What is the management for a patient with a perforated viscus?

Management of Perforated Viscus

Surgery is the treatment of choice for perforated viscus and should be performed as soon as possible, ideally within 24 hours of diagnosis, as every hour of delay increases mortality. 1, 2

Immediate Resuscitation and Stabilization

• Keep the patient NPO immediately and initiate aggressive intravenous fluid resuscitation to address potential septic shock and hemodynamic instability 1, 2, 3, 4

• Start broad-spectrum antibiotics without delay covering Gram-negative and anaerobic organisms 1, 2, 3, 4

• Place a nasogastric tube for gastric decompression to minimize further spillage through the perforation 1, 2, 3, 4

• Obtain urgent surgical consultation immediately, even if considering endoscopic or conservative management 1, 2, 4

Diagnostic Confirmation

• Obtain urgent CT scan with IV contrast to confirm perforation, assess extent of contamination, identify the source, and evaluate for abscess formation 2, 3, 4

• CT is more sensitive than plain radiographs for detecting free air and provides critical information about the magnitude, extent, complexity, and location of the perforation 1, 2, 4

• Look specifically for free air, fluid collections, peritoneal contamination, and any foreign body that may have caused the perforation 3

Surgical Management Algorithm by Location

Perforated Peptic Ulcer

• Simple closure with or without an omental patch is the standard approach for small perforations (<2 cm) 1, 2, 4

• Surgery remains the treatment of choice and should be performed urgently 1, 4

Small Bowel Perforation

• Primary repair is recommended for small perforations 1

• Resection with primary anastomosis or exteriorization is indicated for larger perforations, ischemic bowel, or multiple perforations 1

• For abdominal tuberculosis perforation specifically, resection of the affected area with anastomosis is preferred over primary closure 1

Colonic Perforation

• Right hemicolectomy with primary anastomosis is preferred for cecal perforation in hemodynamically stable patients with minimal contamination 3

• Hartmann's procedure remains the standard for diffuse peritonitis in critically ill patients, though primary resection with anastomosis (with or without diverting stoma) may be performed in clinically stable patients 1, 3

• Laparoscopic peritoneal lavage and drainage should not be considered the treatment of choice in patients with diffuse peritonitis 1

Colonoscopic Perforation

• Immediate surgical intervention is required for diffuse peritonitis, typically involving primary repair or resection 1

• Early laparoscopic approach may be safe and effective for experienced surgeons in selected cases 1, 5

Perforated Colonic Carcinoma

• Treatment must both stabilize the emergency peritonitis and fulfill oncological objectives 1

Endoscopic Management (Highly Selected Cases Only)

• For upper GI perforations <2 cm, endoscopic closure using through-the-scope clips or over-the-scope clips may be attempted if diagnosed immediately during the procedure 1, 2, 4

• For perforations >2 cm, endoscopic suturing or combination techniques may be considered 2, 4

• Minimize carbon dioxide insufflation to avoid compartment syndrome and position the patient to bring the perforation into a non-dependent location 1, 4

• Urgent surgical consultation is mandatory even when endoscopic repair appears technically successful 1, 2, 4

Conservative Management (Extremely Limited Indications)

Conservative management may only be considered in highly selected patients who meet ALL of the following criteria:

• Hemodynamically stable with no signs of peritonitis or sepsis 1, 2

• No contrast extravasation on water-soluble contrast study 2

• Small perforated diverticulitis with abscess <4 cm in diameter 1

• Peri-appendiceal mass without diffuse peritonitis 1

• Perforated peptic ulcer with pericolic extra-luminal air only (not distant free air) 1

Components of conservative management include:

• Absolute NPO status 2, 4
• Nasogastric tube decompression 2, 4
• Intravenous proton pump inhibitor therapy 2
• Broad-spectrum intravenous antibiotics 2, 4
• Serial clinical examinations every 3-6 hours 2, 3
• Clinical improvement must occur within 24 hours or proceed to surgery 2

Critical Timing Considerations

• The timing and adequacy of source control are the most important factors in management; late and/or incomplete procedures severely worsen outcomes, especially in critically ill patients 1

• Every hour of delay between diagnosis and surgery increases mortality 1, 2, 3

• Source control should be performed as soon as possible, though intervention could be delayed up to 24 hours in patients with localized infection if appropriate antimicrobial therapy is given and careful clinical monitoring is provided 1

• Elderly patients (>70 years) have significantly worse outcomes with delayed intervention and are less likely to respond to conservative management 2, 3, 4

Post-Operative Management

• Admit all patients to ICU or monitored setting for continuous observation 3

• Continue nasogastric decompression until bowel function returns 3

• Maintain broad-spectrum antibiotics until clinical improvement is documented 3

• Perform water-soluble upper GI series before initiating clear liquid diet to confirm absence of ongoing leak 1, 2, 4

• Serial clinical evaluations every 3-6 hours to detect complications early 2, 3

• Monitor for development of peritoneal signs, fever, tachycardia, or sepsis 4

Re-Laparotomy Strategies

• On-demand re-laparotomy should be performed when required by the patient's clinical condition 1

• Planned re-laparotomy every 36-48 hours may be considered for severe peritonitis with ongoing contamination until the abdomen is free of peritonitis 1

• Open abdomen procedure is the best way of implementing re-laparotomies in selected cases 1

Special Populations

• Immunocompromised patients and transplant recipients require surgical management regardless of perforation size 2

• Patients with significant comorbidities or hemodynamic instability should undergo damage control surgery with Hartmann's procedure or diversion rather than primary anastomosis 3

Critical Pitfalls to Avoid

• Do not delay surgical consultation even if endoscopic closure appears successful 1, 2, 4

• Do not attempt conservative management in patients with peritoneal signs, hemodynamic instability, or significant distant free air 1, 2, 3

• Do not miss CT findings of distant free air or fluid in the fossa of Douglas, which predict failure of non-operative treatment 1

• Recognize that complication rates and hospital stays are significantly higher in patients requiring delayed surgery after failed conservative management compared to those treated surgically from the outset 4

• Inadequate or late source control triggers excessive immune response leading to sepsis, septic shock, and organ failure 1

• Do not underestimate the magnitude, extent, complexity, and location of the perforation, as this is the principal cause for failure of percutaneous drainage when attempted 1