Bowel perforation

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.

Clinical Features

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

Causes^1,2

• Peptic ulcers (i.e., gastric, duodenal; causes 75% of pneumoperitoneum cases)
• Gastrointestinal cancer
• Diverticulitis
• Appendicitis
• Abdominal trauma (penetrating > blunt)
• Bowel obstruction
• Foreign body ingestion
• Necrotizing enterocolitis (premature infants)
• Instrumentation (i.e., endoscopic biopsy)

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^1,2

• Physical exam
  • Perforation with peritonitis
    • Abdominal tenderness, distention
    • Involuntary guarding
    • Rebound tenderness
  • Perforation without peritonitis
    • Abdominal tenderness
    • Voluntary guarding
• Imaging - use only if physical exam is non-specific, exam findings of peritonitis warrant immediate surgical consult and/or admission to OR:
  • X-ray (only if physical exam is non-specific, exam findings of peritonitis warrant immediate surgical consultation)
    • 3 views of the abdomen (upright, supine, and left lateral decubitus) and upright CXR

• 

  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>.

• • Abdominal CT (only if physical exam, x-ray are non-diagnostic)

• 

  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 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>.

Management^1,3-4

• Intravenous fluid resuscitation³
  • Resuscitation guidelines for sepsis taken from the Surviving Sepsis Campaign 2016 recommendations:
    • At least 30 mL/kg of IV crystalloid within first 3 hrs
    • Initial target mean arterial pressure (MAP) of 65 mm Hg in patients with septic shock requiring vasopressors
    • Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion
• Initiate broad-spectrum antibiotics (start as soon as possible)⁴
  • Community-acquired: Therapy should target enteric gram-negative aerobic and facultative bacilli, obligate anaerobic bacilli, and enteric gram-positive streptococci
    • Adult regimen: (for dosage, see table 1)
      • Mild to moderate severity community acquired GI perforation:
        • Single agent: Cefoxitin, ertapenem, moxifloxacin, tigecycline, and 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, and piperacillin-tazobactam
        • Combination therapy: Cefepime, ceftazidime, ciprofloxacin, or levofloxacin -AND-
        • Metronidazole
    • Pediatric regimen: (for dosage, see table 1)
      • Community acquired GI perforation: Ertapenem, meropenem, imipenem-cilastatin, ticarcillin-clavulanate, and piperacillin-tazobactam (single-agent); Ceftriaxone, cefotaxime, cefepime, or ceftazidime, each in combination with metronidazole (combo); gentamicin or tobramycin, each in combination with metronidazole or clindamycin, and with or without ampicillin (alt. combo)
  • Therapy for iatrogenic intra-abdominal infection should be driven by local microbiologic results; Broad-spectrum antimicrobial therapy should be tailored when culture and susceptibility reports become available
    • Iatrogenic regimen:
      • <20% Resistant Resudomonas aeruginosa, ESBL-producing Enterobacteriaceae, Acinetobacter, or other MDR GNB: Carbapenem, piperacillin-tazobactam (single-agent); Ceftazidime or cefepime, each in combination with metronidazole (combo)
      • ESBL-producing Enterobacteriaceae: Carbapenem, piperacillin-tazobactam, or aminoglycoside (single-agent)
      • P. aeruginosa >20% resistant to ceftazidime: Carbapenem, piperacillin-tazobactam, or aminoglycoside (single-agent)
      • MRSA: Vancomycin only (single-agent)
  • 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 NPO¹
• Obtain blood and urine cultures¹
• Obtain surgical consult¹

Disposition¹

• Obtain surgical consult

Antibiotic Dosage Information⁴

File:Book2.pdf

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. 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.
4. 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.