Treatment of Bowel Perforation Peritonitis
Patients presenting with diffuse peritonitis caused by bowel perforation should undergo immediate surgical intervention, which typically involves primary repair or resection depending on the size and location of perforation. 1
Initial Assessment and Diagnosis
- Patients with suspected bowel perforation should be evaluated with laboratory tests including white blood cell count and C-reactive protein 1
- CT scan is the preferred imaging modality to confirm perforation, as it is more sensitive than standard abdominal radiographs for detecting free air 1
- Double contrast enhanced CT scan can help determine if non-operative management is feasible in cases with localized peritoneal signs 1
Treatment Algorithm
Surgical Management
Surgical intervention is the cornerstone of treatment for bowel perforation with peritonitis and should be prioritized based on:
Large perforations or diffuse peritonitis: Emergency surgery is reasonable and safe 1
Type of perforation:
- For small bowel perforations: Primary repair is recommended for small perforations, while resection with anastomosis is preferred for larger defects 1
- For colonic perforations: Primary repair or resection depending on size and tissue viability 1
- For perforated peptic ulcers: Simple closure with or without omental patch for small perforations (<2 cm) 1
- For abdominal tuberculosis perforation: Resection of affected area with anastomosis rather than primary closure 1
Surgical approach options:
- Hartmann's procedure remains useful for diffuse peritonitis in critically ill patients 1
- In clinically stable patients, primary resection with anastomosis (with or without diverting stoma) may be performed 1
- Laparoscopic approach may be safe and effective for experienced surgeons, particularly in colonoscopy-related perforations 1
Conservative Management
Conservative management may be appropriate in selected cases:
Indications: Patients with localized pain, free air without diffuse free fluids, hemodynamic stability, and absence of fever 1
Best candidates: Small, sealed-off perforations with optimal bowel preparation 1
Conservative treatment protocol:
Important caveat: Initial success with non-surgical treatment does not rule out potential need for surgery. Clinical deterioration or progression to sepsis requires immediate surgical intervention 1
Endoscopic Treatment
- Possible when perforation site is recognized intra-procedurally or within 4 hours following procedure 1
- Endoscopic clip closure recommended for small perforations (<1 cm) 1
- Success rates range from 59-100% 1
Special Considerations
- Immunocompromised patients: Surgical management is recommended regardless of perforation size 1
- Transplant patients: Surgical approach is preferred over conservative management 1
- Timing of surgery: Decision to pursue surgery should be made as early as possible after diagnosis, as delayed surgical treatment can worsen peritonitis and colonic wall inflammation 1
- Mortality factors: Extent of peritoneal contamination significantly affects mortality rates 3, 4
Antibiotic Therapy
- Intravenous broad-spectrum antibiotics are essential in both surgical and conservative management 1
- Meropenem is FDA-approved for complicated intra-abdominal infections including peritonitis 2
- Coverage should include common pathogens such as E. coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Bacteroides fragilis, and Peptostreptococcus species 2
Monitoring and Follow-up
- Continuous and strict clinical and biochemical follow-up is recommended for all patients 1
- Clinical improvement should gradually occur within 24 hours if conservative treatment is successful 1
- Higher complication rates and longer hospital stays are associated with delayed surgical intervention after failed conservative management 1