What is the management of enteric microperforation?

Management of Enteric Microperforation

Enteric microperforation requires immediate initiation of broad-spectrum antibiotics, fluid resuscitation, and careful clinical assessment to determine whether conservative management with bowel rest and nasogastric drainage is appropriate, or whether surgical intervention is necessary based on hemodynamic stability, extent of peritoneal contamination, and patient comorbidities. 1, 2

Initial Assessment and Stabilization

Diagnostic Workup

• Obtain CT scan with IV contrast immediately - this is more sensitive than plain radiographs for detecting extraluminal gas, intra-abdominal fluid, and intestinal wall thickening that characterize microperforation 1, 2, 3
• Measure white blood cell count and C-reactive protein to assess severity of inflammation 4, 2
• Look specifically for imaging findings of intestinal wall thickening, pericolonic fat inflammation, extraluminal gas, and intra-abdominal fluid 1

Immediate Medical Management

• Start aggressive fluid resuscitation and correct electrolyte imbalances 3, 5
• Initiate broad-spectrum IV antibiotics immediately covering gram-negative bacilli, gram-positive organisms, and anaerobes 1, 2

Decision Algorithm: Conservative vs Surgical Management

Conservative Management Criteria (All Must Be Present)

Conservative management may be appropriate only when patients meet ALL of the following criteria:

• Hemodynamically stable with localized peritoneal signs 1, 2
• No diffuse peritonitis or frank peritoneal signs 1, 2
• Minimal peritoneal contamination on imaging 1, 2
• Immunocompetent status (immunocompromised patients require surgery regardless of perforation size) 4, 2

Conservative Management Protocol

If conservative management is selected:

• Absolute bowel rest with NPO status for 4-5 days 2, 6
• Nasogastric tube drainage for approximately 2-3 days 6
• Serial clinical and imaging monitoring every 3-6 hours 2, 3
• Clinical improvement should occur within 24 hours - if not, proceed to surgery 2
• Continue IV antibiotics for 5-6 days 6

Surgical Management Indications (Any One Requires Surgery)

Proceed immediately to surgery if any of the following are present:

• Hemodynamic instability or septic shock 1, 4
• Diffuse peritonitis or frank peritoneal signs 1, 2
• Immunocompromised status or transplant recipient 4, 2
• Multiple perforations or severe peritoneal contamination 1
• Failure of conservative management within 24 hours 2
• Delayed presentation with established peritonitis 1

Surgical Approach

Small Bowel Microperforation

• Primary repair for small perforations with minimal contamination and healthy tissue 1, 2
• Segmental resection with primary anastomosis for larger defects or unhealthy tissue 1
• Resection with stoma creation (ileostomy) in critically ill patients or when severe inflammation creates friable tissue that precludes safe anastomosis 1
• Laparoscopic approach may be considered in stable patients, but maintain low threshold for conversion to open surgery 1, 3

Colonic Microperforation

• Primary closure or wedge resection for small perforations with minimal contamination 3
• Colonic resection for large perforations or significant contamination 3
• Hartmann's procedure for critically ill patients with diffuse peritonitis and multiple comorbidities 1, 2

Antibiotic Regimen

For Adequate Source Control (Immunocompetent, Non-Critically Ill)

• Piperacillin/tazobactam 6g/0.75g loading dose, then 4g/0.5g q6h or 16g/2g continuous infusion 1
• Duration: 4 days if source control adequate 1

For Critically Ill or Immunocompromised Patients

• Piperacillin/tazobactam (same dosing as above) 1
• Eravacycline 1mg/kg q12h as alternative 1
• Duration: up to 7 days based on clinical conditions and inflammatory markers 1

For Septic Shock

Choose one of the following:

• Meropenem 1g q6h by extended or continuous infusion 1
• Doripenem 500mg q8h by extended or continuous infusion 1
• Imipenem/cilastatin 500mg q6h by extended infusion 1
• Eravacycline 1mg/kg q12h 1

For Inadequate/Delayed Source Control or High ESBL Risk

• Ertapenem 1g q24h 1
• Eravacycline 1mg/kg q12h as alternative 1

For Beta-Lactam Allergy

• Eravacycline 1mg/kg q12h 1
• Tigecycline 100mg loading dose, then 50mg q12h 1

Critical Pitfalls to Avoid

• Do not attempt endoscopic closure in hemodynamically unstable patients or those with delayed perforation and peritoneal signs - these require immediate surgical management 1
• Do not delay surgery beyond 24 hours if conservative management fails - delayed surgical intervention increases complication rates and hospital stays 2, 3
• Do not use prophylactic antibiotics beyond 24 hours (3 doses) in stable patients - this increases risk of C. difficile and multidrug-resistant organisms 1
• Do not pursue conservative management in immunocompromised patients regardless of perforation size 4, 2
• Patients with ongoing signs of infection beyond 7 days of antibiotics warrant diagnostic investigation for complications such as intra-abdominal abscess 1

Special Considerations

Typhoid Perforation (Endemic Areas)

• Resection of unhealthy tissue segment with primary anastomosis of healthy edges approximately 10cm on each side is preferred over simple closure 1
• Mortality rates can reach 15-60% with multiple perforations and severe contamination 1

Post-Endoscopic Microperforation

• Conservative management with fasting, nasogastric drainage, and IV antibiotics is often successful for gastric microperforation after endoscopic mucosal resection 6
• Mean duration: 2-3 days nasogastric drainage, 4 days fasting, 5-6 days antibiotics 6