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KembaraXtra -Medicine- Emergency and Acute Medicine – Perforated Viscus
A perforated viscus is a full-thickness disruption of a hollow abdominal organ that allows gastrointestinal contents to spill into the peritoneal cavity. This results in chemical and bacterial peritonitis, leading rapidly to systemic inflammatory response and potential septic shock. Perforation may occur from ulceration, inflammation, obstruction, ischemia, trauma, or iatrogenic injury. It is a surgical emergency requiring rapid recognition and intervention.
The most common cause is perforated peptic ulcer disease, frequently associated with NSAID use or Helicobacter pylori infection. Other causes include small bowel ischemia, inflammatory bowel disease, neoplasms, foreign bodies, diverticular disease, appendicitis, penetrating or blunt abdominal trauma, endoscopic procedures, and radiation enteritis or proctitis. In pediatric patients, trauma is the most common cause, particularly in neonates after difficult delivery, nonaccidental trauma, motor vehicle collisions, or falls. The jejunum is a common rupture site in children.
Patients typically present with sudden, severe abdominal pain that is initially localized but rapidly becomes diffuse as peritonitis develops. Examination reveals rigidity, guarding, rebound tenderness, and absent bowel sounds. Systemic findings may include fever, tachycardia, tachypnea, and hypotension. In advanced cases, patients may present in hypovolemic or septic shock. Elderly patients often have atypical presentations with less pronounced pain, minimal guarding, absence of leukocytosis, altered mental status, hypothermia, or blunted tachycardia due to medications or comorbidities.
The essential initial study is an upright chest radiograph to detect pneumoperitoneum. After the patient has been upright for 5–10 minutes, as little as 1–2 mL of free air may be visualized under the diaphragm. Sensitivity ranges from 50% to 85%. A left lateral decubitus abdominal radiograph may be more sensitive than a supine film. The double wall (Rigler) sign, in which both the mucosal and serosal surfaces of bowel are visible, suggests free intraperitoneal air. Abdominal CT is highly sensitive for detecting small amounts of free air and is indicated when clinical suspicion remains high despite normal plain films.
Laboratory evaluation includes CBC, electrolytes, renal function, glucose, liver function tests, coagulation profile, urinalysis, lipase, arterial blood gas, and lactate. Leukocytosis and elevated lactate support the diagnosis but are not required. Type and cross-match should be performed in unstable patients. ECG may be necessary to exclude cardiac causes of abdominal pain. In pregnant patients, ectopic pregnancy must be excluded.
Management begins with aggressive resuscitation following trauma and sepsis principles. Hypotension and tachycardia are treated with rapid infusion of 0.9% normal saline, typically 500 mL to 1 L boluses in adults, repeated as needed. Pediatric patients receive 20 mL/kg boluses. Vasopressors may be required if fluids are insufficient. Nasogastric decompression and Foley catheter placement are recommended. Broad-spectrum intravenous antibiotics must be administered promptly to cover enteric gram-negative bacilli, gram-positive cocci, and anaerobes. Appropriate regimens include a carbapenem, piperacillin–tazobactam, or a third- or fourth-generation cephalosporin combined with metronidazole. Analgesia should be provided without delaying surgical consultation.
Immediate surgical consultation is mandatory for all suspected or confirmed cases. Imaging should not delay operative intervention in unstable patients. Discharge is not appropriate, as perforated viscus is a surgical emergency requiring admission and definitive management. Early recognition, prompt antibiotic therapy, aggressive resuscitation, and urgent surgical intervention are critical to reducing morbidity and mortality.
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