perforated viscus

see also:

• the patient with acute abdominal pain in the ED

• this refers to perforation of the gastro-intestinal tract
  • free perforation occurs when GIT contents spill freely into the abdominal cavity, causing diffuse peritonitis
  • contained perforation occurs when a full-thickness hole is created but free spillage is prevented because contiguous organs wall off the area (eg. a penetrating DU walled off by the pancreas)
• the patient with a perforated abdominal viscus generally becomes rapidly unwell and presents with severe pain and a rigid abdomen.
• this is a surgical emergency requiring immediate fluid resuscitation and transfer to theatre ASAP once diagnosis is made
• diagnosis in free perforations is usually supported by the finding of free gas under the diaphragm on an erect CXR
  • not to be confused with normal gastric or hiatus hernia air bubble, nor with lucencies from adipose tissue, nor the normal post-laparotomy/laparoscopy free gas

• penetrating or perforated peptic ulcer disease (PUD)
  • relatively rare now that proton pump inhibitors (PPIs) are commonly used
  • duodenal ulcer perforations are 2-3 times more common than are gastric ulcer perforations
  • 1/3rd of gastric perforations are due to stomach cancer
  • even a short course of non-steroidal anti-inflammatory drugs (NSAIDs) can result in perforated viscus - especially when taken while fasting!
  • corticosteroids
  • aspirin (acetylsalicylic acid)
• complication of diverticulitis
  • free perforation is said to occur in 10-15%
  • non-steroidal anti-inflammatory drugs (NSAIDs) can result in perforated diverticulosis as well as peptic ulcer!
• complication of appendicitis
  • this is particularly an issue in the elderly
• complication of ischaemic colitis
• inflamed Meckel diverticulum
• trauma
  • blunt abdominal trauma in children causing small bowel injury is said to cause perforation in up to 7%
  • blunt handlebar injuries to the epigastrium are well known to cause duodenal injury with perforation
  • penetrating trauma to chest or abdomen may cause direct bowel injury
• ingested sharp foreign bodies
• ingestion of caustic substances may cause delayed GIT perforation over the next few days in addition to the oesophageal injury
• rectal foreign bodies - often used as sex aides
• ERCP
  • perforated viscus is said to occur in 1% of patients who have had an ERCP
• colonoscopy, particularly with biopsy
  • risk is much higher in certain patient groups such as those with collagen disorders
• endoscopic biliary stent
• intestinal puncture as a complication of laparoscopy
  • risk factors include obesity, pregnancy, acute and chronic bowel inflammation, and bowel obstruction
• inflammatory bowel disease (IBD)
• colorectal cancer (bowel cancer)
• lymphoma
• metastatic renal malignancies
• radiotherapy
• necrotising vasculitis such as Wegener's granulomatosis affecting the viscera
• high doses of immunosuppressive medications such as in transplant patients
• Salmonella typhi (typhoid enteric fever)
  • perforation is said to occur in 5% of patients

• if free perforation, usually patient lies still, often with hips flexed, and abdomen usually has board-like rigidity
• bowel sounds are usually absent in generalised peritonitis
• tachycardia +/- the shocked hypotensive patient, +/- signs of severe sepsis

• pancreatitis
• peptic ulcer disease (PUD)
• cholecystitis
• ectopic pregnancy
• endometriosis
• ovarian torsion
• pelvic inflammatory disease (PID)
• gastroenteritis
• Salmonella typhi (typhoid enteric fever)
• inflammatory bowel disease (IBD)
• ischaemic colitis

• nil orally
• fluid balance chart
• iv access
• bloods for FBE, U&E, glucose, LFTs, lipase, (HCG if possibly pregnant), VBG/serum lactate
• commence iv fluid resuscitation
• notify surgical team ASAP for emergent theatre
• if diagnosis is not clear consider:
  • erect CXR +/- erect/supine AXR
  • CT abdo without oral contrast as time will not usually permit oral contrast to be administered
• iv antibiotics as per hospital guidelines