Doctor123.org

Perforated Viscous, Emergency Medicine

Basics

Description

  • Perforation/break in the containing walls of an organ with contents spilling into peritoneal cavity
  • Inflammation/infection
  • Ulceration
  • Shearing/crushing or bursting forces in trauma
  • Obstruction
  • Chemical and/or bacterial peritonitis occurs as result of disruption of gastric or intestinal lining into peritoneal cavity.

Etiology

  • Peptic ulcer disease:Majority of cases caused by NSAIDS and Helicobacter pylori
  • Esophageal
  • Small bowel:Ischemia, foreign body, neoplasms, inflammatory bowel disease
  • Large bowel:Diverticular disease, foreign body, neoplasms, inflammatory bowel disease
  • Appendicitis
  • Penetrating or blunt trauma
  • Iatrogenic:
  • Radiation enteritis and proctitis
  • Trauma is the more common cause of rupture:Neonates with difficult birth/child abuse/motor vehicle accidents and falls
  • Jejunum is the most common site of rupture.

Diagnosis

Signs and Symptoms

  • Sudden severe abdominal pain:Initially localOften rapidly becoming diffuse due to peritonitisConsider persistent local pain due to abscess/phlegmon formation
  • Rigidity
  • Guarding
  • Rebound tenderness
  • Absent bowel sounds
  • SIRS
  • Hypovolemic or septic shock:HypotensionTachycardiaTachypnea
  • 1/3 without complaints of PUD
  • May not have dramatic pain/peritoneal findings on exam:Less rebound and guarding due to less abdominal wall musculatureChronic use of pain meds
  • May present with altered mental status
  • Hypothermic, suppressed tachycardia

Essential Workup

Upright chest radiograph:

  • Best demonstrates pneumoperitoneum
  • When in upright position for 5 " 10 min, may detect as little as 1 " 2 mL of free air under diaphragm

Diagnosis Tests & Interpretation

Lab

  • CBC
  • Electrolytes, BUN/creatinine, glucose
  • Lipase
  • Urinalysis
  • Liver function test, coagulation panel
  • ABG
  • Lactate
  • Consider type and cross match for blood

Imaging

  • Upright CXR:To detect air under diaphragmSensitivity ranges from 50% to 85%
  • Abdominal radiographs:Left lateral decubitus film more helpful than supine abdomen.Double wall sign of perforated viscous:Air in intestinal lumen and peritoneal cavity allows for visualization of both serosal (not normally seen) and mucosal surfaces of intestine.
  • Abdominal CT:Detects small amounts of free air from perforated viscous
  • ECG

Differential Diagnosis

  • Pneumomediastinum with peritoneal extension
  • Appendicitis/cholecystitis/pancreatitis
  • Pneumonia
  • DKA
  • Intra-abdominal abscess
  • Peptic ulcer disease
  • Inferior wall myocardial infarction
  • Obstruction

Atypical symptoms of pain, lack of fever, absence of leukocytosis more likely due to populations suppressed immunity, common comorbidities

  • AAA
  • Acute mesenteric ischemia
  • Atypical presentations of conditions listed in DDx

Rule out ectopic pregnancy

Treatment

Pre-Hospital

Initiate IV fluids for patients with history of vomiting or abnormal vital signs.

Initial Stabilization/Therapy

Treat hypotension/tachycardia with 0.9% normal saline:

  • Adults: 500 mL " 1 L bolus:Repeat bolus as necessary permitting patient can tolerate aggressive fluid resuscitationConsider vasopressors if fluids not tolerated or not sufficient to maintain physiologic stability
  • Pediatric: 20 mL/kg bolus:Considerations similar as in adult population

Ed Treatment/Procedures

  • Nasogastric tube
  • Foley catheter
  • Administer broad-spectrum antibiotics:Cephalosporin/broad-spectrum penicillin +Aminoglycoside/broad-spectrum penicillin/antianaerobe
  • Immediate surgical consultation for operative intervention

Medication

Broad coverage antibiotics should be given for enteric gram-negative aerobic and facultative bacilli and enteric gram-positive streptococci

  • Metronidazole 500 mg IV (peds: 30 " 40 mg/kg/d q8h) in addition to 1 of the antibiotics below
  • Carbapenem:Meropenem 1 g IV q 8h (peds: 60 mg/kg/d in div. doses q8h)Imipenem " cilastatin 500 mg IV q6h (peds: 60 " 100 mg/kg/d in div. doses q6h)Doripenem 500 mg IV q8h
  • ²-lactamase inhibitor combination:Piperacillin " tazobactam 3.375 " 4 g IV q4 " 6h (peds: 200 " 300 mg/kg/d of piperacillin component in div. doses q6 " 8h)
  • Flouroquinolones (used only if hospital surveys indicate >90% susceptibility of Escherichia coli to this class):Ciprofloxacin 400 mg IV q12hLevofloxacin 750 mg IV q24h
  • Cephalosporin:Ceftazidime 2 g IV q8h (peds: 150 mg/kg/d in div. doses q8h)Cefepime 2 g IV q8 " 12h (peds: 100 mg/kg/d in div. doses q12h)Ceftriaxone 1 " 2 g IV q12 " 24h (peds: 50 " 75 mg/kg/d in div. doses q12 " 24h)
  • Morphine sulfate: 2 " 4 mg (peds: 0.1 mg/kg) IV q2 " 3h

Follow-Up

Disposition

Admission Criteria

Suspected or confirmed perforation requires admission and immediate surgical consultation.

Discharge Criteria

Discharge not applicable in this situation, as acute perforations are surgical emergencies

Issues for Referral

  • General surgery consult for operative intervention
  • Consider trauma consult/transfer if applicable

Followup Recommendations

Postoperative surgery follow-up

Pearls and Pitfalls

  • Obtain upright CXR and abdominal radiographs for patients with suspected perforated viscous.
  • CXR without free air does not rule out perforation
  • If high clinical suspicion for perforation and plain films normal, obtain CT of abdomen to detect small perforation.
  • Obtain immediate surgical consult for operative intervention.

Additional Reading

  • Gans SL, Stoker J, Boermeester MA. Plain abdominal radiography in acute abdominal pain; past, present, and future. Int J Gen Med. 2012;5:525 " 533.
  • Langell JT, Mulvihill SJ. Gastrointestinal perforation and the acute abdomen. Med Clin North Am. 2008;92:599 " 625.
  • Lyon C, Clark DC. Diagnosis of acute abdominal pain in older patients. Am Fam Physician. 2006;74:1537 " 1544.
  • Solomkin JS, Mazuski JE, Bradley JS, et al. 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. Clin Infect Dis. 2010;50:133 " 164.

See Also (Topic, Algorithm, Electronic Media Element)

Abdominal Pain

Codes

ICD9

  • 533.50 Chronic or unspecified peptic ulcer of unspecified site with perforation, without mention of obstruction
  • 562.11 Diverticulitis of colon (without mention of hemorrhage)
  • 868.00 Injury to other intra-abdominal organs without mention of open wound into cavity, unspecified intra-abdominal organ
  • 540.0 Acute appendicitis with generalized peritonitis
  • 567.9 Unspecified peritonitis
  • 863.29 Other injury to small intestine, without mention of open wound into cavity
  • 868.10 Injury to other intra-abdominal organs with open wound into cavity, unspecified intra-abdominal organ

ICD10

  • K27.5 Chronic or unsp peptic ulcer, site unsp, with perforation
  • K57.20 Diverticulitis of large intestine with perforation and abscess without bleeding
  • S36.99XA Other injury of unspecified intra-abdominal organ, initial encounter
  • K35.2 Acute appendicitis with generalized peritonitis
  • K65.9 Peritonitis, unspecified
  • S36.498A Other injury of other part of small intestine, init encntr

SNOMED

  • 49011004 Internal injury of abdominal organs (disorder)
  • 88169003 Peptic ulcer with perforation (disorder)
  • 76953007 Diverticulitis of colon with perforation (disorder)
  • 286967008 Acute perforated appendicitis
  • 20784007 Internal injury of abdominal organs with open wound into cavity (disorder)
  • 282061008 Rupture of jejunum (disorder)
  • 48661000 Peritonitis (disorder)