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intestinal perforation
Perforation of the intestine
Etiology:
- endoscopy
- appendicitis
- erlotinib (Tarceva)
- fish bone [3]
Pathology:
- performation of the proximal GI tract (stomach, proximal small bowel, biliary tree) involves gram-positive & gram-negative aerobic & facultative bacteria, but may also involve obligate anaerobes (Bacteroides sp.) when associated with abscess, ileus, or intestinal obstruction
- perforation of the colon generally involves facultative organisms (E. coli), obligate anaerobes (Bacteroides sp.), S. milleri, & enterococci
Clinical manifestations:
- perforation of the descending colon generally manifests as subacute peritonitis [4]
Radiology:
- abdominal computed tomography
- plain abdominal films: pneumoperitoneum
Management:
1) surgical emergency
- for perforated bowel due to diverticulitis, surgical resection comparable to peritoneal lavage in complications (26-31%) & overall mortality (12-14%), but less likely to need reoperation & sigmoid colon cancers may be revealed during surgery [2]
2) empiric antibiotic coverage: see appendicitis
General
intestinal disease
gastrointestinal perforation
References
- Prescriber's Letter 17(3): 2010
CHART: Antibiotics for Complicated Intra-Abdominal Infections
GUIDELINES: Diagnosis and Management of Complicated Intra-
abdominal Infections
Detail-Document#: 260321
(subscription needed) http://www.prescribersletter.com
- Schultz JK, Yaqub S, Wallon C et al
Laparoscopic Lavage vs Primary Resection for Acute Perforated
Diverticulitis. The SCANDIV Randomized Clinical Trial.
JAMA. 2015;314(13):1364-1375.
PMID: 26441181
- Strong SA, Soper NJ
Minimally Invasive Approaches to Rectal Cancer and
Diverticulitis. Does Less Mean More?
JAMA. 2015;314(13):1343-1345
PMID: 26441178
- Taguchi T, Kitagawa H.
Fish Bone Perforation.
N Engl J Med 2019; 381:762. August 22, 2019
PMID: 31433923
https://www.nejm.org/doi/full/10.1056/NEJMicm1900442
- NEJM Knowledge+ Question of the Week. Dec 13, 2022
https://knowledgeplus.nejm.org/question-of-week/3001/