Ruptured Bowel

para>A ruptured bowel with peritonitis is a surgical emergency. ‚

Definitive treatment should not be delayed by extensive workup in the setting of peritonitis.

HISTORY

Abdominal pain: often sudden onset or after a specific insult like trauma, ingestion of fish
Abdominal distention, nausea, and/or vomiting
Preference for fixed supine or fetal position; pain worse with movement
In patients with suspected appendicitis, right lower quadrant pain that suddenly lessens is suspicious for a ruptured appendix.
Pain may become more generalized as time passes.
Symptoms often are more subtle in the elderly and very young; maintain a high index of suspicion.

PHYSICAL EXAM

Fever
Tachycardia, hypotension (sepsis signs)
Abdominal guarding
Rebound tenderness
Rigid abdomen
Absent bowel sounds

DIFFERENTIAL DIAGNOSIS

Varies according to age and gender ‚

Pancreatitis
Peptic ulcer disease " ”perforated ulcer
Strangulated hernias
Bowel obstruction
Sickle cell crisis
Ischemic colitis
Men: testicular torsion
Women
- Ectopic pregnancy
- Ruptured ovarian cyst
- Pelvic inflammatory disease (may mimic ruptured appendix)
- Ovarian torsion

DIAGNOSTIC TESTS & INTERPRETATION

CBC with differential (leukocytosis with left shift)
Chemistries may indicate metabolic acidosis/AKI.
LFTs
Amylase and lipase
Urinalysis (often normal)
Lactic acid
Pregnancy test
Type and screen (type and cross if transfusion is anticipated)
Plain films
- Upright chest x-ray and/or upright abdominal x-ray: free air under the diaphragm is visible in 80% of duodenal perforations
CT
- Not needed if diagnosis is certain in patients with peritonitis; may delay appropriate operative intervention
- May help localize an intra-abdominal abscess around a perforation amenable to radiographically placed drainage catheters
- 97% specific in detecting bowel injuries in patients with abdominal trauma (2)

Diagnostic Procedures/Other
Diagnostic peritoneal lavage (DPL): if clinical diagnosis is uncertain; DPL suggests peritonitis if >500 WBCs or >100,000 RBCs; difficult to interpret if patient is immunocompromised ‚

TREATMENT

General resuscitation ‚

Admit to hospital.
Crystalloid fluid resuscitation to achieve early goal-directed therapy if the patient is in septic shock
- Mean arterial pressure: >65 mm Hg
- Urine output: >0.5 mL/kg/hr
- Mixed venous O2 saturation: 65 " “75%
Early operative intervention for source control
Time to operative intervention in patients with traumatic bowel ruptures/injuries is the only modifiable determinant of morbidity and outcome (3).
Some centers manage selected cases conservatively (4).

MEDICATION

First Line
Antibiotics ‚

Antibiotics alone are typically not adequate treatment.
In patients with mild to moderate severity community-acquired infections (e.g., perforated appendicitis), cefoxitin, ertapenem, moxifloxacin, tigecycline may be used.
Imipenem-cilastatin, meropenem, doripenem, Zosyn
Tailor antibiotic therapy to culture results.
In cases of typhoid, ciprofloxacin has largely replaced chloramphenicol.
Typically need polymicrobial coverage
- Escherichia coli is the most common bacteria implicated in a perforated abdominal viscus.
- Streptococcus is the most common gram-positive organism.
- Bacteroides is the most common anaerobe.
- Other common organisms: Klebsiella, Proteus, Enterobacter, Clostridium, Enterococcus, Pseudomonas
- Further consideration should be given to adding an antifungal agent in perforated peptic ulcer disease.

SURGERY/OTHER PROCEDURES

For perforated gastric ulcer
- Antrectomy and pyloroplasty
- Billroth I versus II gastrectomy, depending on the amount of scar tissue in the duodenal region
For perforated duodenal ulcer
- Omental patch repair
- Proximal, selective, or highly selective gastric vagotomy for stable patients who have failed/are noncompliant with medical therapy.
- For PPI-naive patients, forgo vagotomy and use long-term PPIs postoperatively.
Perforated appendix
- Appendectomy, open versus laparoscopic: depends on anatomy, habitus, and surgeon preference
- Older patients: Consider malignancy masking as appendicitis.
Perforated diverticulitis (open surgery)
- Resection of perforated portion with primary anastomosis yields lower mortality and rate of fistulization and increases odds of restoring GI continuity.
- In hemodynamic unstable and critically ill patients, Hartmann procedure is preferred (quicker operation).
- Laparoscopic explorations: emerging approach
Trauma
- If hemodynamically unstable: laparotomy
- If unstable, gross contamination, >6 hours from the time of the trauma, or patient requiring >4 units of blood: resection with end-colostomy
- If patient presents early and is stable: may attempt resection with primary anastomosis
- Laparoscopic primary or assisted repair of bowel injuries in hemodynamically stable children with focal injuries has favorable outcomes (5).

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization
Patients with perforated viscus may present in septic shock; aggressive fluid management in ICU setting ‚

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Peptic ulcer disease
- Compliance with acid-reducing medications
- If ulcers do not heal, consider Zollinger-Ellison syndrome or malignancy; repeat endoscopy.
Diverticulitis
- High-fiber diet and avoid straining during bowel movements
- If the patient did not have a colonoscopy before the perforation, one is recommended within 6 months (to assess for a colonic mass) prior to reversal of stoma.

PROGNOSIS

Perforated peptic ulcer
- Nonsurgical management
  - Check contrast studies to document closure.
  - Interval endoscopy to rule out gastric cancer
Surgical management
- 6 " “10% postoperative mortality
- Factors that increase mortality are:
  - Age >60 years
  - Delay in treatment >24 hours
  - Shock on presentation
  - Comorbid conditions
  - Boey score predicts morbidity and mortality.
Perforated appendicitis
- 2% mortality rate
Perforated diverticulitis
- 7 " “15% mortality, depending on delay of presentation and underlying comorbidities
Trauma
- Prognosis and follow-up depend on the mechanism of trauma, extent of injury, and success of the operation.

COMPLICATIONS

Following operative repair, monitor for intra-abdominal abscess
- Prolonged postoperative ileus
- Dietary intolerance (after initially tolerating)
- Persistent fevers
- Persistent leukocytosis
- Pain out of proportion to expectations
- Wound infection may be a sign of an intra-abdominal infection.
Ileus
Leak, anastomosis failure
Septic shock
Wound infection
Enterocutaneous fistula
Long-term complications of operative management of perforated peptic ulcer disease are as follows:
- Diarrhea: 30% after vagotomy
- Dumping syndromes: 10% after vagotomy and drainage procedures
- Gastric outlet obstruction
- Recurrent peptic ulcer

REFERENCES

11 Schiessel ‚ R. The research progress of acute small bowel perforation. JAD. 2015;4(3):173 " “177.22 Taourel ‚ P, Merigeaud ‚ S, Millet ‚ I, et al. Trauma of the thoraco-abdominal area: imaging strategy [in French]. J Radiol. 2008;89(11, Pt 2):1833 " “1854.33 Faria ‚ GR, Almeida ‚ AB, Moreira ‚ H, et al. Prognostic factors for traumatic bowel injuries: killing time. World J Surg. 2012;36(4):807 " “812.44 Chang ‚ H, Choi ‚ W. Nonoperative treatment of perforated duodenal ulcer: a case report and review of the literature. J Emerg Crit Care Med. 2007;18(4):167 " “171.55 Streck ‚ CJ, Lobe ‚ TE, Pietsch ‚ JB, et al. Laparoscopic repair of traumatic bowel injury in children. J Pediatr Surg. 2006;41(11):1864 " “1869.

ADDITIONAL READING

Bertleff ‚ MJ, Lange ‚ JF. Perforated peptic ulcer disease: a review of history and treatment. Dig Surg. 2010;27(3):161 " “169.
Kloss ‚ BT, Broton ‚ CE, Sullivan ‚ AM. Perforated Meckel diverticulum. Int J Emerg Med. 2010;3(4):455 " “457.
Mazuski ‚ JE, Solomkin ‚ JS. Intra-abdominal infections. Surg Clin North Am. 2009;89(2):421 " “437.
Ordo ƒ ±ez ‚ CA, Puyana ‚ JC. Management of peritonitis in the critically ill patient. Surg Clin North Am. 2006;86(6):1323 " “1349.
Rogart ‚ J. Forgut and colonic perforations: practical measures to prevent and assess them. Gastrointest Endosc Clin N Am. 2015;25(1):9 " “27.
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 Disease Society of America. Clin Infect Dis. 2010;50(2):133 " “164.
Toro ‚ A, Mannino ‚ M, Reale ‚ G, et al. Primary anastomosis vs Hartmann procedure in acute complicated diverticulitis. Evolution over the last twenty years. Chirurgia (Bucur). 2012;107(5):598 " “604.
Trenti ‚ L, Biondo ‚ S, Golda ‚ T, et al. Generalized peritonitis due to perforated diverticulitis: Hartmann 's procedure or primary anastomosis? Int J Colorectal Dis. 2011;26(3):377 " “384.

ICD10

K63.1 Perforation of intestine (nontraumatic)
K26.5 Chronic or unspecified duodenal ulcer with perforation
K35.2 Acute appendicitis with generalized peritonitis
K57.20 Diverticulitis of large intestine with perforation and abscess without bleeding

ICD9

569.83 Perforation of intestine
532.50 Chronic or unspecified duodenal ulcer with perforation, without mention of obstruction
540.0 Acute appendicitis with generalized peritonitis
562.11 Diverticulitis of colon (without mention of hemorrhage)

SNOMED

Perforation of intestine (disorder)
Duodenal ulcer with perforation (disorder)
Acute perforated appendicitis (disorder)
Diverticulitis of colon with perforation (disorder)
Nontraumatic perforation of small intestine (disorder)
Nontraumatic perforation of large intestine
Traumatic perforation of large intestine
Traumatic perforation of small intestine

CLINICAL PEARLS

Bowel perforation is often a clinical diagnosis.
Maintaining a high index of suspicion in patients at the extremes of age and in those with multiple comorbidities avoids delays in diagnosis and treatment.
Aggressive fluid resuscitation and source control are key steps in the initial management of a perforated viscus.
If antibiotics are indicated, use broad-spectrum agents such as piperacillin/tazobactam or a carbapenem.

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