Bowel perforation

Background

• 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
• 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

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

• Obtain immediate surgical consult

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.