What are the management options for a small bowel (intestine) perforation?

From the Guidelines

The management options for a small bowel perforation typically involve immediate surgical intervention, with preoperative administration of broad-spectrum antibiotics, such as ceftriaxone 2g IV and metronidazole 500mg IV 1.

Surgical Options

• Open or laparoscopic small bowel segmental resection and primary anastomosis, which is generally recommended for Class A patients with minimal peritoneal contamination and a small and single perforation 1
• Resection and delayed anastomoses at a second look, usually needed in the setting of perforation due to small bowel ischemia 1
• Open or laparoscopic resection and stoma creation or exteriorization of the perforation as a stoma, which should be considered as a valid alternative in severe cases, such as critically ill patients or those with severe inflammation and edema of the bowel 1

Postoperative Care

• Continued antibiotic therapy, with the duration of treatment depending on the patient's clinical conditions and inflammation indices, typically 4-7 days in immunocompetent patients and up to 7 days in immunocompromised or critically ill patients 1
• Bowel rest and total parenteral nutrition, as well as nasogastric decompression and aggressive fluid resuscitation with crystalloids and colloids to maintain hemodynamic stability 1

Special Considerations

• A multidisciplinary approach is necessary due to the often-multifactorial causative events, involving a surgeon, ICU doctor, infectious disease specialist, and gastroenterologist 1
• Damage control procedures should be considered in the event of severe hemodynamic instability and diffuse intra-abdominal infection, independently of the patient's class 1

From the Research

Management Options for Small Bowel Perforation

The management options for small bowel perforation include:

• Surgical intervention, such as perforation repair, segmental resection with primary anastomosis, and small-bowel ostomy 2
• Conservative management via bowel rest and initiation of total parenteral nutrition (TPN) in selected cases, such as those with multidrug-resistant gastrointestinal tuberculosis 3
• Surgical resection for cases where the perforation is caused by a foreign body 4
• Laparoscopic primary repair, which has been shown to be safe and effective in treating colonic perforations, although its use in small bowel perforation is not well established 5

Surgical Approaches

Surgical approaches for small bowel perforation include:

• Exploratory laparotomy (ex-lap) to identify and repair the perforation 3
• Right hemicolectomy for cases where the perforation is located in the terminal ileum 3
• Ileocolic anastomosis and fascial closure for cases where a resection is performed 3

Non-Surgical Management

Non-surgical management options for small bowel perforation include:

• Bowel rest and initiation of total parenteral nutrition (TPN) 3
• Use of antibiotics, such as broad-spectrum penicillins or tetracycline, to treat bacterial overgrowth 6
• Nutritional support, by enteral or parenteral means, to manage severe intestinal dysmotility 6
• Use of prokinetic agents, such as cisapride or erythromycin, to improve intestinal motility 6