What are the possible sources of a ruptured viscus?

Sources of Ruptured Viscus

A ruptured viscus can originate from any hollow organ in the gastrointestinal tract, including the stomach, small bowel (duodenum, jejunum, ileum), and large bowel (colon), with the exception of retroperitoneal portions of the duodenum and colon. 1

Traumatic Causes

Blunt Abdominal Trauma

• Small bowel and colon injuries occur in approximately 1% of blunt trauma cases, with the jejunum being the most commonly affected segment (Grade II-III injuries in 13.33% of cases) 2, 3
• Transverse colon represents another frequent site of perforation (Grade I injuries in 13.33% of cases) 3
• Fixed segments of intestine are particularly vulnerable to high-impact mechanisms due to their anatomic tethering 3
• The presence of a seatbelt sign should raise high suspicion for bowel injury and warrants CT imaging 2

Penetrating Abdominal Trauma

• Hollow viscus injuries occur in approximately 17% of penetrating trauma cases 2
• These injuries typically result from gunshot wounds, stab wounds, or other penetrating mechanisms 2

Non-Traumatic Causes

Gastrointestinal Perforation

• Perforated duodenal ulcer is a classic cause of secondary peritonitis from loss of gastrointestinal tract integrity 2
• Gangrenous appendicitis can lead to perforation and secondary peritonitis through direct invasion 2
• Diverticular perforation represents another common source requiring surgical source control 2

Postoperative Complications

• Anastomotic dehiscences are common causes of secondary peritonitis in the postoperative period 2
• These typically occur following bowel resection and anastomosis procedures 2

Associated Visceral Structures

Solid Organ Complications

• Ruptured hepatic abscess can mimic perforated viscus by causing pneumoperitoneum, though this represents rupture of an infected solid organ rather than hollow viscus 4

Vascular Structures

• Mycotic aneurysms of visceral arteries (superior mesenteric, hepatic, renal) can rupture into the gastrointestinal tract, causing catastrophic hemorrhage 2
• Aortoenteric fistulae occur in up to 4% of patients following abdominal aortic aneurysm repair, representing communication between the aorta and bowel 2

Clinical Pitfalls

Critical diagnostic consideration: Pneumoperitoneum on imaging strongly suggests hollow viscus perforation requiring emergency surgery, but CT is more sensitive than plain radiographs for detecting free intraperitoneal air 5, 1. However, CT alone cannot reliably exclude bowel, diaphragm, or pancreas injury in blunt trauma 2.

High-risk mechanisms (handlebar injuries, seatbelt injuries) with non-specific CT findings mandate admission for serial clinical examination and inflammatory marker trending, as isolated hollow viscus perforations represent less than 1% of blunt trauma injuries but carry significant morbidity when missed 2, 3.