From the Guidelines
Conservative management of duodenal perforation should prioritize immediate admission for observation, intravenous fluids, nothing by mouth, broad-spectrum antibiotics, and surgical consultation, as outlined in the 2021 expert review published in Clinical Gastroenterology and Hepatology 1. When managing duodenal perforation conservatively, the primary goals are to prevent infection, promote healing, and minimize complications. Key components of this approach include:
- Admission for observation to closely monitor the patient's condition
- Administration of intravenous fluids to maintain hydration and support the patient's overall health
- Keeping the patient nothing by mouth (NPO) to reduce the risk of further perforation or leakage
- Prescribing broad-spectrum antibiotics, such as those that cover Gram-negative and anaerobic organisms, to prevent or treat infection
- Placement of a nasogastric tube (NGT) in most cases, although there may be exceptions based on the patient's specific condition
- Mandatory surgical consultation to ensure that the patient receives timely and appropriate surgical intervention if their condition worsens or if conservative management is not effective. This approach is supported by the most recent and highest quality evidence, which emphasizes the importance of prompt and comprehensive management to reduce morbidity, mortality, and improve quality of life for patients with duodenal perforation 1.
From the Research
Conservative Management of Duty Perforation
- The management of perforation of the colon at colonoscopy can be conservative in certain cases, such as silent perforations and in patients with mild or localized symptoms and signs diagnosed within 4-8 h of injury 2.
- Conservative management is also advocated for patients with acute perforated diverticulitis without generalized peritonitis, with a success rate of 94.0% and 71.4% for patients with pericolic and distant free air, respectively 3.
- The decision to manage colonoscopic perforations conservatively depends on the etiology, size, severity, location, available expertise, and general health status of the patient, with peritonitis, sepsis, or hemodynamic compromise requiring immediate surgical management 4.
- Conservative management may be suitable for patients with localized peritonitis without signs of sepsis, and those with postpolypectomy coagulation syndrome, but surgery is indicated in the presence of a large perforation, generalized peritonitis, or ongoing sepsis 5.
- Antibiotic therapy should be given to all patients immediately upon diagnosis, with single-agent therapy with cefoxitin used in immunocompetent patients, and combination antibiotic treatment indicated in other circumstances 2.
Factors Influencing Conservative Management
- The size and site of the perforation, adequacy of bowel preparation, amount of peritoneal soilage, underlying colonic pathology, and overall clinical condition of the patient can influence the management of colonic perforation secondary to colonoscopy 5.
- The presence of concomitant pathology at the time of colonoscopic perforation, such as a large sessile polyp likely to be a carcinoma, unremitting colitis, or perforation proximal to a nearly obstructing distal colonic lesion, may force immediate surgery 5.
- The use of empiric anti-fungal therapy in the treatment of perforated peptic ulcer disease is not recommended, as the current evidence does not demonstrate efficacy in improving outcomes in patients with perforated peptic ulcers 6.