Management of Suspected Perforated Viscus with Peritonitis
This patient requires immediate surgical consultation and preparation for emergency laparotomy, as the clinical presentation of severe epigastric pain with abdominal rigidity and exquisite tenderness strongly suggests a perforated viscus with diffuse peritonitis—a surgical emergency that demands urgent source control. 1
Immediate Resuscitation and Stabilization
Begin aggressive intravenous fluid resuscitation immediately upon suspicion of intra-abdominal infection, as volume depletion is common due to third-space fluid losses, fever-induced tachypnea, and poor oral intake from nausea. 1
Administer empiric broad-spectrum antibiotics as soon as the diagnosis is suspected, without waiting for imaging or surgical consultation, as delays in antimicrobial therapy worsen outcomes in patients with septic shock and intra-abdominal infection. 1
Monitor for signs of septic shock (hypotension, tachycardia, altered mental status) and escalate resuscitation accordingly, as patients with peritonitis can rapidly deteriorate. 1
Diagnostic Approach
Imaging is unnecessary when obvious signs of diffuse peritonitis are present and immediate surgery is planned. 1 However, given this patient's presentation:
The clinical triad of severe epigastric pain, abdominal rigidity, and exquisite tenderness indicates peritonitis and likely perforated peptic ulcer or other upper gastrointestinal perforation. 1, 2
If the patient is hemodynamically stable enough to tolerate brief imaging, CT scan with IV contrast is the imaging modality of choice to confirm perforation (extraluminal gas, intra-abdominal fluid) and identify the source. 1
Do not delay surgery for imaging if the patient has obvious peritonitis and is deteriorating, as clinical examination findings are sufficient to proceed to laparotomy. 1
Empiric Antibiotic Selection
For suspected perforated peptic ulcer with peritonitis:
If Patient is NOT Critically Ill:
- Amoxicillin/clavulanate 2 g/0.2 g IV every 8 hours 1
- For documented beta-lactam allergy: Eravacycline 1 mg/kg IV every 12 hours or Tigecycline 100 mg loading dose then 50 mg IV every 12 hours 1
If Patient is Critically Ill or Immunocompromised:
- Piperacillin/tazobactam 6 g/0.75 g loading dose then 4 g/0.5 g IV every 6 hours (or 16 g/2 g by continuous infusion) 1
- For beta-lactam allergy: Eravacycline 1 mg/kg IV every 12 hours 1
If Septic Shock is Present:
- Meropenem 1 g IV every 6 hours by extended infusion or continuous infusion 1
- Alternative options: Doripenem 500 mg IV every 8 hours by extended infusion, Imipenem/cilastatin 500 mg IV every 6 hours by extended infusion, or Eravacycline 1 mg/kg IV every 12 hours 1
Surgical Management
The definitive treatment is surgical source control:
For perforated peptic ulcer: Laparoscopic or open simple/double-layer suture repair with or without omental patch is the standard procedure for small perforations. 1
For large perforations near the pylorus or if malignancy is suspected: Distal gastrectomy may be required. 1
Ensure adequate antimicrobial drug levels are maintained during the surgical procedure, which may require additional antibiotic administration just before surgery. 1
Duration of Antibiotic Therapy
4 days of antibiotics if source control is adequate in immunocompetent, non-critically ill patients 1
Up to 7 days based on clinical conditions and inflammatory markers if source control is adequate in immunocompromised or critically ill patients 1
Patients with ongoing signs of infection beyond 7 days warrant diagnostic re-investigation for inadequate source control or complications. 1
Critical Pitfalls to Avoid
Do not delay antibiotics while awaiting imaging or surgical consultation, as early antimicrobial therapy improves outcomes in septic patients. 1
Do not undertake prolonged imaging workup in patients with obvious peritonitis, as this delays life-saving surgery. 1
Do not underestimate fluid requirements, as third-space losses in peritonitis are substantial and inadequate resuscitation worsens outcomes. 1
Ensure surgical consultation occurs simultaneously with resuscitation and antibiotic administration, not sequentially, to minimize time to source control. 1