From the Guidelines
Steroids can increase the risk of intestinal perforation, particularly in patients with underlying gastrointestinal conditions, and therefore, their use should be carefully managed to minimize this risk. The risk of intestinal perforation due to steroids is a significant concern, especially in patients with conditions such as diverticulitis, inflammatory bowel disease, or peptic ulcer disease 1. Corticosteroids like prednisone, dexamethasone, and methylprednisolone can impair intestinal healing and increase perforation risk by suppressing inflammatory responses and inhibiting collagen synthesis needed for tissue repair.
Risk Factors
The risk of intestinal perforation due to steroids is higher with:
- Higher doses (typically >20mg prednisone equivalent daily)
- Longer duration of treatment (weeks to months)
- Concurrent use of NSAIDs
- Underlying gastrointestinal conditions such as diverticulitis, inflammatory bowel disease, or peptic ulcer disease
Warning Signs
Warning signs of potential perforation include:
- Severe, persistent abdominal pain
- Rigid abdomen
- Fever
- Signs of sepsis If perforation is suspected, immediate medical attention is required as this is a surgical emergency.
Management
To minimize the risk of intestinal perforation due to steroids:
- Use the lowest effective steroid dose for the shortest duration possible
- Consider gastroprotective agents like proton pump inhibitors during treatment
- Avoid NSAIDs when possible
- Monitor patients with pre-existing GI conditions more closely
- Wean off steroids preoperatively, ideally 4 weeks, to decrease the risk of postoperative complications 1 Patients on steroids should be educated about warning signs and instructed to seek immediate medical attention if concerning symptoms develop.
Surgical Intervention
In cases of intestinal perforation, surgical intervention may be necessary, and the management of patients with inflammatory bowel disease in the emergency setting requires coordination between medical and surgical services 1. The decision to operate should be made on a case-by-case basis, taking into account the patient's overall condition, the severity of the perforation, and the presence of any underlying medical conditions.
Nutritional Support
Nutritional support is also crucial in the management of patients with intestinal perforation, and administering nutritional support (parenteral or enteral, according to GI function and in conjunction with a dietician/nutrition team) as soon as possible is recommended 1. Malnutrition is a common problem in patients with inflammatory bowel disease, and it can increase the risk of postoperative complications 1. Therefore, assessing the patient's nutritional status and providing adequate nutritional support is essential to optimize outcomes.
From the FDA Drug Label
Gastrointestinal Steroids should be used with caution in active or latent peptic ulcers, diverticulitis, fresh intestinal anastomoses, and nonspecific ulcerative colitis, since they may increase the risk of a perforation Signs of peritoneal irritation following gastrointestinal perforation in patients receiving corticosteroids may be minimal or absent.
The use of steroids, such as prednisone, may increase the risk of intestinal perforation, particularly in patients with certain gastrointestinal conditions like peptic ulcers, diverticulitis, fresh intestinal anastomoses, and nonspecific ulcerative colitis. Key points to consider include:
- Caution is advised when using steroids in these patients
- Signs of peritoneal irritation may be minimal or absent in patients receiving corticosteroids who experience gastrointestinal perforation 2
From the Research
Intestinal Perforation due to Steroids
- Intestinal perforation is a serious complication that can occur in patients taking steroids, with mortality rates as high as 100% 3.
- The use of high-dose steroids can decrease the clinical expression of peritonitis, leading to delayed recognition and treatment of gastrointestinal perforation 3.
- Studies have shown that patients on steroid therapy are at increased risk of gastrointestinal perforation, particularly those with inflammatory bowel disease (IBD) 4.
- Severe disease on endoscopy and steroid use have been identified as independent risk factors for bowel perforation during colonoscopy in IBD patients 4.
Clinical Presentation and Diagnosis
- The clinical presentation of intestinal perforation in patients on steroid therapy can be masked by the anti-inflammatory effect of the steroids, making diagnosis more difficult 5.
- Abdominal tenderness is a common symptom of intestinal perforation in patients on high-dose steroids, but other symptoms may be absent or mild 3.
- Delayed diagnosis and treatment of intestinal perforation can lead to increased morbidity and mortality in patients on steroid therapy 3, 5.
Management and Treatment
- The management of colonoscopic perforations depends on the etiology, size, severity, location, available expertise, and general health status of the patient 6.
- Surgical intervention is often required, with primary repair being the most common surgical procedure 6.
- Endoscopic techniques are evolving and may offer a high success rate with minimal post-procedure complications, but further studies are needed to compare these techniques 6.