In a hemodynamically stable adult presenting with sudden severe abdominal pain and signs of peritonitis suggestive of hollow‑viscus perforation, what is the recommended diagnostic approach and initial management?

Hollow Viscus Perforation: Diagnostic Approach and Initial Management

In a hemodynamically stable adult with sudden severe abdominal pain and peritonitis suggesting hollow viscus perforation, obtain immediate CT imaging to confirm and localize the perforation, initiate broad-spectrum antibiotics and fluid resuscitation, keep the patient NPO with nasogastric decompression, and proceed urgently to surgical repair—either open or laparoscopic depending on perforation location, duration, and surgeon expertise.

Diagnostic Approach

Imaging Modality of Choice

• CT scan is the diagnostic modality of choice for suspected hollow viscus perforation due to its high sensitivity for detecting pneumoperitoneum and ability to localize the perforation site 1.

• Look for these specific CT findings to localize the perforation:

  • Segmental bowel wall thickening 1
  • Focal bowel wall defect 1
  • Extraluminal gas bubbles concentrated near the bowel wall 1
  • Free intraperitoneal air 1

Critical Timing Consideration

• Diagnostic delay exceeding 8 hours before surgical repair significantly increases morbidity and likely mortality 2.

• This time-sensitive nature mandates rapid imaging and decision-making rather than prolonged observation 2.

Initial Management

Immediate Resuscitative Measures

• Initiate aggressive fluid resuscitation to maintain hemodynamic stability 3.

• Start broad-spectrum intravenous antibiotics immediately upon suspicion, covering gram-negative and anaerobic organisms 3.

• Keep patient NPO (nothing by mouth) and place nasogastric tube for gastric decompression 4.

Surgical Decision-Making

Urgent surgical intervention is the standard of care for confirmed hollow viscus perforation in patients with peritonitis 5, 3.

Surgical Approach Selection

• Laparoscopic management is a safe alternative to open surgery in favorable circumstances, offering diagnostic and therapeutic advantages 5.

• Laparoscopic approach depends on:

  • Nature and location of the perforation 5
  • Duration since perforation occurred 5
  • Degree of peritoneal contamination 5
  • Surgeon expertise and available resources 5

• Open surgery remains appropriate for extensive contamination, hemodynamic instability developing during evaluation, or unfavorable anatomic locations 5.

Common Etiologies to Consider

• Duodenal ulcer is the most common cause of hollow viscus perforation in adults 3.

• Other etiologies include gastric ulcers, appendicitis, malignancy, trauma, and inflammatory bowel disease 3, 4.

• Large intestinal perforations carry particularly high mortality rates (up to 25% case fatality) 3.

Critical Pitfalls to Avoid

• Do not pursue non-operative management in patients with clinical peritonitis, even if hemodynamically stable—this approach is only described for blunt trauma patients without perforation signs 2.

• Do not delay surgery for additional diagnostic testing once perforation with peritonitis is confirmed—the 8-hour window is critical 2.

• Anticipate wound infection as the most common postoperative complication (occurring in approximately 29% of cases), followed by pneumonia and acute respiratory distress syndrome 3.

• If diagnosis or surgical repair is delayed, expect significantly increased risk of multiple organ failure 4.