unable to poo or fart as reasons to call 999.

The NHS says to call 999 or go to A&E if you have severe tummy pain, particularly with vomiting, a swollen tummy, bleeding heavily from the bottom, confusion, pale or blotchy skin, a very high or low temperature, or breathlessness or rapid breathing, because these could be signs of sepsis. It says not to drive yourself to A&E, and to bring any medicines you take.

Ask for an urgent GP appointment or call NHS 111 if you have tummy pain that is getting worse or does not go away, a high temperature, or blood or mucus in your poo, as the NHS advises for diverticular disease and appendicitis.

Doctors examine the tummy, check blood pressure, pulse, temperature and oxygen levels, and arrange blood tests. The NHS says scans such as an ultrasound or CT scan may be used in suspected appendicitis and diverticular disease, and that for a stomach ulcer a gastroscopy or tests for H. pylori may be arranged. In an emergency with signs of peritonitis the priority is to stabilise the person and decide quickly whether an operation is needed.

The NHS notes that there is no test that can always show appendicitis, so doctors sometimes observe for a few hours, but if the appendix may have burst they may recommend surgery rather than wait for more tests.

The NHS says that peritonitis needs treatment in hospital to get rid of the infection, usually with antibiotics given into a vein. Help with eating may involve a feeding tube or nutrients given into a vein. Surgery may be needed to remove seriously damaged tissue, to drain pus-filled swellings (abscesses), or to deal with the cause, for example removing a burst appendix.

For diverticulitis complicated by a perforation, the NHS says problems may be treated with antibiotics or surgery, and some people need a colostomy, where the bowel is brought out through a hole in the tummy and a bag collects the poo. A perforated ulcer is also an emergency and requires hospital care, typically with acid-suppressing medicines and treatment of H. pylori afterwards, as the NHS describes for stomach ulcers.

Recovery depends on the cause, how quickly treatment started and the person's overall health. The NHS says most people recover from appendicitis in 1 to 2 weeks, and longer if complications such as a burst appendix occur. After bowel surgery there may be a longer hospital stay and a period of rehabilitation.

Prevention depends on the underlying disease. The NHS advises people with stomach ulcers not to take anti-inflammatory painkillers such as ibuprofen without speaking to a doctor, not to smoke and to avoid too much alcohol, and advises people with diverticular disease to eat a balanced high-fibre diet, drink plenty of water, stop smoking and avoid NSAIDs and opioid painkillers.

A suspected perforation is managed through emergency departments and emergency surgical teams in NHS hospitals, since the priority is to reach a hospital with surgery, imaging and intensive care quickly. Independent hospitals with emergency departments exist but may transfer very unwell patients to NHS hospitals with critical care.