Bowel perforation

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

• 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

Primary Features

History

• Abdominal pain, abdominal distention / rigidity
  • Occasionally focal if regionally confined (less common)
• Nausea, vomiting, fever, and anorexia often present

Physical exam

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

Secondary Features

• Sepsis (fever, leukocytosis, tachycardia, hypotension)
• Possible sepsis-related end-organ dysfunction (i.e., ARDS, renal failure)

Differential Diagnosis

• Acute myocardial infarction
• Intestinal obstruction
• Acute mesenteric ischemia
• Mesenteric venous thrombosis
• Pelvic inflammatory disease
• Tubo-ovarian abscess
• Pancreatitis
• Ruptured ectopic pregnancy
• Spontaneous bacterial peritonitis

Evaluation

Free air under the right diaphragm from a perforated bowel.

Subdiaphragmatic free gas. .

Large bowel perforation..

Duodenal perforation..

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
• Surgical consult
• IV fluid resuscitation
  • 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

Start as soon as possible; ideally within the first hour

• 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)

Disposition

• Admission (typically directly to operating room)

See Also

• Sepsis