Bowel perforation: Difference between revisions
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==Background==
==Background==
Bowel perforation describes a full-thickness breach of the intestinal wall, allowing air and/or gastrointestinal contents to enter the surrounding peritoneal cavity, which can be a potentially life-threatening cause of sepsis. Perforation typically presents acutely (i.e., appendicitis, diverticulitis, perforated peptic ulcer, penetrating trauma) and often requires immediate surgical intervention.  However, when the perforation is immediately contained (i.e., by the omentum or retroperitoneum) it may occasionally present with a more indolent course. Similarly, immunosuppression or systemic corticosteroid therapy may blunt the inflammatory response resulting in a protracted, indolent presentation.
[[File:Blausen 0817 SmallIntestine Anatomy.png |thumb|Illustration of GI track]]
*Definition: a full-thickness breach of the intestinal wall, allowing air and/or gastrointestinal contents to enter the surrounding peritoneal cavity
*Can be a potentially life-threatening cause of [[sepsis]]
*Typically presents acutely (i.e., [[appendicitis]], [[diverticulitis]], perforated [[peptic ulcer]], penetrating [[abdominal trauma|trauma]]) and often requires immediate surgical intervention.   
*When the perforation is immediately contained (i.e., by the omentum or retroperitoneum), it may occasionally present with a more indolent course
**Immunosuppression or systemic corticosteroid therapy may also blunt the inflammatory response resulting in a protracted, indolent presentation.
 
===Causes<ref>Sabiston, David C.,Townsend, Courtney M.,eds. Sabiston Textbook Of Surgery: The Biological Basis Of Modern Surgical Practice. Philadelphia, PA : Elsevier Saunders, 2012.</ref><ref>Tanner, T., Hall, B., & Oran, J. (2018). Pneumoperitoneum. Surgical Clinics of North America., 98(5), 915–932. https://doi.org/10.1016/j.suc.2018.06.004.</ref>===
* [[Peptic ulcer disease]]
* Malignancy
* [[Diverticulitis]]
* [[Appendicitis]]
* [[Abdominal trauma]] (penetrating > blunt)
* [[Bowel obstruction]]
* [[Intestinal ischemia]]
* [[Foreign body ingestion]]
* [[Necrotizing enterocolitis]] (premature infants)
* Iatrogenic (i.e., endoscopy)


==Clinical Features==
==Clinical Features==
* Primary features:
===Primary Features===
** Abdominal pain, abdominal distention/rigidity (see acute abdomen)
;History
*** Occasionally focal if regionally confined (less common)
*[[Abdominal pain]], abdominal distention / rigidity
** Nausea, vomiting, fever, and anorexia often present
**Occasionally focal if regionally confined (less common)
* Secondary features:
*[[Nausea]], [[vomiting]], [[fever]], and anorexia often present
** Sepsis (fever, leukocytosis, tachycardia, hypotension)
** Possible sepsis-related end-organ dysfunction (i.e., ARDS, renal failure)


==Causes<sup>1,2</sup>==
;Physical exam
* Peptic ulcer disease
* Perforation with [[peritonitis]]
* Malignancy
** Abdominal tenderness, distention
* Diverticulitis
** Involuntary guarding
* Appendicitis
** Rebound tenderness
* Abdominal trauma (penetrating > blunt)
* Perforation without peritonitis
* Bowel obstruction
** Abdominal tenderness
* Foreign body ingestion
** Voluntary guarding
* Necrotizing enterocolitis (premature infants)
 
* Iatrogenic (i.e., endoscopy)
===Secondary Features===
*[[Sepsis]] ([[fever]], [[leukocytosis]], [[tachycardia]], [[hypotension]])
*Possible [[sepsis]]-related end-organ dysfunction (i.e., [[ARDS]], [[renal failure]])


==Differential Diagnosis==
==Differential Diagnosis==
* [[Acute myocardial infarction]]
* [[Acute myocardial infarction]]
* Intestinal obstruction  
* [[Intestinal obstruction]]
* Acute mesenteric ischemia  
* Acute [[mesenteric ischemia]]
* Mesenteric venous thrombosis  
* [[Mesenteric venous thrombosis]]
* Pelvic inflammatory disease  
* [[Pelvic inflammatory disease]]
* Tubo-ovarian abscess  
* [[Tubo-ovarian abscess]]
* Pancreatitis  
* [[Pancreatitis]]
* Ruptured ectopic pregnancy  
* Ruptured [[ectopic pregnancy]]
* Spontaneous bacterial peritonitis
* [[Spontaneous bacterial peritonitis]]


==Evaluation<sup>1,2</sup>==
==Evaluation<ref>Sabiston, David C.,Townsend, Courtney M.,eds. Sabiston Textbook Of Surgery: The Biological Basis Of Modern Surgical Practice. Philadelphia, PA : Elsevier Saunders, 2012.</ref><ref>Tanner, T., Hall, B., & Oran, J. (2018). Pneumoperitoneum. Surgical Clinics of North America., 98(5), 915–932. https://doi.org/10.1016/j.suc.2018.06.004.</ref>==
* Physical exam
[[File:Free air2010.png|thumb|Free air under the right diaphragm from a perforated bowel.]]
** Perforation with peritonitis
[[File:sub free gas.jpg|thumb|Subdiaphragmatic free gas. <ref>Case courtesy of Dr Rahul Kulkarni, https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/21444">rID: 21444</ref>.]]
*** Abdominal tenderness, distention
[[File:large bowel perf.jpg|thumb|Large bowel perforation.<ref>Case courtesy of Dr Ian Bickle, "https://radiopaedia.org/">Radiopaedia.org</a>. From the case < href="https://radiopaedia.org/cases/55375">rID: 55375</ref>.]]
*** Involuntary guarding
[[File:duodenal perf.jpg|thumb|Duodenal perforation.<ref>Case courtesy of Dr Ian Bickle,  "https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/55491">rID: 55491</ref>.]]
*** Rebound tenderness
===Workup===
** Perforation without peritonitis
*CBC, BMP, PT/PTT, [[LFTs]], lipase, T&S
*** Abdominal tenderness
*Blood cultures (as long as this does not delay the initiation of antimicrobial therapy)
*** Voluntary guarding
* Imaging (use only if physical exam is non-specific, exam findings of peritonitis warrant immediate surgical consultation):
* Imaging (use only if physical exam is non-specific, exam findings of peritonitis warrant immediate surgical consultation):
** X-ray  
** X-ray vs CT abdomen/pelvis with IV contrast (and PO contrast if possible)
*** 3 views of the abdomen (upright, supine, and left lateral decubitus) and upright CXR
*** IV contrast improves soft tissue resolution and improves diagnostic accuracy and should be considered even in the presence of acute kidney injury.
<gallery>
*** PO contrast improves bowel resolution and identification of perforation. Presence of PO contrast may help to distinguish intra-abdominal abscesses from adjacent bowel.
sub free gas.jpg|Subdiaphragmatic free gas. Case courtesy of Dr Rahul Kulkarni, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/21444">rID: 21444</a>.
 
</gallery>
===Diagnosis===
** CT abdomen/pelvis with IV contrast (and PO contrast if possible)
* Physical exam vs. imaging
*** IV contrast improves soft tissue resolution in the abdomen and pelvis and improves diagnostic accuracy and should be considered even in the presence of acute kidney injury.
*** PO contrast improves bowel resolution and the identification of perforation. Presence of PO contrast may help to distinguish intra-abdominal abscesses from adjacent bowel.
<gallery>
large bowel perf.jpg|Large bowel perforation. Case courtesy of Dr Ian Bickle, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/55375">rID: 55375</a>.
duodenal perf.jpg|Duodenal perforation. Case courtesy of Dr Ian Bickle, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/55491">rID: 55491</a>.
</gallery>


==Management<sup>1,3-4</sup>==
==Management==
* Intravenous fluid resuscitation<sup>3</sup>
===General Treatment===
** Resuscitation guidelines for sepsis (taken from the Surviving Sepsis Campaign 2016 recommendations):
*NPO<ref>Sabiston, David C.,Townsend, Courtney M.,eds. Sabiston Textbook Of Surgery: The Biological Basis Of Modern Surgical Practice. Philadelphia, PA : Elsevier Saunders, 2012.</ref>
*Surgical consult<ref>Sabiston, David C.,Townsend, Courtney M.,eds. Sabiston Textbook Of Surgery: The Biological Basis Of Modern Surgical Practice. Philadelphia, PA : Elsevier Saunders, 2012.</ref>
*IV [[fluid resuscitation]]<ref>Rhodes, A., Evans, L.E., Alhazzani, W. et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 43, 304–377 (2017). https://doi.org/10.1007/s00134-017-4683-6.</ref>
** Resuscitation guidelines for [[sepsis]] (taken from the Surviving Sepsis Campaign 2016 recommendations):
*** For sepsis-induced hypoperfusion, administration of 30 mL/kg of IV isotonic crystalloid within first 3 hrs  
*** For sepsis-induced hypoperfusion, administration of 30 mL/kg of IV isotonic crystalloid within first 3 hrs  
**** Additional fluid resuscitation should be guided by frequent reassessment of hemodynamic status
**** Additional fluid resuscitation should be guided by frequent reassessment of hemodynamic status
*** Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion
*** Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion
*** Initial target mean arterial pressure (MAP) of 65 mmHg in patients with septic shock requiring vasopressors
*** Initial target mean arterial pressure (MAP) of 65 mmHg in patients with [[septic shock]] requiring vasopressors
* Microbiology cultures: Routine microbiology cultures should be obtained prior to starting antimicrobial therapy, as long as this does not delay the initiation of antimicrobial therapy.
* Initiate broad-spectrum antibiotics (start as soon as possible; ideally within the first hour)<sup>4</sup>
** Community-acquired:
*** Therapy should target enteric gram-negative aerobic and facultative bacilli, obligate anaerobic bacilli, and enteric gram-positive streptococci
*** Adult regimen (see '''TABLE 1'''):
**** '''Mild to moderate severity community acquired GI perforation''':
***** '''Single agent''': Cefoxitin, ertapenem, moxifloxacin, tigecycline, or ticarcillin/clavulanic acid
***** '''Combination therapy''':
****** Cefazolin, cefuroxime, ceftriaxone, cefotaxime, ciprofloxacin, or levofloxacin -AND-
****** Metronidazole
**** '''High risk/severity community acquired GI perforation''':
***** '''Single agent''': Imipenem-cilastatin, meropenem, doripenem, or piperacillin/tazobactam
***** '''Combination therapy''': Cefepime, ceftazidime, ciprofloxacin, or levofloxacin -AND-
***** Metronidazole
*** Pediatric regimen: (for dosage, see '''TABLE 1''')
**** '''Community acquired GI perforation''':
***** '''Single agent''': Ertapenem, meropenem, imipenem-cilastatin, ticarcillin/clavulanate, and piperacillin/tazobactam
***** '''Combination therapy''':
****** Ceftriaxone, cefotaxime, cefepime, or ceftazidime, each in combination with metronidazole
****** Gentamicin or tobramycin, each in combination with metronidazole or clindamycin, and with or without ampicillin
** Iatrogenic/hospital-associated perforation: Therapy should be driven by local microbiologic results.
*** Drug-resistant bacteria regimen (common in hospital-associated perforation):
**** '''<20% Resistant Resudomonas aeruginosa, ESBL-producing Enterobacteriaceae, Acinetobacter, or other MDR GNB''':
***** '''Single agent''': Carbapenem, piperacillin-tazobactam
***** Ceftazidime or cefepime, each in combination with metronidazole
**** '''ESBL-producing Enterobacteriaceae''': Carbapenem, piperacillin/tazobactam, or aminoglycoside
**** '''P. aeruginosa >20% resistant to ceftazidime''': Carbapenem, piperacillin/tazobactam, or aminoglycoside
**** '''MRSA''': Vancomycin only
** '''Fungal infection''': Antifungal therapy for patients with severe community-acquired or health care-associated infection is recommended if Candida is grown from intra-abdominal cultures (fluconazole; echinocandins for triazole-resistant species)
* Designate patient as NPO<sup>1</sup>
* Obtain surgical consult<sup>1</sup>


==Disposition<sup>1</sup>==
===Broad-Spectrum [[Antibiotics]]<ref>Joseph S. Solomkin, John E. Mazuski, John S. Bradley, Keith A Rodvold, Ellie J.C. Goldstein, Ellen J. Baron, Patrick J. O'Neill, Anthony W. Chow, E. Patchen Dellinger, Soumitra R. Eachempati, Sherwood Gorbach, Mary Hilfiker, Addison K. May, Avery B. Nathens, Robert G. Sawyer, John G. Bartlett, Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 50, Issue 2, 15 January 2010, Pages 133–164, https://doi.org/10.1086/649554.</ref>===
''Start as soon as possible; ideally within the first hour''
* Obtain immediate surgical consult
* Community-acquired:
** Therapy should target enteric gram-negative aerobic and facultative bacilli, obligate anaerobic bacilli, and enteric gram-positive streptococci
**Adult regimen:
***'''Mild to moderate severity community acquired GI perforation''':
**** '''Single agent''': [[Cefoxitin]], [[ertapenem]], [[moxifloxacin]], [[tigecycline]], or [[ticarcillin/clavulanic acid]]
**** '''Combination therapy''':
***** [[Cefazolin]], [[cefuroxime]], [[ceftriaxone]], [[cefotaxime]], [[ciprofloxacin]], or [[levofloxacin]] -AND-
***** [[Metronidazole]]
*** '''High risk/severity community acquired GI perforation''':
**** '''Single agent''': [[Imipenem-cilastatin]], [[meropenem]], [[doripenem]], or [[piperacillin/tazobactam]]
**** '''Combination therapy''': [[Cefepime]], [[ceftazidime]], [[ciprofloxacin]], or [[levofloxacin]] -AND-
**** [[Metronidazole]]
** Pediatric regimen:
*** '''Community acquired GI perforation''':
**** '''Single agent''': [[Ertapenem]], [[meropenem]], [[imipenem-cilastatin]], [[ticarcillin/clavulanate]], and [[piperacillin/tazobactam]]
**** '''Combination therapy''':
***** [[Ceftriaxone]], [[cefotaxime]], [[cefepime]], or [[ceftazidime]], each in combination with [[metronidazole]]
***** [[Gentamicin]] or [[tobramycin]], each in combination with [[metronidazole]] or [[clindamycin]], and with or without [[ampicillin]]
* Iatrogenic/hospital-associated perforation: Therapy should be driven by local microbiologic results.
** Drug-resistant bacteria regimen (common in hospital-associated perforation):
*** '''<20% Resistant [[Pseudomonas aeruginosa]], ESBL-producing [[Enterobacteriaceae]], [[Acinetobacter]], or other MDR [[GNB]]''':
**** '''Single agent''': [[Carbapenem]], [[piperacillin-tazobactam]]
**** [[Ceftazidime]] or [[cefepime]], each in combination with [[metronidazole]]
*** '''ESBL-producing [[Enterobacteriaceae]]''': [[Carbapenem]], [[piperacillin/tazobactam]], or [[aminoglycoside]]
*** '''[[P. aeruginosa]] >20% resistant to [[ceftazidime]]''': [[Carbapenem]], [[piperacillin/tazobactam]], or [[aminoglycoside]]
*** '''[[MRSA]]''': [[Vancomycin]] only
* '''Fungal infection''': Antifungal therapy for patients with severe community-acquired or health care-associated infection is recommended if candida is grown from intra-abdominal cultures ([[fluconazole]]; echinocandins for triazole-resistant species)


=='''TABLE 1'''. Antibiotic Dosage Information<sup>4</sup>==
==Disposition==
[[File:TABLE 1. Antibiotic dosage information.pdf|thumb|Adult and pediatric antibiotic dosage information]]
* Admission (typically directly to operating room)<ref>Sabiston, David C.,Townsend, Courtney M.,eds. Sabiston Textbook Of Surgery: The Biological Basis Of Modern Surgical Practice. Philadelphia, PA : Elsevier Saunders, 2012.</ref>


==See Also==
==See Also==
 
*[[Sepsis]]


==External Links==
==External Links==
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==References==
==References==
<references/>
<references/>
# Sabiston, David C.,Townsend, Courtney M.,eds. Sabiston Textbook Of Surgery: The Biological Basis Of Modern Surgical Practice. Philadelphia, PA : Elsevier Saunders, 2012.
 
# Tanner, T., Hall, B., & Oran, J. (2018). Pneumoperitoneum. Surgical Clinics of North America., 98(5), 915–932. https://doi.org/10.1016/j.suc.2018.06.004.
[[Category:Surgery]]
# Rhodes, A., Evans, L.E., Alhazzani, W. et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 43, 304–377 (2017). https://doi.org/10.1007/s00134-017-4683-6.
[[Category:GI]]
# Joseph S. Solomkin, John E. Mazuski, John S. Bradley, Keith A Rodvold, Ellie J.C. Goldstein, Ellen J. Baron, Patrick J. O'Neill, Anthony W. Chow, E. Patchen Dellinger, Soumitra R. Eachempati, Sherwood Gorbach, Mary Hilfiker, Addison K. May, Avery B. Nathens, Robert G. Sawyer, John G. Bartlett, Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 50, Issue 2, 15 January 2010, Pages 133–164, https://doi.org/10.1086/649554.

Latest revision as of 00:44, 1 February 2024

Background

Illustration of GI track
  • Definition: a full-thickness breach of the intestinal wall, allowing air and/or gastrointestinal contents to enter the surrounding peritoneal cavity
  • Can be a potentially life-threatening cause of sepsis
  • Typically presents acutely (i.e., appendicitis, diverticulitis, perforated peptic ulcer, penetrating trauma) and often requires immediate surgical intervention.
  • When the perforation is immediately contained (i.e., by the omentum or retroperitoneum), it may occasionally present with a more indolent course
    • Immunosuppression or systemic corticosteroid therapy may also blunt the inflammatory response resulting in a protracted, indolent presentation.

Causes[1][2]

Clinical Features

Primary Features

History
Physical exam
  • Perforation with peritonitis
    • Abdominal tenderness, distention
    • Involuntary guarding
    • Rebound tenderness
  • Perforation without peritonitis
    • Abdominal tenderness
    • Voluntary guarding

Secondary Features

Differential Diagnosis

Evaluation[3][4]

Free air under the right diaphragm from a perforated bowel.
Subdiaphragmatic free gas. [5].
Large bowel perforation.[6].
Duodenal perforation.[7].

Workup

  • CBC, BMP, PT/PTT, LFTs, lipase, T&S
  • Blood cultures (as long as this does not delay the initiation of antimicrobial therapy)
  • Imaging (use only if physical exam is non-specific, exam findings of peritonitis warrant immediate surgical consultation):
    • X-ray vs CT abdomen/pelvis with IV contrast (and PO contrast if possible)
      • IV contrast improves soft tissue resolution and improves diagnostic accuracy and should be considered even in the presence of acute kidney injury.
      • PO contrast improves bowel resolution and identification of perforation. Presence of PO contrast may help to distinguish intra-abdominal abscesses from adjacent bowel.

Diagnosis

  • Physical exam vs. imaging

Management

General Treatment

  • NPO[8]
  • Surgical consult[9]
  • IV fluid resuscitation[10]
    • Resuscitation guidelines for sepsis (taken from the Surviving Sepsis Campaign 2016 recommendations):
      • For sepsis-induced hypoperfusion, administration of 30 mL/kg of IV isotonic crystalloid within first 3 hrs
        • Additional fluid resuscitation should be guided by frequent reassessment of hemodynamic status
      • Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion
      • Initial target mean arterial pressure (MAP) of 65 mmHg in patients with septic shock requiring vasopressors

Broad-Spectrum Antibiotics[11]

Start as soon as possible; ideally within the first hour

Disposition

  • Admission (typically directly to operating room)[12]

See Also

External Links

References

  1. ↑ Sabiston, David C.,Townsend, Courtney M.,eds. Sabiston Textbook Of Surgery: The Biological Basis Of Modern Surgical Practice. Philadelphia, PA : Elsevier Saunders, 2012.
  2. ↑ Tanner, T., Hall, B., & Oran, J. (2018). Pneumoperitoneum. Surgical Clinics of North America., 98(5), 915–932. https://doi.org/10.1016/j.suc.2018.06.004.
  3. ↑ Sabiston, David C.,Townsend, Courtney M.,eds. Sabiston Textbook Of Surgery: The Biological Basis Of Modern Surgical Practice. Philadelphia, PA : Elsevier Saunders, 2012.
  4. ↑ Tanner, T., Hall, B., & Oran, J. (2018). Pneumoperitoneum. Surgical Clinics of North America., 98(5), 915–932. https://doi.org/10.1016/j.suc.2018.06.004.
  5. ↑ Case courtesy of Dr Rahul Kulkarni, https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/21444">rID: 21444
  6. ↑ Case courtesy of Dr Ian Bickle, "https://radiopaedia.org/">Radiopaedia.org</a>. From the case < href="https://radiopaedia.org/cases/55375">rID: 55375
  7. ↑ Case courtesy of Dr Ian Bickle, "https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/55491">rID: 55491
  8. ↑ Sabiston, David C.,Townsend, Courtney M.,eds. Sabiston Textbook Of Surgery: The Biological Basis Of Modern Surgical Practice. Philadelphia, PA : Elsevier Saunders, 2012.
  9. ↑ Sabiston, David C.,Townsend, Courtney M.,eds. Sabiston Textbook Of Surgery: The Biological Basis Of Modern Surgical Practice. Philadelphia, PA : Elsevier Saunders, 2012.
  10. ↑ Rhodes, A., Evans, L.E., Alhazzani, W. et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 43, 304–377 (2017). https://doi.org/10.1007/s00134-017-4683-6.
  11. ↑ Joseph S. Solomkin, John E. Mazuski, John S. Bradley, Keith A Rodvold, Ellie J.C. Goldstein, Ellen J. Baron, Patrick J. O'Neill, Anthony W. Chow, E. Patchen Dellinger, Soumitra R. Eachempati, Sherwood Gorbach, Mary Hilfiker, Addison K. May, Avery B. Nathens, Robert G. Sawyer, John G. Bartlett, Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 50, Issue 2, 15 January 2010, Pages 133–164, https://doi.org/10.1086/649554.
  12. ↑ Sabiston, David C.,Townsend, Courtney M.,eds. Sabiston Textbook Of Surgery: The Biological Basis Of Modern Surgical Practice. Philadelphia, PA : Elsevier Saunders, 2012.
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