What is the treatment for peritonitis complicated by intestinal perforation?

Treatment of Peritonitis Complicated by Intestinal Perforation

Patients with peritonitis from intestinal perforation require immediate surgical intervention with source control, consisting of resection or repair of the perforated segment, peritoneal lavage, and broad-spectrum antibiotics, with the specific surgical approach determined by hemodynamic stability and extent of contamination. 1

Initial Resuscitation and Diagnosis

• All patients require aggressive fluid resuscitation, broad-spectrum intravenous antibiotics covering anaerobes and gram-negative bacteria, and hemodynamic stabilization before definitive intervention. 1, 2
• CT imaging with contrast is the diagnostic gold standard, detecting pneumoperitoneum, fluid collections, and the perforation site with 82% sensitivity. 1, 3
• Laboratory markers including white blood cell count, C-reactive protein, and procalcitonin (if >12 hours from presentation) help assess severity of sepsis. 1

Surgical Approach Based on Patient Stability

For Hemodynamically Stable Patients Without Severe Comorbidities

Primary resection with anastomosis is the preferred approach, demonstrating 40% lower mortality compared to Hartmann's procedure in observational studies. 1, 4

• In stable patients with purulent peritonitis, primary anastomosis can be performed safely with or without protective diverting ileostomy. 1, 4
• Laparoscopic approach may be utilized if technical expertise and equipment are available, with conversion rates of 0-19% and mean hospital stay of 6-16 days. 1
• Simple primary repair with or without omental patch is appropriate for small perforations (<2 cm), particularly in gastroduodenal ulcer perforations. 1

For Hemodynamically Unstable Patients or Those with Multiple Comorbidities

Hartmann's procedure (resection with end colostomy) is the safest option for unstable patients or those with extensive fecal contamination. 1, 2, 4

• This approach provides definitive source control while avoiding the risk of anastomotic leak in physiologically compromised patients. 1
• Stoma reversal can be performed later once the patient recovers, with success rates of approximately 76%. 1

For Patients in Physiological Extremis

Damage control surgery should be employed, consisting of limited resection or primary closure of perforation, peritoneal lavage, temporary abdominal closure, and planned second-look surgery after ICU resuscitation. 1

• Initial surgery focuses solely on source control (closure of perforation or limited resection), followed by ICU optimization before definitive reconstruction. 1
• This strategy allows physiological stabilization and potentially increases the rate of primary anastomosis at the second operation, avoiding permanent stoma formation. 1
• Second-look laparotomy is typically performed 24-48 hours later for bowel anastomosis or further debridement. 1, 4

Specific Considerations by Etiology

Diverticular Perforation

• Emergency sigmoidectomy with primary anastomosis is preferred in stable patients, while Hartmann's procedure is indicated for unstable patients. 1, 2
• Laparoscopic lavage alone is not recommended as first-line treatment for diffuse peritonitis, reserved only for highly selected patients with purulent (not fecal) peritonitis. 1

Colonoscopic Perforation

• Immediate surgical intervention with primary repair or resection is required for patients with diffuse peritonitis. 1
• In cases of extensive contamination or poor tissue quality, fecal diversion after repair should be performed. 1
• Early laparoscopic approach is safe and effective for experienced surgeons if the perforation can be localized. 1

Gastroduodenal Ulcer Perforation

• Simple closure with omental patch is safe and effective for small perforations in stable patients. 1
• Distal gastrectomy is reserved for large perforations near the pylorus, gastric corpus perforations, or suspicion of malignancy. 1

Perforated Colonic Carcinoma

• Hartmann's procedure is widely accepted for left-sided colonic cancer perforations, providing both oncological resection and emergency stabilization. 1
• The procedure must achieve adequate R0 resection while managing the peritonitis. 1

Antibiotic Management

• Broad-spectrum antibiotics should be initiated immediately and continued for 3-5 days after adequate source control in immunocompetent patients. 2, 4
• Extend antibiotic duration to 7 days for immunocompromised or critically ill patients. 4
• Short-course antibiotics are sufficient for stable patients (Class A) after successful repair. 1

Postoperative Management

• Early enteral feeding (within 12 hours postoperatively) via feeding jejunostomy reduces septic morbidity and achieves positive nitrogen balance by postoperative day 3. 5
• Close monitoring for anastomotic leak, intra-abdominal abscess, and ongoing sepsis is mandatory. 1
• Mortality is directly related to severity of peritonitis as measured by APACHE II score and Mannheim Peritonitis Index, not the specific surgical procedure chosen. 6, 7

Critical Pitfalls to Avoid

• Delayed diagnosis beyond 24 hours significantly increases mortality and the need for more invasive interventions. 1
• Attempting primary anastomosis in hemodynamically unstable patients or those with severe fecal contamination risks catastrophic anastomotic leak. 1
• Inadequate source control (incomplete drainage, retained necrotic tissue) leads to tertiary peritonitis and persistent sepsis. 1
• Failure to recognize physiological extremis and proceeding with complex reconstruction rather than damage control surgery increases mortality. 1