Overview
Perforated Viscus
Topic Overview
Summary
Perforated viscus is a surgical emergency where a hole develops in a hollow abdominal organ, allowing contents to leak into the peritoneal cavity, causing peritonitis. Common causes include perforated peptic ulcer, perforated diverticular disease, perforated appendix, and bowel obstruction. Classic presentation is sudden severe abdominal pain with peritonism. Erect CXR or CT shows free intra-abdominal air. Treatment is urgent resuscitation, IV antibiotics, and emergency surgery.
Key Facts
- Classic presentation: Sudden severe abdominal pain → peritonism → sepsis
- Examination: Board-like rigidity, guarding, absent bowel sounds
- Imaging: Erect CXR (free air under diaphragm); CT is gold standard
- Treatment: Resuscitation + IV antibiotics + emergency surgery
- Mortality: High if delayed — time to surgery is critical
Clinical Pearls
"Free air under the diaphragm = perforated viscus until proven otherwise"
Elderly and immunosuppressed patients may have minimal signs despite severe pathology
Perforated peptic ulcer classically presents with sudden "thunderclap" abdominal pain
Why This Matters Clinically
Perforated viscus is a life-threatening emergency. Delayed surgery leads to sepsis and death. Rapid recognition, resuscitation, and surgical referral are life-saving.
Visual Summary
Visual assets to be added:
- Erect CXR showing free air under diaphragm
- CT showing pneumoperitoneum
- Causes of perforation diagram
- Perforated viscus management algorithm
Epidemiology
Incidence
- Perforated peptic ulcer: 2-10 per 100,000/year
- Perforated diverticular disease: Common in elderly
- Perforated appendix: 15-30% of appendicitis cases
Demographics
- All ages
- Peptic ulcer: middle-aged, male predominance
- Diverticular disease: Elderly
- Appendicitis: Young adults
Causes
| Cause | Notes |
|---|---|
| Peptic ulcer | Duodenal or gastric; NSAID, H. pylori related |
| Diverticular disease | Sigmoid most common; elderly |
| Appendicitis | Delayed presentation → perforation |
| Bowel obstruction | Closed-loop obstruction → ischaemia → perforation |
| Malignancy | Colorectal cancer perforation |
| Trauma | Penetrating or blunt |
| Iatrogenic | Endoscopy, colonoscopy |
| Inflammatory bowel disease | Toxic megacolon |
Pathophysiology
Mechanism
- Perforation of hollow viscus (stomach, duodenum, small bowel, colon)
- GI contents (gastric acid, bile, faeces, bacteria) leak into peritoneum
- Chemical peritonitis (early — gastric acid) → bacterial peritonitis
- Systemic inflammatory response → sepsis → multi-organ failure
Why Site Matters
| Site | Contents | Effect |
|---|---|---|
| Upper GI | Gastric acid, bile | Chemical peritonitis (initially sterile) |
| Small bowel | Bile, bacteria | Intermediate |
| Colon | Faeces, bacteria | Faecal peritonitis (most severe) |
Time Course
- Early: Localised peritonitis
- Late: Generalised peritonitis → septic shock
Clinical Presentation
Symptoms
Signs
Classic Presentations
| Cause | Presentation |
|---|---|
| Perforated DU | Sudden epigastric pain → generalised; "thunderclap" onset |
| Perforated appendix | RIF pain → generalised; signs of appendicitis |
| Perforated diverticular | LIF pain → generalised; elderly |
| Perforated colon cancer | Obstructive symptoms → sudden deterioration |
Red Flags
| Finding | Significance |
|---|---|
| Board-like rigidity | Peritonitis |
| Septic shock | Urgent surgery |
| Free air on imaging | Confirms perforation |
| Silent abdomen | Ileus from peritonitis |
Sudden severe abdominal pain — often described as "worst ever"
Common presentation.
Initially localised, then generalised
Common presentation.
Nausea, vomiting
Common presentation.
Anorexia
Common presentation.
Fever (may be absent early)
Common presentation.
Clinical Examination
General
- Shocked, unwell appearance
- Tachycardia, tachypnoea
- Fever or hypothermia
- Lying still (movement worsens pain)
Abdominal
- Guarding — voluntary initially, then involuntary
- Rigidity — "board-like"
- Tenderness — generalised
- Rebound tenderness
- Absent bowel sounds
- Percussion tenderness
Rectal/Vaginal
- May reveal pelvic pathology
Investigations
Blood Tests
| Test | Finding |
|---|---|
| FBC | Raised WCC; may have anaemia |
| CRP | Elevated |
| U&E | AKI (dehydration, sepsis) |
| Lactate | Elevated (sepsis, ischaemia) |
| LFTs, amylase | Exclude pancreatitis |
| Group & Save | Pre-operative |
Imaging
| Modality | Findings |
|---|---|
| Erect CXR | Free air under diaphragm (sensitivity ~80%) |
| CT abdomen/pelvis | Gold standard; shows free air, free fluid, site of perforation |
Other
- ABG (metabolic acidosis, lactate)
- Blood cultures (if septic)
Classification & Staging
By Location
| Location | Common Causes |
|---|---|
| Oesophageal | Boerhaave syndrome, iatrogenic |
| Gastric/duodenal | Peptic ulcer |
| Small bowel | Obstruction, Crohn's, trauma |
| Colonic | Diverticular, cancer, obstruction |
By Severity
- Localised perforation (contained)
- Free perforation (generalised peritonitis)
- Perforation with septic shock
Management
Immediate Resuscitation
| Action | Details |
|---|---|
| IV access | Large bore; bloods including G&S |
| IV fluids | Aggressive resuscitation |
| Analgesia | IV opioids |
| NBM | Nil by mouth |
| NG tube | Decompress stomach |
| Urinary catheter | Monitor output |
| IV antibiotics | Broad-spectrum (e.g., co-amoxiclav + metronidazole; or piperacillin-tazobactam) |
Surgical Management — Emergency
| Procedure | Indication |
|---|---|
| Laparotomy | Standard approach |
| Laparoscopy | Selected cases (stable, localised) |
| Repair | Primary closure ± omental patch (peptic ulcer) |
| Resection | If tissue non-viable or malignancy |
| Washout | Peritoneal lavage |
| Stoma | May be needed (Hartmann's for diverticular) |
Post-Operative Care
- ICU if severe sepsis
- IV antibiotics (typically 5-7 days)
- NG drainage until bowel function returns
- VTE prophylaxis
- Nutritional support
Conservative Management (Rare)
- Only if contained perforation, stable patient, no generalised peritonitis
- Close monitoring and IV antibiotics
Complications
Pre-Operative
- Septic shock
- Multi-organ failure
- Death
Post-Operative
- Wound infection
- Intra-abdominal abscess
- Anastomotic leak
- Ileus
- Respiratory complications
- VTE
Prognosis & Outcomes
Mortality
- Perforated peptic ulcer: 5-30% (age and delay dependent)
- Perforated colon: 10-40% (faecal peritonitis)
- Higher in elderly and comorbid patients
Factors Affecting Outcome
- Time to surgery (delay = worse outcome)
- Site of perforation (colonic worse)
- Degree of contamination
- Patient age and comorbidities
Evidence & Guidelines
Key Guidelines
- NICE NG37: Gallstone Disease (principles apply)
- World Society of Emergency Surgery (WSES) Guidelines
Key Evidence
- Early surgery improves outcomes
- Damage control surgery in unstable patients
Patient & Family Information
What is a Perforated Viscus?
A perforated viscus is a hole in an organ in the abdomen (like the stomach or bowel). This allows contents to leak into the abdomen, causing a serious infection called peritonitis.
Symptoms
- Sudden severe abdominal pain
- Feeling very unwell
- Fever
Treatment
- Emergency surgery to repair the hole and clean the abdomen
- Antibiotics to treat infection
What Happens Next?
- Recovery in hospital, sometimes in intensive care
- Most people recover fully with prompt treatment
Resources
References
Primary Guidelines
- Sartelli M, et al. WSES guidelines for the management of intra-abdominal infections. World J Emerg Surg. 2017;12:22. PMID: 28529534
Key Studies
- Søreide K, et al. Emergency surgery for perforated peptic ulcer: outcome and risk factors. Langenbecks Arch Surg. 2007;392(4):445-451. PMID: 17453236
- Møller MH, et al. Perforated peptic ulcer: mortality and predictors of mortality. Ann Surg. 2015;261(6):1146-1152. PMID: 24441816