What is the appropriate management for a patient with peritonitis and bowel obstruction?

Management of Peritonitis and Bowel Obstruction

Patients with peritonitis and bowel obstruction require immediate surgical exploration if they present with signs of diffuse peritonitis, hemodynamic instability, or septic shock, while hemodynamically stable patients without peritonitis may undergo initial nonoperative management with close monitoring for 24-48 hours. 1

Initial Assessment and Resuscitation

Immediate Actions:

• Begin rapid intravenous fluid resuscitation to restore intravascular volume as soon as peritonitis or bowel obstruction is suspected 1
• For patients with septic shock, fluid resuscitation must begin immediately when hypotension is identified 1
• Administer broad-spectrum antibiotics targeting gram-negative and anaerobic bacteria as soon as the diagnosis is suspected or confirmed 1, 2
• For septic shock patients, antibiotics should be given as rapidly as possible 1
• Initiate low-molecular-weight heparin for thromboprophylaxis 3
• Correct electrolyte abnormalities and anemia 3

Diagnostic Imaging:

• CT scan with IV contrast is the imaging modality of choice for hemodynamically stable patients to determine the presence, source, and extent of infection 1, 3
• CT scan should never delay appropriate treatment in unstable patients 1
• Patients with obvious diffuse peritonitis requiring immediate surgery do not need further imaging 1

Surgical Decision-Making Algorithm

Immediate Emergency Surgery (No Delay)

Proceed directly to operating room for:

• Diffuse peritonitis with hemodynamic instability or septic shock 1
• Free perforation with generalized fecal peritonitis 1
• Pneumoperitoneum with clinical signs of peritonitis 1, 2
• Signs of bowel ischemia or strangulation 1
• Clinical deterioration despite resuscitation 1

Urgent Surgery (Within 24 Hours)

Surgery should not be delayed beyond 24 hours for:

• Complete bowel obstruction with signs of peritonitis 1
• Failure to improve after 24-48 hours of aggressive medical therapy 2
• Progressive colonic distension on serial imaging 2
• Persistent fever after 48-72 hours suggesting occult perforation 2
• Evidence of bowel ischemia on imaging 1, 4

Initial Nonoperative Management

May attempt conservative management for:

• Adhesive small bowel obstruction without peritonitis, ischemia, or strangulation 1, 4
• Partial bowel obstruction in hemodynamically stable patients without peritonitis 4
• Small abscesses (<3 cm) with percutaneous drainage and antibiotics 3

Nonoperative management includes:

• Nil by mouth with nasogastric decompression 1
• Duration of conservative management should not exceed 48-72 hours 1, 4
• Water-soluble contrast studies should be considered at 48-72 hours for both diagnostic and therapeutic purposes 4

Surgical Approach Selection

Open Laparotomy (Preferred Approach)

Open surgery is mandatory for:

• Hemodynamically unstable patients to minimize operative time 1, 2
• Patients with septic shock or severe sepsis 1
• Free perforation with generalized peritonitis 1
• When laparoscopic expertise is unavailable or equipment inadequate 1

Laparoscopic Approach (Selected Cases)

May consider laparoscopy for:

• Hemodynamically stable patients without signs of severe sepsis 1
• Localized contamination without diffuse peritonitis 1
• When appropriate expertise exists to minimize operative time 1

Important caveat: Laparoscopy carries risk of viral/aerosol spread and should only be performed with appropriate safety equipment and expertise 1

Operative Strategy

For Hemodynamically Unstable Patients

Damage control surgery principles:

• Resect necrotic or perforated bowel 1
• Create end stoma rather than anastomosis 1
• Avoid primary anastomosis in the presence of shock, severe contamination, or multiple risk factors 1
• Consider temporary abdominal closure (open abdomen) if abdominal compartment syndrome is expected 1
• Plan return to operating room in 24-48 hours for second look if open abdomen created 1

For Hemodynamically Stable Patients

Resection with anastomosis may be considered if:

• Patient is hemodynamically stable 1
• Only localized contamination present 1
• Fewer than 2 risk factors for anastomotic complications 1
• Adequate source control can be achieved 1

Otherwise, perform resection with stoma creation 1

Specific Scenarios

Colonic obstruction/perforation:

• Right-sided: right colectomy with primary anastomosis or end ileostomy with colonic fistula 1
• Left-sided: Hartmann's procedure (resection with end colostomy) is preferred in unstable or high-risk patients 1
• Loop colostomy may be considered for unresectable tumors or patients unfit for major surgery 1

Small bowel obstruction with peritonitis:

• Resection of compromised bowel with primary anastomosis if stable 1
• Stoma creation if unstable or multiple risk factors present 1

Open Abdomen Management

Indications for open abdomen:

• Expected abdominal compartment syndrome 1
• Need to reassess bowel viability after resection 1
• Severe sepsis/septic shock requiring damage control 1

Critical management points:

• Peritoneal contamination alone does NOT mandate open abdomen 1
• Planned relaparotomy should occur within 24-48 hours 1
• Definitive fascial closure should be achieved within 7 days to reduce complications 1
• Early closure (4-7 days) reduces mortality compared to delayed closure 1

Antimicrobial Therapy

Empiric antibiotic selection:

• Must cover gram-negative aerobic bacteria, gram-positive streptococci, and obligate anaerobes 1, 3
• Ensure satisfactory drug levels are maintained during source control procedures 1
• May require additional dosing immediately before surgery 1
• Adjust dosing based on pharmacokinetic parameters in critically ill patients 5

For healthcare-associated infections:

• Consider coverage for multidrug-resistant organisms based on local epidemiology 3, 5
• Consider antifungal coverage in high-risk patients 5

Critical Communication and Monitoring

Intraoperative communication:

• Close communication between surgeon and anesthesiologist is essential to assess resuscitation effectiveness and guide treatment decisions 1
• Continuously reassess patient stability to determine if damage control versus definitive surgery is appropriate 1

Postoperative monitoring:

• Majority of patients develop complications including worsening organ dysfunction 5
• Monitor for surgical complications and healthcare-associated infections 5
• Provide supportive care including pain management, hemodynamic monitoring, renal support, and nutrition 5

Common Pitfalls to Avoid

• Never delay surgery in patients with diffuse peritonitis, hemodynamic instability, or signs of bowel ischemia 1, 2
• Avoid primary anastomosis in hemodynamically unstable patients or those with severe contamination 1
• Do not routinely perform planned relaparotomy in the absence of specific indications (intestinal discontinuity, fascial loss, or intra-abdominal hypertension) 1
• Do not extend nonoperative management beyond 48-72 hours without clear clinical improvement 1, 4
• Avoid creating stomas in patients who may require open abdomen management, as this complicates subsequent care 1