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Peritonitis, Gastric & Duodenal Perforations - MS General Surgery Theory

PART I: PERITONITIS

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Definition

• Bailey and Love's Short Practice of Surgery 28th Ed., p.1109

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Classification

• Localised (walled off by omentum/bowel)
• Diffuse/Generalised (life-threatening)

• Bacterial (GI/non-GI origin)
• Chemical (bile, barium, gastric acid)
• Allergic (starch peritonitis)
• Traumatic (operative handling)
• Ischaemic (strangulated bowel, vascular occlusion)
• Miscellaneous (Familial Mediterranean Fever)

• GI perforation (ulcer, appendix, diverticulum)
• Transmural translocation without perforation (pancreatitis, ischaemic bowel, primary bacterial peritonitis)
• Exogenous contamination (drains, peritoneal dialysis, trauma)
• Female genital tract (PID - Chlamydia, gonococci; Fitz-Hugh-Curtis syndrome)
• Haematogenous spread (rare)

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Localised Peritonitis

• Parietal peritoneum involved → somatic pain localised to the area
• Involuntary guarding and rebound tenderness = peritonism
• Referred phrenic pain (shoulder tip) if sub-diaphragmatic involvement (C5 dermatome)
• Pelvic peritonitis: signs may be minimal abdominally; detected on PR/PV exam
• Signs attenuated in obese patients or those on immunosuppressants

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Diffuse (Generalised) Peritonitis

• Pressure-related perforation of viscus (obstructed colon)
• Large volume blood entry (ruptured AAA)
• Sustained leak (perforated duodenal ulcer, anastomotic leak)

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Clinical Features of Peritonitis (Summary Box)

• Abdominal pain, worse on movement, coughing, deep respiration
• Constitutional upset: anorexia, malaise, fever, lassitude
• GI upset: nausea ± vomiting
• Pyrexia (may be absent early), raised pulse rate
• Tenderness ± guarding / rigidity / rebound
• Board-like rigidity of entire abdomen
• Hippocratic facies - gravely ill, lies still
• Absent or reduced bowel sounds
• Generalised ileus → abdominal distension
• Scaphoid abdomen in thin patients (rectus contraction)
• Septic shock (SIRS/MODS) in later stages
• PR/PV tenderness in pelvic peritonitis

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Investigations

1. Erect CXR - free gas under diaphragm (present in >50% of perforated PU; 75% on abdominal film)
2. CT scan - investigation of choice; most accurate; identifies source
3. Lateral decubitus X-ray - if patient too unwell for erect position
4. FBC, LFT, U&E, glucose, coagulation
5. Serum amylase - elevated in perforated PU but not as high as pancreatitis; CT distinguishes both
6. Blood cultures
7. Ultrasound - limited specificity; useful for tubo-ovarian pathology
8. Laparoscopy - if above inconclusive

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Management of Peritonitis

Resuscitation ("ABCDE" + source control)

1. IV access - large bore, two lines
2. Fluid resuscitation - crystalloids (follow Surviving Sepsis guidelines)
3. Foley catheter + nasogastric tube
4. Analgesia - do not withhold (adequate analgesia actually makes signs more obvious)
5. Oxygen supplementation
6. Monitoring: urine output >0.5 mL/kg/hr

• Broad-spectrum IV antibiotics targeting gram-negatives and anaerobes
• Typical regimens: Piperacillin-tazobactam, or Cefuroxime + Metronidazole, or Meropenem (in resistant/tertiary peritonitis)
• De-escalate based on culture results

• ICU care for MODS/septic shock
• Vasopressors if refractory hypotension

• Source control - remove or exclude the cause
• Peritoneal lavage ± drainage
• Timing: urgent (within hours) once resuscitation initiated
• Damage control surgery in unstable patients: control contamination, close abdomen temporarily (open abdomen technique with VAC dressing), definitive repair in 24-48 hours

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Spontaneous Bacterial Peritonitis (SBP)

• Occurs in cirrhotic patients with ascites
• Organisms: Gram-negatives (E. coli, Klebsiella), Streptococcus pneumoniae
• Diagnosis: ascitic fluid PMN > 250 cells/mm³
• Treatment: Cefotaxime 2g IV 8-hourly for 5 days; albumin infusion reduces AKI
• Prophylaxis: Norfloxacin 400 mg/day in high-risk patients

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PART II: GASTRIC AND DUODENAL PERFORATIONS (Perforated Peptic Ulcer)

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Epidemiology

• Steady increase in age of patients
• Increase in females - PPU now most common in elderly females
• NSAIDs responsible for most perforations (especially elderly)
• Duodenal > Gastric, but rising proportion of GU perforations in elderly NSAID users
• Globally: up to 5% of all PUD patients present with perforation
• 30-day mortality remains significant: ~6-30% depending on setting
• Bailey and Love 28th Ed., p.1186; Sleisenger & Fordtran p.X

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Aetiology

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Pathology

• Most common on anterior wall of first part of duodenum (perforate into peritoneal cavity)
• Posterior wall DU penetrate into pancreas → can erode gastroduodenal artery → haemorrhage

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Clinical Features

• Sudden onset, severe generalised abdominal pain - patient may specify exact moment of onset ("knife-like/tearing pain")
• Initially chemical peritonitis from gastric acid → bacterial peritonitis supervenes over hours
• Board-like rigidity of entire abdomen
• Abdomen does not move with respiration
• Patient lies still (peritoneal irritation worsens with movement)
• Hippocratic facies - gravely ill, anxious, sunken features
• Initially shocked + tachycardic; pyrexia not usually present until hours later
• Referred shoulder tip pain (diaphragmatic irritation)

• Less dramatic (steroid/NSAID use blunts signs)
• Board-like rigidity may be absent
• "Contained" leak: pain in epigastrium + right iliac fossa (fluid tracking down right paracolic gutter)
• Self-sealing perforations can occur (inflammatory response + adhesions)
• NSAID switch from opioids → rising frequency in younger patients (recent epidemiological shift)

• Both present similarly; GU more likely to be contaminated with food/bacteria
• Free peritoneal gas more reliable in GU (larger stomach volume)

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Investigations

• FBC (leucocytosis), CRP elevated
• U&E, LFT, glucose, coagulation, cross-match
• Serum amylase - may be elevated (up to 3× normal) in PPU, but not as high as pancreatitis; CT distinguishes

1. Erect CXR - free gas under diaphragm in >50% of cases (Bailey & Love); 75% detectable on abdominal film (Fordtran)
2. CT abdomen + pelvis - most accurate; demonstrates:
   • Extraluminal free air
   • Fluid/pus collections
   • Edema around antrum/duodenum
   • May identify perforation site
   • Preferred investigation
3. Lateral decubitus X-ray - alternative if patient too unwell to stand
4. Endoscopy is CONTRAINDICATED when PPU suspected - insufflation can convert sealed perforation to free perforation

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Prognostic Scoring

• Score 0: mortality ~0-1%
• Score 1: ~10%
• Score 2: ~45%
• Score 3: ~100%

• Includes age, ASA class, shock, co-morbidities, perforation size, time to surgery

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Treatment

Initial Resuscitation (All patients)

1. IV fluids - aggressive crystalloid resuscitation
2. Analgesia (do not withhold - titrate the dose)
3. Broad-spectrum IV antibiotics
4. NGT decompression
5. Foley catheter (monitor UO)
6. Blood tests + cross-match
7. Urgent surgical consultation

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Conservative (Non-operative) Management

• Patient haemodynamically stable
• No signs of generalised peritonitis
• Radiologically demonstrated sealed perforation (CT/water-soluble contrast study)
• Age < 70 (relative)
• Presentation < 24 hours

• Strict NBM
• IV fluids
• NGT suction
• IV broad-spectrum antibiotics
• PPI infusion
• Serial clinical review - any deterioration = immediate surgery

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Surgical Management

1. Open (Upper midline incision) - traditional standard
2. Laparoscopic - now preferred where expertise available

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Laparoscopic vs. Open Repair - KEY EXAM EVIDENCE

• Systematic review + meta-analysis + trial sequential analysis of 9 RCTs, 670 patients
• Laparoscopic repair vs. open repair
• Results:
  • Mortality: RR 0.37 (p=0.03) - significantly lower with laparoscopic
  • Total complications: RR 0.57 (p=0.0009) - significantly lower
  • Ileus: RR 0.43 (p=0.04) - lower
  • Wound complications: RR 0.36 (p<0.0001) - lower
  • Length of stay: MD -2.37 days (p=0.0003) - shorter
  • No significant difference in: leak rate, abdominal collection, sepsis, respiratory complications, reoperation, operating time
• Conclusion: "Laparoscopic approach should be the management of choice subject to laparoscopic expertise."

• SR & MA, 29 studies, 5,311 patients (LOPR vs. OOPR)
• LOPR associated with: lower 30-day mortality (OR 0.57), lower overall morbidity (OR 0.31), lower SSI (OR 0.27), shorter LOS (MD -2.84 days)
• Postoperative leakage was comparable (OR 1.06, p=0.90)
• Note: LOPR performed mainly by consultants vs. trainees for open → selection bias acknowledged

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Operative Technique

• Omental patch repair (Graham patch) - most commonly performed
  • Close ulcer with 2-3 interrupted absorbable sutures (transversely, as in pyloroplasty)
  • Do NOT tie so tight that sutures cut through; ensure adequate tissue in each bite
  • Place pedicled omental patch over closure; tie sutures gently (preserve omental blood supply)
  • If primary closure difficult: omental patch alone (plug technique)
• Definitive surgery (now rarely done):
  • Patch + Highly Selective Vagotomy (HSV) - in stable patient with chronic symptoms or failed medical therapy
  • Patch + Truncal Vagotomy + Drainage (V+D)
  • Patch + Truncal Vagotomy + Antrectomy (V+A) - lowest recurrence but highest morbidity

• Biopsy MANDATORY (exclude malignancy) even if perforation repaired
• Type I (most common): Distal gastrectomy in stable low-risk patient; patch + biopsy in high risk
• Type II/III: Patch + Vagotomy + Drainage or distal gastrectomy + vagotomy
• Type IV (near GEJ): Excision with Roux-en-Y reconstruction
• Type V (NSAID): Patch + biopsy; stop NSAIDs
• Massive perforation (GU or DU): Roux-en-Y distal gastrectomy

• Haemodynamic instability + exudative peritonitis (>24h) → simple patch closure only
• Stable patient, chronic symptoms, failed medical therapy → patch + HSV
• V+D acceptable definitive procedure but disability possible

• Stable, low risk → distal gastrectomy (operation of choice; removes ulcer for histology)
• Unstable/high risk → patch + biopsy, or local excision + closure, or biopsy + closure + TV+D

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Post-operative Care

• NGT on suction until bowel function returns
• PPI IV → oral (promotes healing)
• H. pylori testing and mandatory eradication therapy (triple/quadruple regimen)
• Stop NSAIDs permanently; if unavoidable, add long-term PPI
• Lifelong PPIs are a reasonable option after perforation
• Water-soluble contrast swallow on Day 5-7 to check for leak before feeding

• SR & MA of 6 RCTs, 356 patients
• Fast-track recovery after PPU surgery significantly:
  • Shortened LOS (MD -3.50 days, p≤0.00001)
  • Reduced superficial + deep SSIs (p=0.002)
  • Fewer pulmonary complications (p=0.004)
• No increase in overall complications
• Conclusion: Fast-track protocols should be adopted post-PPU surgery

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Laparoscopic Barbed Sutures (Emerging Evidence)

• Meta-analysis of 5 studies, 436 patients
• Barbed sutures vs. conventional sutures in laparoscopic repair
• Barbed sutures: significantly reduced operative time (SMD -0.89, p<0.001) and suturing time (SMD -1.31, p<0.001)
• No difference in postoperative complications (leakage, obstruction, abscess)
• Conclusion: Barbed sutures simplify laparoscopic repair without compromising safety

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Complications of PPU/Peritonitis

• Persistent leak / suture line dehiscence
• Subphrenic/subhepatic abscess
• Enterocutaneous fistula
• Wound infection
• Pulmonary complications (atelectasis, pneumonia, ARDS)
• Septic shock / MODS

• Recurrent ulceration
• Gastric outlet obstruction (from scarring)
• Adhesions / adhesive intestinal obstruction
• Dumping syndrome (post-gastrectomy)
• Nutritional deficiencies (post-gastrectomy)

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Outcomes / Mortality Predictors

1. Presentation > 24 hours (4× higher complication odds)
2. Shock on admission (SBP < 100 mmHg)
3. Advanced age
4. Significant co-morbidities (ASA III-IV)
5. Large perforation size
6. Faeculent peritonitis

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Quick Summary for MS Exam "Must Know" Points

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Recent Evidence Table (Exam Ready)

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