What is viscus perforation?

Viscus Perforation: Definition, Causes, and Management

Viscus perforation is a life-threatening condition characterized by a breach in the wall of a hollow organ in the gastrointestinal tract, leading to leakage of contents into the peritoneal cavity, which requires prompt diagnosis and treatment to prevent sepsis and mortality.

Definition and Etiology

Viscus perforation refers to a hole or rupture in any hollow organ of the gastrointestinal tract, including:

• Common causes:

  • Peptic ulcer disease (particularly duodenal ulcers) - most common cause 1
  • Trauma (both blunt and penetrating injuries) 1, 2
  • Inflammatory conditions (diverticulitis, appendicitis) 3, 1
  • Malignancy (especially colorectal cancer) 1
  • Iatrogenic injuries during procedures (colonoscopy, endoscopy) 3, 1

• Specific mechanisms:

  • In blunt trauma, hollow viscus perforations represent less than 1% of injuries but typically occur due to high-impact mechanisms in fixed segments of intestine 2
  • Iatrogenic colonoscopy perforation has a reported rate of 2.6% with a mortality of 1% 3

Clinical Presentation

Patients with viscus perforation typically present with:

• Sudden onset of severe abdominal pain
• Abdominal rigidity and guarding
• Systemic signs including fever, tachycardia, and hypotension in advanced cases 1
• Progressive organ dysfunction and septic shock in severe cases 1

Diagnosis

Imaging

• CT scan is the gold standard for detecting free air and determining perforation site 1

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

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

• Bedside ultrasound can identify signs of pneumoperitoneum including:

  • Enhanced peritoneal stripe sign
  • Peritoneal stripe reverberations
  • Focal air collections with dirty shadowing 4

Laboratory Findings

• Leukocytosis
• Metabolic acidosis
• Elevated serum amylase 1

Management

Initial Management

1. Resuscitation - IV fluids, correction of electrolyte abnormalities
2. Broad-spectrum antibiotics - strongly recommended for treatment 1
3. Collection of samples for microbiological analysis (bacteria and fungi) 1

Definitive Management

Source control is crucial in the management of perforated viscus 3:

• Operative Management (OM) is indicated for:

  • Hemodynamically unstable patients 3
  • Patients with diffuse peritonitis 3
  • Concomitant internal organ injuries requiring surgery 3
  • Evisceration or impalement 3

• Surgical options include:

  • Primary repair or resection of the perforated segment
  • Peritoneal lavage
  • Drainage of collections 1
  • Laparoscopic approach may be feasible in stable patients 5

• Non-Operative Management (NOM) may be considered in:

  • Highly selected patients with contained perforations 3
  • Small perforated diverticulitis with abscess <4 cm in diameter 3
  • Peri-appendiceal mass 3
  • Perforated peptic ulcer in stable patients responding to antibiotics 3, 1

Special Considerations

• Timing of intervention is critical - mortality increases fourfold when surgical delay exceeds 24 hours after bowel perforation 1

• Damage control surgery is recommended in patients with septic shock and severe physiological derangement 1

• Fungal infections after perforation are common and associated with longer hospital stays and increased mortality 1

Complications

• Peritonitis (present in approximately two-thirds of patients) 1
• Sepsis and septic shock
• Anastomotic leaks (up to 12% of cases, particularly in large ulcers) 1
• Wound infections (most common postoperative complication) 6
• Pneumonia and acute respiratory distress syndrome 6

Prognosis

Prognosis depends on:

• Time to diagnosis and treatment
• Location and extent of perforation
• Patient's underlying health status
• Presence of peritonitis or sepsis

Large intestinal pathology shows a high case fatality rate, with one-quarter of patients succumbing to the condition in some studies 6.

Follow-up

For patients who undergo successful non-operative management:

• Resume normal activity after 3-4 months for uncomplicated cases 3
• Earlier resumption (after 1 month) may be possible if CT scan shows significant healing in grade III-V lesions 3
• Patients should be counseled to return to the hospital immediately if they experience increasing abdominal pain, light-headedness, nausea, or vomiting 3