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:
- Endoscopy, colonoscopy
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 local
- Often rapidly becoming diffuse due to peritonitis
- Consider persistent local pain due to abscess/phlegmon formation
Rigidity
Guarding
Rebound tenderness
Absent bowel sounds
SIRS
Hypovolemic or septic shock:
- Hypotension
- Tachycardia
- Tachypnea

1/3 without complaints of PUD
May not have dramatic pain/peritoneal findings on exam:
- Less rebound and guarding due to less abdominal wall musculature
- Chronic 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 diaphragm
- Sensitivity 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 resuscitation
- Consider 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 q12h
- Levofloxacin 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.

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)

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