From the Guidelines
A free perforation of the jejunum is a life-threatening condition that requires immediate surgical intervention with exploratory laparotomy to repair the perforation, along with aggressive fluid resuscitation and broad-spectrum antibiotics. The symptoms of a free perforation of the jejunum include sudden, severe abdominal pain that becomes diffuse, along with abdominal rigidity, rebound tenderness, and board-like abdomen due to peritonitis. Patients typically develop fever, tachycardia, hypotension, nausea, vomiting, and may show signs of septic shock as the condition progresses.
Treatment Approach
The treatment approach involves:
- Open or laparoscopic small bowel segmental resection and primary anastomosis, as recommended by the Italian Council for the Optimization of Antimicrobial Use 1
- In cases of perforation due to small bowel ischemia, resection and delayed anastomoses at a second look may be necessary, along with open or endovascular mesenteric vessel reconstruction
- Antibiotic therapy for 4 days in immunocompetent patients and up to 7 days in immunocompromised or critically ill patients, depending on clinical conditions and inflammation indices 1
Pre-Surgical Stabilization
Before surgery, patients should be stabilized with:
- Aggressive fluid resuscitation, typically with crystalloids like normal saline or lactated Ringer's at 20 ml/kg bolus initially
- Broad-spectrum antibiotics, such as piperacillin-tazobactam or a combination of ceftriaxone and metronidazole
- Vasopressors if needed for hemodynamic support
- Nasogastric tube decompression, nothing by mouth status, and pain management are essential supportive measures
Importance of Prompt Treatment
Mortality rates increase significantly with delayed diagnosis and treatment beyond 24 hours. Therefore, prompt recognition and treatment of a free perforation of the jejunum are crucial to improve outcomes and reduce morbidity and mortality. The perforation occurs when the intestinal wall ruptures, allowing intestinal contents to spill into the peritoneal cavity, causing chemical and bacterial peritonitis that can rapidly progress to sepsis if not treated promptly.
From the Research
Symptoms of Free Perforation of the Jejunum
- Severe abdominal pain [(2,3,4,5)]
- Nausea and vomiting [(3,4,5)]
- Fever [(2,3,4,5)]
- Abdominal distension 3
- Non-passage of flatus and stool 3
- Tachycardia and hypotension 3
- Generalized abdominal tenderness and guarding 3
Treatment for Free Perforation of the Jejunum
- Emergency exploratory laparotomy [(3,4)]
- Resection of the involved gut portion [(2,6,4)]
- Primary anastomosis [(6,4)]
- Repair of the perforation in two layers 4
- Peritoneal toileting 5
- Administration of antibiotics 4
- Avoidance of steroids to decrease the risk of bowel perforation, especially in immune reconstitution inflammatory syndrome (IRIS) 5
Diagnosis of Free Perforation of the Jejunum
- High index of suspicion is needed, especially in patients with chronic central abdominal pain, malabsorption, and anemia 2
- Laparoscopy can be valuable in diagnosis and treatment 2
- CT scan of the abdomen can show large-volume free intraperitoneal air 4
- Chest radiography can diagnose perforation of hollow organ 5