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Ruptured Bowel

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Ruptured Bowel

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

Varies according to age and gender ‚

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 ‚

Admission Criteria/Initial Stabilization

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.

  • 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

  • Pancreatitis
  • Peptic ulcer disease " ”perforated ulcer
  • Strangulated hernias
  • Bowel obstruction
  • Sickle cell crisis
  • Ischemic colitis
  • Men: testicular torsion
  • WomenEctopic pregnancyRuptured ovarian cystPelvic inflammatory disease (may mimic ruptured appendix)Ovarian torsion
  • 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 filmsUpright chest x-ray and/or upright abdominal x-ray: free air under the diaphragm is visible in 80% of duodenal perforations
  • CTNot needed if diagnosis is certain in patients with peritonitis; may delay appropriate operative interventionMay help localize an intra-abdominal abscess around a perforation amenable to radiographically placed drainage catheters97% specific in detecting bowel injuries in patients with abdominal trauma (2)
  • Upright chest x-ray and/or upright abdominal x-ray: free air under the diaphragm is visible in 80% of duodenal perforations
  • 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)

TREATMENT

  • Admit to hospital.
  • Crystalloid fluid resuscitation to achieve early goal-directed therapy if the patient is in septic shockMean arterial pressure: >65 mm HgUrine output: >0.5 mL/kg/hrMixed 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).
  • Mean arterial pressure: >65 mm Hg
  • Urine output: >0.5 mL/kg/hr
  • Mixed venous O2 saturation: 65 " “75%

MEDICATION

  • 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 coverageEscherichia 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, PseudomonasFurther consideration should be given to adding an antifungal agent in perforated peptic ulcer disease.
  • 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 ulcerAntrectomy and pyloroplastyBillroth I versus II gastrectomy, depending on the amount of scar tissue in the duodenal region
  • For perforated duodenal ulcerOmental patch repairProximal, 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 appendixAppendectomy, open versus laparoscopic: depends on anatomy, habitus, and surgeon preferenceOlder 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
  • TraumaIf hemodynamically unstable: laparotomyIf unstable, gross contamination, >6 hours from the time of the trauma, or patient requiring >4 units of blood: resection with end-colostomyIf patient presents early and is stable: may attempt resection with primary anastomosisLaparoscopic primary or assisted repair of bowel injuries in hemodynamically stable children with focal injuries has favorable outcomes (5).
  • Antrectomy and pyloroplasty
  • Billroth I versus II gastrectomy, depending on the amount of scar tissue in the duodenal region
  • 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.
  • Appendectomy, open versus laparoscopic: depends on anatomy, habitus, and surgeon preference
  • Older patients: Consider malignancy masking as appendicitis.
  • 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
  • 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

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Peptic ulcer diseaseCompliance with acid-reducing medicationsIf ulcers do not heal, consider Zollinger-Ellison syndrome or malignancy; repeat endoscopy.
  • DiverticulitisHigh-fiber diet and avoid straining during bowel movementsIf 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.
  • Compliance with acid-reducing medications
  • If ulcers do not heal, consider Zollinger-Ellison syndrome or malignancy; repeat endoscopy.
  • 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 ulcerNonsurgical managementCheck contrast studies to document closure.Interval endoscopy to rule out gastric cancer
  • Surgical management6 " “10% postoperative mortalityFactors that increase mortality are:Age >60 yearsDelay in treatment >24 hoursShock on presentationComorbid conditionsBoey score predicts morbidity and mortality.
  • Perforated appendicitis2% mortality rate
  • Perforated diverticulitis7 " “15% mortality, depending on delay of presentation and underlying comorbidities
  • TraumaPrognosis and follow-up depend on the mechanism of trauma, extent of injury, and success of the operation.
  • Nonsurgical managementCheck contrast studies to document closure.Interval endoscopy to rule out gastric cancer
  • Check contrast studies to document closure.
  • Interval endoscopy to rule out gastric cancer
  • 6 " “10% postoperative mortality
  • Factors that increase mortality are:Age >60 yearsDelay in treatment >24 hoursShock on presentationComorbid conditionsBoey score predicts morbidity and mortality.
  • Age >60 years
  • Delay in treatment >24 hours
  • Shock on presentation
  • Comorbid conditions
  • Boey score predicts morbidity and mortality.
  • 2% mortality rate
  • 7 " “15% mortality, depending on delay of presentation and underlying comorbidities
  • 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 abscessProlonged postoperative ileusDietary intolerance (after initially tolerating)Persistent feversPersistent leukocytosisPain out of proportion to expectationsWound 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 vagotomyDumping syndromes: 10% after vagotomy and drainage proceduresGastric outlet obstructionRecurrent peptic ulcer
  • 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.
  • Diarrhea: 30% after vagotomy
  • Dumping syndromes: 10% after vagotomy and drainage procedures
  • Gastric outlet obstruction
  • Recurrent peptic ulcer

REFERENCES

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.