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Hollow Viscus Perforation - MD Emergency Medicine

Definition

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Causes / Etiology

Most Common (by frequency)

Risk Factors

• Chronic NSAID/steroid use
• H. pylori infection
• Alcoholism/smoking
• Immunocompromised state
• Advanced age
• Prior abdominal surgery

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Pathophysiology

1. Breach in viscus wall → luminal contents (gastric acid, bile, intestinal flora) spill into peritoneal cavity
2. Chemical peritonitis (early, sterile) → intense inflammatory response within hours
3. Bacterial peritonitis (delayed) → gram-negative organisms + anaerobes; progresses to sepsis
4. Septic shock → multi-organ dysfunction → death if untreated

• Site: Gastric/duodenal perforation causes early chemical peritonitis; colonic perforation is rapidly bacterially contaminated
• Size of perforation
• Time since perforation

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Clinical Features

Symptoms

• Sudden-onset severe abdominal pain - hallmark; may initially localize then become generalized
• Nausea, vomiting
• Abdominal distension
• Fever (may be absent in elderly/immunosuppressed)
• Cessation of bowel sounds (paralytic ileus)
• History of NSAID use, prior ulcer, inflammatory bowel disease

Signs

Elderly patients may not have dramatic pain or impressive peritoneal findings - Tintinalli's Emergency Medicine. Maintain a high index of suspicion.

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Investigations

Immediate / Bedside

• Vitals + monitoring - tachycardia, hypotension indicate septic shock
• FAST ultrasound - free fluid in peritoneum; free air in experienced hands
• Urinary catheter - urine output monitoring

Laboratory

Imaging

1. Erect Chest X-Ray (First-line)

• Free air under the diaphragm (pneumoperitoneum) - most important sign
• Present in ~60-75% of perforated peptic ulcers
• Right subdiaphragmatic crescent of air is classic
• False negative in 25-40% - absence does NOT rule out perforation

2. Erect Abdominal X-Ray / Lateral Decubitus

• Pneumoperitoneum visible between liver and right diaphragm
• Useful when patient cannot stand
• Other features: Rigler's sign (air on both sides of bowel wall), football sign (massive pneumoperitoneum)

3. CT Abdomen + Pelvis (Gold Standard)

• Sensitivity ~98% for pneumoperitoneum - superior to plain films
• Identifies: free air, free fluid, site of perforation, associated pathology
• Guides surgical planning
• Oral contrast adds little to evaluation
• If plain films negative but clinical suspicion persists → CT is mandatory

4. Focused Abdominal Ultrasound

• Bedside tool: detects free fluid (not air well)
• Limited by operator experience and bowel gas
• Useful as adjunct

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Differential Diagnosis

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Emergency Management

Initial Resuscitation (ABCDE Approach)

1. Airway + Breathing - high-flow oxygen; prepare for intubation if GCS impaired
2. Circulation - 2 large-bore IV access (14-16G); aggressive crystalloid resuscitation (NS or Lactated Ringer's); if septic shock: push 30 mL/kg in first hour
3. Nasogastric tube (NGT) - decompress stomach, reduce further contamination; suction
4. Urinary catheter - monitor urine output (target >0.5 mL/kg/hr)
5. Cardiac monitoring + pulse oximetry
6. Nothing by mouth (NPO)
7. Analgesia - IV opioids (morphine/fentanyl); do NOT withhold - does not mask exam findings

Medications

Free air on radiograph + peritonitis + appropriate history = broad-spectrum antibiotics + prompt surgical consultation - Tintinalli's Emergency Medicine.

Surgical Consultation

• Early surgical consultation is mandatory - do not wait for imaging confirmation
• Definitive management is surgical in most cases
• Consult as soon as perforated viscus is suspected

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Definitive Management

Surgical Options (determined by site, severity, patient status)

1. Identification and closure/repair of perforation
2. Thorough peritoneal washout (large volume)
3. Drainage placement
4. Definitive bowel management

Conservative Management

• Only for select patients: small contained perforations, hemodynamically stable, no free peritoneal contamination on CT
• Components: NPO, nasogastric suction, IV antibiotics, close monitoring with serial abdominal exams
• Risk: worsening peritonitis if fails - requires close supervision

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Prognosis & Mortality

• Overall mortality: 30-50% (SAEM data)
• PUD perforation mortality: 10-40% depending on age and timeliness (Tintinalli's)

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Specific Conditions in Brief

Typhoid Perforation

• Complicates 1-3% of typhoid fever (Salmonella typhi)
• Ileal perforation (Peyer's patches) in 2nd-3rd week
• Features: rose spots, step-ladder fever, relative bradycardia, splenomegaly, then peritonitis
• Diagnosis: Widal test, blood culture; X-ray shows pneumoperitoneum
• Management: antibiotics (ciprofloxacin + metronidazole) + surgical repair

Traumatic Hollow Viscus Injury

• Associated with motor vehicle accidents, seat belt injuries, penetrating trauma
• "Seatbelt sign" (abdominal wall bruising) + Chance fracture = high risk for bowel injury
• CT may miss hollow viscus injury - serial abdominal exams mandatory
• Persistent/worsening pain, bilious vomiting, fever = red flags for occult perforation
• Duodenal hematoma classically presents 48-72 hours post-injury (Tintinalli's)

Appendicular Perforation

• Most common in <20 years and elderly
• Walled-off = appendicular mass/abscess; generalized = peritonitis
• Rovsing's sign, Psoas sign, Obturator sign
• CT: periappendiceal fat stranding, abscess, free air

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Pearls for Exam

• Do NOT rely on absence of free air to rule out perforation - 25-40% of perforations have no free air on X-ray; CT is gold standard (98% sensitivity)
• Elderly and immunosuppressed may have subtle presentations - board-like rigidity may be absent
• Start antibiotics before imaging if septic shock is present - every hour of delay increases mortality
• Opioids do NOT mask peritoneal findings - withholding analgesia is unethical and outdated
• Perforated gastric ulcer may present atypically - 25% have no prior ulcer history
• Seat belt sign in trauma = strong predictor of hollow viscus injury; requires serial exams even if CT is negative
• Surgical consultation first - do not delay by waiting for test results in a clearly sick patient

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