Intestinal Perforation

Question 1

Diagnosis of intestinal perforation

Answer 1

• A plain film erect chest radiograph (eCXR) can show free air under the diaphragm. Pneumomediastinum or widened mediastinum may also be present if the perforation is thoracic in origin.
• The gold standard for diagnosis of any perforation is with a CT scan, confirming any free air presence and suggesting a location of the perforation (as well as a possible underlying cause).
• Rigler’s sign – both sides of the bowel wall can be seen, due to free intra-abdominal air acting as an additional contrast
• Psoas sign – loss of the sharp delineation of the psoas muscle border, secondary to fluid in the retroperitoneum

Question 2

Management of intestinal perforation

Answer 2

• Broad spectrum antibiotics should be started early, especially in patients deemed to need surgery for contamination. Patients should be placed NBM and an NG tube considered. Provide adequate IV fluid support and appropriate analgesia.
• Surgical Intervention
  
  • Identification and (where possible) management of underlying cause
  • Appropriate management of perforation, such as:
    
    • Repairing perforated peptic ulcer with an omental patch
    • Resecting a perforated diverticulae
    • Thorough washout
• Conservative Management
  
  • Select physiologically well patients may be managed conservatively, including patients with:
    
    • Localised diverticular abscess / perforation* with only localised peritonitis and tenderness, and no evidence of generalised contamination on CT imaging
    • Patients with a sealed upper GI perforation on CT imaging without generalised peritonism
    • Elderly frail patients with extensive co-morbidities who would be very unlikely to survive surgery