Bowel Perforation

Definition/Etiology:

Perforation is a full-thickness injury of the bowel wall; however, partial-thickness bowel injury can progress over time to become a full-thickness injury or perforation, subsequently releasing gastrointestinal contents.

Pathophysiology:

Bowel obstruction can cause ischemia of the bowel wall and then necrosis.

Gastric contents have pH 1-2, and are very erosive and painful in the peritoneum.

Mechanisms:

• Instrumentation (endoscopy, contrast instillation, electrocautery during surgery, NG/OG)
• Trauma (blunt or penetrating)
• Bowel obstruction
• Cancer or other tumor
• Peptic ulcer disease
• Medication erosion (aspirin, NSAIDs)
• Diverticulitis
• Esophageal dilatation
• Foreign object (toothpick, fishbone, battery)
• Vomiting
• Crohn’s 
• Appendicitis
• Mesenteric ischemia
• Bicycle/motorcycle handlebars
• Stabbing / gunshot wound
• Pelvic fracture
• Seatbelt

Clinical Presentation:

• Abdominal / chest / neck pain
• Curled up, unable to lay flat
• Toxic, septic
• Crepitus on palpation of mediastinum if esophageal perf

Collaborative Management:

Labs:

• CBC, CMP, amylase, lipase, CRP
• Blood cultures, lactate
• Type and cross

Imaging:

• FAST exam
• Abdominal x-rays, multiple views
• Neck x-rays (subq emphysema?)
• Abdominal CT (gas under the diaphragm, abscess?)

Management:

• IV fluids
• Broad spectrum IV antibiotics
• NPO
• Surgical consult

Evaluation | Patient Monitoring | Education:

Monitor for shock:

• Hypovolemic if bleeding or if third-spacing
• Septic
• Neurogenic if multi-trauma

Linchpins: (Key Points)

• Prevent septic shock.
• Early antibiotics and fluids.
• Understand third spacing.
• Treat pain.