What is the appropriate management for a patient with perforated colitis?

Management of Perforated Colitis

Immediate surgical intervention is mandatory for patients with perforated colitis, with subtotal colectomy with ileostomy being the surgical treatment of choice in most cases. 1, 2

Initial Assessment and Stabilization

• Assess hemodynamic stability (blood pressure, heart rate, respiratory rate)
• Evaluate for signs of peritonitis (abdominal rigidity, rebound tenderness)
• Order laboratory tests: CBC, CRP, electrolytes, blood cultures
• Obtain CT scan with contrast as the preferred imaging modality 2
• Begin resuscitation measures:
  • Intravenous fluid resuscitation
  • Broad-spectrum antibiotics covering gram-negative and anaerobic bacteria
  • Correction of electrolyte abnormalities
  • Nutritional support in conjunction with a dietician/nutrition team 1

Surgical Management

Indications for Immediate Surgery

• Free perforation with generalized peritonitis 1
• Hemodynamic instability or shock 1, 2
• Toxic megacolon with perforation 1, 2
• Massive bleeding with hemodynamic instability 1
• Clinical deterioration despite medical therapy 1

Surgical Approach

1. Subtotal colectomy with ileostomy:

   • First-line surgical treatment for perforated colitis in ulcerative colitis patients 1
   • Associated with lower mortality compared to proctocolectomy in emergency settings 3

2. Damage control surgery:

   • Recommended for unstable patients with diffuse peritonitis 1
   • Initial surgery limited to source control
   • Patient transferred to ICU for physiologic optimization
   • Subsequent operation for anatomical restoration after stabilization 1

3. Laparoscopic approach:

   • May be considered in hemodynamically stable patients if technical skills and equipment are available 1
   • Not recommended in unstable patients or those with diffuse peritonitis 1

Special Considerations

Ulcerative Colitis

• Mortality is high in free perforation without colonic dilatation (57%) 4
• Classic signs of peritonitis may be absent; watch for:
  • Sudden increase in abdominal pain
  • Marked abdominal distention
  • Sharp decrease in frequency of bowel movements
  • Deterioration in general condition 4

Diverticular Perforation

• Hartmann's procedure remains useful for diffuse peritonitis in critically ill patients
• In stable patients, primary resection with anastomosis (with or without diverting stoma) may be performed 1
• Damage control surgery with staged laparotomies should be considered in unstable patients 1

Timing of Surgery

• Do not delay surgical intervention in patients with free perforation, as delayed surgery is associated with higher complication rates and mortality 2, 5
• If a patient's condition does not improve or deteriorates within 48-72 hours of medical therapy, surgical intervention should be strongly considered 1

Postoperative Care

• Continue broad-spectrum antibiotics
• Provide venous thromboprophylaxis 1
• Nutritional support
• Monitor for complications:
  • Wound infections
  • Intra-abdominal abscesses
  • Anastomotic leaks (if primary anastomosis was performed)
  • Sepsis

Common Pitfalls to Avoid

1. Delaying surgery in patients with clear indications for immediate intervention
2. Performing primary anastomosis in hemodynamically unstable patients or those with severe peritonitis
3. Failing to recognize perforation in ulcerative colitis patients without classic signs of peritonitis
4. Inadequate resuscitation before surgical intervention
5. Overlooking nutritional support which should be initiated as soon as possible 1

Early involvement of a multidisciplinary team including gastroenterologists and surgeons is crucial for optimal outcomes in patients with perforated colitis 5.