Intestinal perforation

A brief review of intestinal perforation, presented by Dr. Sara Khalid Memon, from LUMHS, Jamshoro, Sindh, Pakistan

1. INTESTINAL PERFORATION PRESENTED BY: Dr. Sara Khalid Memon House officer, surgical unit 04

2. ETIOLOGY

3. Penetrating injury to the lower chest or abdomen ( i.e , knife injuries ) Blunt abdominal trauma to the stomach( esp in children) Presence of a predisposing condition - Predisposing conditions include peptic ulcer disease, acute appendicitis, acute diverticulitis, and inflamed Meckel diverticulum Bacterial infections ( eg , typhoid fever, Tuberculosis, etc ) Ingestion of aspirin, NSAIDs   and steroids ( esp in elderly ) Bowel perforation by intra-abdominal malignancy, lymphoma, or metastatic renal carcinoma

4. Perforation secondary to intestinal ischemia  Radiotherapy of cervical carcinoma and other intra-abdominal malignancies - This may be associated with late complications, including bowel obstruction and bowel perforation.  Necrotizing vasculitis (WG) Inflammatory bowel disease (CD>UC ) Bowel injuries associated with endoscopy - Injuries can occur with ERCP and Colonoscopy. Endoscopic biliary stent Intestinal puncture as a complication of laparoscopy   Ingestion of caustic substances  Foreign body ingestion

5. CLASSIFICATION

6. Small bowel Perforation Free Contained Large bowel Perforation

7. How would you diagnose ? HISTORY Age Abdominal Pain(All questions of pain) Vomiting Hiccups Endoscopic procedures Chronic history (As in UC) History of Trauma (Penetrating) History of NSAID use

8. EXAMINATION Assess the patient's general appearance Examine the abdomen for any external signs of injury, abrasion, and/or ecchymosis . Observe patients' breathing patterns and abdominal movements with breathing, and note any abdominal distention or discoloration . Tenderness on percussion may suggest peritoneal inflammation. Bowel sounds are usually absent in generalized peritonitis . Rectal and bimanual vaginal and pelvic examinations may help in assessing conditions such as acute appendicitis, ruptured tubo -ovarian abscess, and perforated acute diverticulitis .

9. INVESTIGATIONS Baseline Investigations Complete blood count Serum Electrolytes RBS Virology LFTs and RFTs

10. Specific Investigations Ultrasound Abdomen X-ray ABDOMEN erect and supine CT Scan abdomen Laparoscopy Peritoneal Diagnostic Tap Peritoneal lavage (Alkaline phosphatase concentration) Fine-catheter peritoneal cytology

11. TREATMENT TREATMENT FOR INTESTINAL PERFORATION IS ALWAYS SURGICAL !!! Contraindications to Surgery are: Severe heart failure, respiratory or multi organ failure If Patient doesn’t give CONSENT. I f a contrast meal confirms spontaneous sealing of the perforation

12. MEDICAL THERAPY (or pre operative therapy) Keep Patient NPO Establish intravenous access, and initiate crystalloid therapy in patients with clinical signs of dehydration or septicemia Start intravenous administration of antibiotics to patients with signs of septicemia Metronidazole(7.5 mg/kg IV before surgery) Gentamicin (for an aerobic cover)( It may be given IV/IM. In adults, the loading dose before surgery is 2 mg/kg IV; thereafter, dosing is 3-5 mg/kg/day divided tid / qid ) Cefotetan or Cefoxitin (2gmIV before surgery) Cefoperazone sodium ( Adult dosing is 2-4 g/day IV divided q12hr. Pediatric dosing is 100-150 mg/kg/day IV divided q8-12hr, not to exceed 12 g/day.

13. SURGICAL THERAPY The goals of surgical therapy are as follows: To correct the underlying anatomic problem To correct the cause of peritonitis To remove any foreign material in the peritoneal cavity that might inhibit WBC function and promote bacterial growth ( eg , feces, food, bile, gastric or intestinal secretions, blood)

14. CONVENTIONAL LAPAROTOMY Operative management depends on the cause of perforation. Perform urgent surgery either on patients not responding to resuscitation or following stabilization and maintenance of adequate urine output. All necrotic material and contaminated fluid should be removed and accompanied by lavage with antibiotics (tetracycline 1 mg/mL). Decompress distended bowel via a nasogastric tube . LAPROSCOPIC LAPARATOMY/MINI LAPAROTOMY Laparoscopic or laparoscopic-assisted ( minilaparotomy ) surgery is also being increasingly used with outcomes comparable with conventional laparotomy.Experience and the advancement in accessories have enabled endoscopic repair of a significant number of intestinal perforations, such as iatrogenic perforation.  

15. POST OPERATIVE CARE Intravenous replacement therapy Nasogastric drainage Antibiotics Analgesics

16. If no obvious improvement in the patient's condition occurs within 2-3 days, consider the following possibilities: The initial operative procedure was inadequate. Complications have occurred. A superinfection has occurred at a new site. The dose of antibiotic is inadequate. The antibiotics used do not provide adequate coverage for anaerobes and gram-negative organisms.

17. COMPLICATIONS

18. Wound infection Localized abdominal abscess Multi organ failure OR Septic shock Renal failure and fluid, electrolyte, and pH imbalance. Gastrointestinal mucosal hemorrhage is usually associated with failure of multiple organ systems and is probably related to a defect in the protective gastric mucosa. Mechanical obstruction of the intestine is most often caused by postoperative adhesions .

19. PATIENT related causes of wound failure: Malnutrition Sepsis Uremia Diabetes mellitus Corticosteroid therapy Obesity Heavy coughing Hematoma (with or without infection)

20. SURGEON related causes of Wound Failure: In proper suturing material used In proper technique for suturing Increased stress on wound edges

21. JAZAKALLAHUKHAIR FOR LISTENING