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>===
===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
* [[Peptic ulcer disease]]
* Malignancy
* Malignancy
* Diverticulitis
* [[Diverticulitis]]
* Appendicitis
* [[Appendicitis]]
* Abdominal trauma (penetrating > blunt)
* [[Abdominal trauma]] (penetrating > blunt)
* Bowel obstruction
* [[Bowel obstruction]]
* Foreign body ingestion  
* [[Intestinal ischemia]]
* Necrotizing enterocolitis (premature infants)
* [[Foreign body ingestion]]
* [[Necrotizing enterocolitis]] (premature infants)
* Iatrogenic (i.e., endoscopy)
* Iatrogenic (i.e., endoscopy)


==Clinical Features==
==Clinical Features==
===Primary features===
===Primary Features===
;History
;History
*[[Abdominal]] pain, abdominal distention / rigidity (see [[acute abdomen]])
*[[Abdominal pain]], abdominal distention / rigidity
**Occasionally focal if regionally confined (less common)
**Occasionally focal if regionally confined (less common)
*[[Nausea]], [[vomiting]], [[fever]], and anorexia often present
*[[Nausea]], [[vomiting]], [[fever]], and anorexia often present


;Physical exam
;Physical exam
* Perforation with peritonitis
* Perforation with [[peritonitis]]
** Abdominal tenderness, distention
** Abdominal tenderness, distention
** Involuntary guarding
** Involuntary guarding
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** Voluntary guarding
** Voluntary guarding


===Secondary features:===
===Secondary Features===
*[[Sepsis]] ([[fever]], [[leukocytosis]], [[tachycardia]], [[hypotension]])
*[[Sepsis]] ([[fever]], [[leukocytosis]], [[tachycardia]], [[hypotension]])
*Possible [[sepsis]]-related end-organ dysfunction (i.e., [[ARDS]], [[renal failure]])
*Possible [[sepsis]]-related end-organ dysfunction (i.e., [[ARDS]], [[renal failure]])
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* [[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<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>==
==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>==
[[File:Free air2010.png|thumb|Free air under the right diaphragm from a perforated bowel.]]
[[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>.]]
[[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>.]]
[[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>.]]
[[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>.]]
[[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>.]]
[[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>.]]
===Workup===
===Workup===
*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.
*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):
* 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.
** CT abdomen/pelvis with IV contrast (and PO contrast if possible)
*** PO contrast improves bowel resolution and identification of perforation. Presence of PO contrast may help to distinguish intra-abdominal abscesses from adjacent bowel.
*** 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.


===Diagnosis===
===Diagnosis===
* Physical exam vs. imaging


 
==Management==
==Management<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>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><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>==
===General Treatment===
* Designate patient as 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>
*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>
* Obtain 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>
*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>
* Intravenous 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>
*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):
** 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


===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>===
===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''
''Start as soon as possible; ideally within the first hour''
* Community-acquired:  
* Community-acquired:  
** Therapy should target enteric gram-negative aerobic and facultative bacilli, obligate anaerobic bacilli, and enteric gram-positive streptococci
** Therapy should target enteric gram-negative aerobic and facultative bacilli, obligate anaerobic bacilli, and enteric gram-positive streptococci
** Adult regimen (see '''TABLE 1'''):
**Adult regimen:
*** '''Mild to moderate severity community acquired GI perforation''':
***'''Mild to moderate severity community acquired GI perforation''':
**** '''Single agent''': Cefoxitin, ertapenem, moxifloxacin, tigecycline, or ticarcillin/clavulanic acid  
**** '''Single agent''': [[Cefoxitin]], [[ertapenem]], [[moxifloxacin]], [[tigecycline]], or [[ticarcillin/clavulanic acid]]
**** '''Combination therapy''':
**** '''Combination therapy''':
***** Cefazolin, cefuroxime, ceftriaxone, cefotaxime, ciprofloxacin, or levofloxacin -AND-  
***** [[Cefazolin]], [[cefuroxime]], [[ceftriaxone]], [[cefotaxime]], [[ciprofloxacin]], or [[levofloxacin]] -AND-  
***** Metronidazole  
***** [[Metronidazole]]
*** '''High risk/severity community acquired GI perforation''':  
*** '''High risk/severity community acquired GI perforation''':  
**** '''Single agent''': Imipenem-cilastatin, meropenem, doripenem, or piperacillin/tazobactam  
**** '''Single agent''': [[Imipenem-cilastatin]], [[meropenem]], [[doripenem]], or [[piperacillin/tazobactam]]
**** '''Combination therapy''': Cefepime, ceftazidime, ciprofloxacin, or levofloxacin -AND-  
**** '''Combination therapy''': [[Cefepime]], [[ceftazidime]], [[ciprofloxacin]], or [[levofloxacin]] -AND-  
**** Metronidazole  
**** [[Metronidazole]]
** Pediatric regimen: (for dosage, see '''TABLE 1''')
** Pediatric regimen:
*** '''Community acquired GI perforation''':  
*** '''Community acquired GI perforation''':  
**** '''Single agent''': Ertapenem, meropenem, imipenem-cilastatin, ticarcillin/clavulanate, and piperacillin/tazobactam  
**** '''Single agent''': [[Ertapenem]], [[meropenem]], [[imipenem-cilastatin]], [[ticarcillin/clavulanate]], and [[piperacillin/tazobactam]]
**** '''Combination therapy''':
**** '''Combination therapy''':
***** Ceftriaxone, cefotaxime, cefepime, or ceftazidime, each in combination with metronidazole  
***** [[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
***** [[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.
* Iatrogenic/hospital-associated perforation: Therapy should be driven by local microbiologic results.
** Drug-resistant bacteria regimen (common in hospital-associated perforation):
** Drug-resistant bacteria regimen (common in hospital-associated perforation):
*** '''<20% Resistant Resudomonas aeruginosa, ESBL-producing Enterobacteriaceae, Acinetobacter, or other MDR GNB''':  
*** '''<20% Resistant [[Pseudomonas aeruginosa]], ESBL-producing [[Enterobacteriaceae]], [[Acinetobacter]], or other MDR [[GNB]]''':  
**** '''Single agent''': Carbapenem, piperacillin-tazobactam  
**** '''Single agent''': [[Carbapenem]], [[piperacillin-tazobactam]]
**** Ceftazidime or cefepime, each in combination with metronidazole
**** [[Ceftazidime]] or [[cefepime]], each in combination with [[metronidazole]]
*** '''ESBL-producing Enterobacteriaceae''': Carbapenem, piperacillin/tazobactam, or aminoglycoside  
*** '''ESBL-producing [[Enterobacteriaceae]]''': [[Carbapenem]], [[piperacillin/tazobactam]], or [[aminoglycoside]]
*** '''P. aeruginosa >20% resistant to ceftazidime''': Carbapenem, piperacillin/tazobactam, or aminoglycoside  
*** '''[[P. aeruginosa]] >20% resistant to [[ceftazidime]]''': [[Carbapenem]], [[piperacillin/tazobactam]], or [[aminoglycoside]]
*** '''MRSA''': Vancomycin only  
*** '''[[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)
* '''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)


==Disposition<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>==
==Disposition==
* Obtain immediate surgical consult
* 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>
 
=='''TABLE 1'''. Antibiotic Dosage Information<sup>4</sup>==
[[File:TABLE 1. Antibiotic dosage information.pdf|thumb|Adult and pediatric antibiotic dosage information]]


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


==External Links==
==External Links==
Line 114: Line 118:
==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.
# 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.
# 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.


[[Category:Surgery]]
[[Category:Surgery]]
[[Category:GI]]
[[Category:GI]]

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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