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Colon perforation is a serious illness. Surgery used to be the gold standard but treatment has changed since studies have shown equal results with less invasive treatment. The aim of this study was to evaluate the incidence of acute colon perforations in Iceland, causes, treatment and changes in treatment.A retrospective, nationwide, multicenter analysis based on ICD-10 codes from databases of the main hospitals in Iceland. Age, gender, year of perforation, cause, means of diagnosis and treatment was registered. Patients under 18 years and post mortem diagnosis were excluded.Two hundred and twenty-eight patients met criteria, 132 women (58%) and 96 men (42%), average age 67 years. Age adjusted incidence is 67 and 86 per million person-years for the first and second 5 years respectively. Causes were diverticulitis (68%), colonoscopy (11%) and complications during operations (5%). During the first study year 27% got conservative treatment while 64% underwent surgery. By the end of the study era this ratio was 65% and 35% respectively.Diverticulitis was the most common cause of colon perforation in Iceland during the study period. The incidence is increasing. Many patients still undergo surgery but there has been a dramatic change toward more conservative treatment.