Treatment

• Bowel rest (NPO)

• IV access with two large-bore peripheral IVs

• Start broad-spectrum IV antibiotics: See “Severe infection” in “Empiric antibiotic therapy for intraabdominal infection.”

• Obtain an urgent surgical consult to determine whether surgery or conservative management is appropriate.

• Patients with signs of sepsis and/or shock additionally require:

  • Immediate hemodynamic support, e.g., aggressive IV fluid resuscitation

  • Urgent critical care consult

• Begin supportive care (e.g., analgesics, antiemetics).

• Reevaluate frequently (serial abdominal examination, vital signs), as the patient's condition may rapidly deteriorate.

• NG tube with continuous or intermittent suction

• Consider IV PPI, e.g., pantoprazole for patients with suspected perforated peptic ulcer. [10]

• Parenteral analgesics

  • Opioid analgesics [11]

  • NSAIDs

• Parenteral antiemetics (see “Antiemetics”)

Ketorolac is contraindicated in patients with suspected bowel perforation.

Opioids are contraindicated in patients with suspected bowel obstruction.

Most patients with GI tract perforation should be managed with urgent explorative laparotomy.

• Indications:

  • Signs of generalized peritonitis

  • Signs of sepsis

• Procedure: Exploratory laparotomy with midline incision is usually preferred.

Patients with only localized peritonitis and no signs of sepsis may be candidates for conservative (nonsurgical) management.

• NPO, maintenance IV fluids, and IV PPI (see “Supportive care” above)

• IV broad-spectrum antibiotics: See “Severe infection” in “Empiric antibiotic therapy for intraabdominal infection”

• If imaging shows evidence of an abscess: Consider image-guided percutaneous drainage of abscess. [15]

• Serial abdominal examination

• Further management:

  • If there are clinical signs of improvement : Obtain an abdominal x-ray with water-soluble contrast to confirm that the perforation has sealed.

    • No leakage of contrast: Initiate enteral feeds and switch to oral antibiotics.

  • If there are clinical signs of deterioration : exploratory laparotomy

• Peritonitis

• Bacteremia

• Sepsis

• Multiorgan dysfunction

• Intraabdominal abscess

• Intraabdominal adhesions

• Subhepatic abscess

• Pyogenic liver abscess

• Pelvic abscess

• Postoperative complications