What is the management of ischemic gastritis with peritonitis due to perforation?

Management of Ischemic Gastritis with Peritonitis due to Perforation

Immediate surgical exploration is recommended for patients with ischemic gastritis complicated by perforation and peritonitis, as this condition requires urgent source control to reduce morbidity and mortality. 1

Initial Assessment and Resuscitation

• Patients with suspected ischemic gastritis with perforation typically present with severe abdominal pain, tenderness, distension, and signs of septic shock 1
• Laboratory evaluation should include at minimum white blood cell count and C-reactive protein to assess inflammatory response 1
• CT scan is the preferred imaging modality to confirm diagnosis, as it is more sensitive than standard abdominal radiographs for detecting free air 1
• Aggressive resuscitation with intravenous fluids and correction of electrolyte imbalances should be initiated immediately while preparing for surgical intervention 1

Surgical Management

Hemodynamically Stable Patients

• For stable patients with perforation less than 1 cm, laparoscopic primary repair with omental patch is recommended as it is associated with decreased operative time, blood loss, and length of hospital stay 1, 2
• During exploration, all anastomoses, the stomach, and excluded segments (if applicable in post-bariatric surgery patients) should be thoroughly assessed 1
• Biopsies of the perforated ulceration should be obtained to exclude malignancy 1
• If the perforation is in the gastric remnant (in post-bariatric surgery patients), options include primary suture with omental patch or stapled resection 1
• Consider placement of a gastrostomy tube proximal to the perforation site if significant postoperative ileus is anticipated due to peritonitis 1

Hemodynamically Unstable Patients

• For unstable patients with diffuse peritonitis, immediate surgical exploration without delay is mandatory 1
• Damage control surgery with abbreviated laparotomy and open abdomen technique is recommended in hemodynamically unstable patients 1, 3
• The open abdomen approach is particularly beneficial in cases of:
  • Severe physiological derangement
  • Need for deferred intestinal anastomosis
  • Extensive visceral edema with risk of abdominal compartment syndrome
  • Persistent source of peritonitis 1, 3
• Planned re-laparotomies every 36-48 hours may be necessary until the abdomen is free of ongoing peritonitis 1

Antimicrobial Therapy

• Broad-spectrum antibiotics should be initiated immediately, covering gram-negative, gram-positive, and anaerobic organisms 1, 4
• Piperacillin-tazobactam is an appropriate choice for intra-abdominal infections caused by beta-lactamase producing organisms 4
• Antimicrobial therapy should be adjusted based on culture results and continued until clinical improvement is observed 1

Postoperative Management

• Close monitoring for signs of persistent or recurrent infection is essential, as delayed perforations can occur even after initial improvement 5
• Serial clinical and imaging monitoring (every 3-6 hours) should be performed in the immediate postoperative period 1
• Maintain bowel rest initially, with enteral nutrition started as soon as possible in hemodynamically stable patients without significant vasopressor requirements 3
• For patients with tertiary peritonitis (persistent peritoneal space infection despite initial intervention), a coordinated multiprofessional team approach is necessary 6

Potential Complications and Management

• Intra-abdominal collections may develop and can often be managed conservatively or with percutaneous drainage 2
• If clinical deterioration occurs after initial improvement, repeat imaging and possible re-exploration should be considered to rule out anastomotic breakdown or new perforation 5
• In cases of extensive gastric necrosis or multiple perforations that cannot be adequately repaired, gastrectomy may be necessary 5

Special Considerations

• The spectrum of perforation peritonitis in developing countries differs from Western countries, with peptic ulcer perforation being the most common cause followed by appendicitis, typhoid, and tubercular perforations 7
• In post-bariatric surgery patients, always explore the jejuno-jejunostomy for stenosis or the gastric remnant for gastro-gastric fistula if diffuse peritonitis is due to a perforated excluded gastrointestinal segment 1
• Indocyanine green (ICG) fluorescence angiography may be useful in evaluating the extent of bowel ischemia when available 1