Difference between revisions of "Bowel perforation"

(/* Broad-Spectrum AntibioticsJoseph 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...)
 
Line 1: Line 1:
 
==Background==
 
==Background==
 
*Definition: a full-thickness breach of the intestinal wall, allowing air and/or gastrointestinal contents to enter the surrounding peritoneal cavity
 
*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.
+
*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.   
+
*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.
+
*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>===
Line 19: Line 20:
 
===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
Line 52: Line 53:
 
[[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===
*CBC, chem, PT, PTT, LFTs, lipase, T&S
+
*CBC, BMP, PT/PTT, [[LFTs]], lipase, T&S
 
*Blood cultures (as long as this does not delay the initiation of antimicrobial therapy)
 
*Blood cultures (as long as this does not delay the initiation of antimicrobial therapy)
*CT abdomen
 
 
* 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 vs CT abdomen/pelvis with IV contrast (and PO contrast if possible)
 
** X-ray vs CT abdomen/pelvis with IV contrast (and PO contrast if possible)
*** 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.
+
*** 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 the identification of perforation. Presence of PO contrast may help to distinguish intra-abdominal abscesses from adjacent bowel.
+
*** PO contrast improves bowel resolution and identification of perforation. Presence of PO contrast may help to distinguish intra-abdominal abscesses from adjacent bowel.
  
 
===Diagnosis===
 
===Diagnosis===
Line 65: Line 65:
 
==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>==
 
==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===
 
===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:  

Latest revision as of 00:41, 22 October 2020

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[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]

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[8][9][10]

General Treatment

  • NPO[11]
  • Surgical consult[12]
  • IV fluid resuscitation[13]
    • 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[14]

Start as soon as possible; ideally within the first hour

Disposition[15]

  • Obtain immediate surgical consult

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. 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.
  10. 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.
  11. Sabiston, David C.,Townsend, Courtney M.,eds. Sabiston Textbook Of Surgery: The Biological Basis Of Modern Surgical Practice. Philadelphia, PA : Elsevier Saunders, 2012.
  12. Sabiston, David C.,Townsend, Courtney M.,eds. Sabiston Textbook Of Surgery: The Biological Basis Of Modern Surgical Practice. Philadelphia, PA : Elsevier Saunders, 2012.
  13. 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.
  14. 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.
  15. Sabiston, David C.,Townsend, Courtney M.,eds. Sabiston Textbook Of Surgery: The Biological Basis Of Modern Surgical Practice. Philadelphia, PA : Elsevier Saunders, 2012.
  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.