What is a perforated viscus?

Perforated Viscus Definition and Management

A perforated viscus is a full-thickness breach in the wall of a hollow internal organ, resulting in leakage of gastrointestinal contents into the peritoneal cavity, leading to peritonitis and potential sepsis if not promptly treated. 1

Etiology

Perforated viscus can result from various causes:

• Peptic ulcer disease: Most common cause, particularly duodenal ulcers 1
• Trauma: Both blunt and penetrating injuries 2
• Inflammatory conditions:
  • Appendicitis with progression to appendicular abscess 1
  • Diverticulitis with perforation 1
• Malignancy: Particularly colorectal cancer 1
• Iatrogenic injuries: During endoscopic or surgical procedures 2, 1

Clinical Presentation

Patients with perforated viscus typically present with:

• Sudden onset of severe abdominal pain
• Abdominal rigidity and guarding
• Peritonitis (present in approximately two-thirds of cases) 1
• Systemic signs: fever, tachycardia, hypotension in advanced cases 1
• Progressive organ dysfunction and septic shock in severe cases 2

Diagnostic Approach

Imaging

• CT scan: Gold standard with higher sensitivity than plain radiographs 1

  • Key findings: pneumoperitoneum, free fluid, bowel wall thickening, mesenteric fat stranding
  • Note: CT may miss up to 12% of perforations, particularly hollow viscus injuries 1

• Plain radiographs: May show free air under the diaphragm in 30-85% of cases 1

Laboratory Tests

• Leukocytosis
• Metabolic acidosis
• Elevated serum amylase 1

Management

Initial Resuscitation

• Fluid resuscitation
• Broad-spectrum antibiotics (strong recommendation) 2
• Collection of samples for microbiological analysis (both bacteria and fungi) 2

Surgical Management

• Source control: Elimination of infectious focus, debridement, and intraoperative lavage 2, 3
  • Primary repair or resection of the perforated segment
  • Peritoneal lavage
  • Drainage of collections

Surgical Approach

• Laparoscopic approach: Feasible for many emergency conditions, allowing both diagnosis and treatment with less invasive abdominal approach 2

  • Caution: Pneumoperitoneum may have negative effects in critically ill patients 2

• Damage control surgery: Recommended in patients with septic shock and severe physiological derangement 2

  • Control hemorrhage and/or sources of sepsis
  • Defer anastomoses and temporarily close abdominal wall
  • Transfer to ICU for continued resuscitation
  • Return for definitive surgical management when patient is hemodynamically stable

Special Considerations

Duodenal Perforations

• Type 1 perforations: Caused by shearing force or angle-related trauma, resulting in intraperitoneal or retroperitoneal leakage 2
• Type 2 perforations: Periampullary perforations caused by overextension of sphincterotomy 2
• Management depends on size and location of perforation:
  • Small perforations: May be closed with clips (success rates 88-100%) 2
  • Large perforations: May require damage control procedures 2

Complications and Outcomes

• Mortality increases fourfold when surgical delay exceeds 24 hours after bowel perforation 1
• Common complications:
  • Wound infections
  • Pneumonia
  • Acute respiratory distress syndrome 4
  • Anastomotic leaks (up to 12% in large ulcers) 2

Pitfalls to Avoid

1. Diagnostic delays: Prompt source control is critical, as delayed diagnosis significantly increases mortality 1

2. Misdiagnosis: Conditions that can mimic perforated viscus include:

   • Ruptured hepatic abscess 5
   • Superior mesenteric artery syndrome with gastric distension 6

3. Inappropriate surgical approach: Avoid definitive resectional approaches (e.g., Whipple procedure) in patients with peritonitis and septic shock 2

4. Overlooking fungal infections: Fungal infections after perforation are common and associated with longer hospital stays and increased mortality 2