EM · Perforated viscus
Perforated viscus
Also known as Perforated viscus · Perforated peptic ulcer · Perforated appendix · Perforated diverticulum · Pneumoperitoneum · Generalised peritonitis
Perforated viscus — the full-thickness breach of a hollow abdominal organ releasing gas and contents into the peritoneal cavity, the perforated peptic ulcer (the sudden severe epigastric pain, the rigid abdomen, the free gas under the diaphragm on the erect CXR), the perforated appendix (the localised right lower quadrant peritonitis), the perforated diverticulum (the Hartmann procedure), the perforated colon (the colorectal cancer, the colitis). The management is the NBM, the NG tube, the IV fluid resuscitation, the broad-spectrum antibiotics (the piperacillin-tazobactam 4.5 g IV or the ceftriaxone 2 g IV plus the metronidazole 500 mg IV), the morphine 5 mg IV, the urgent surgical referral and the laparotomy for the generalised peritonitis. The erect CXR (the free gas under the diaphragm, the sensitivity about 85 per cent), the CT (the definitive test — the free gas, the free fluid, the site of the perforation). The differential — the acute pancreatitis, the mesenteric ischaemia, the ruptured AAA, the inferior MI. ACEM-primary, globally tagged.
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Red flags
- Sudden severe abdominal pain with a rigid, board-like abdomen and free gas under the diaphragm is a perforated viscus until proven otherwise — resuscitate, give antibiotics and refer urgently to surgery
- A normal erect chest X-ray does NOT exclude a perforation — sensitivity is about 85 per cent on the erect film and lower when supine; if the clinical picture fits, go to CT
- The perforated peptic ulcer seals spontaneously in some patients yet still leaks — a contained perforation can deteriorate to generalised peritonitis within hours; reassess repeatedly
- Purulent or faecal peritonitis (Hinchey III to IV) carries a mortality reaching 25 per cent — these patients need the theatre now, not a long ED workup
- The elderly, the diabetic and the immunosuppressed perforate with muted pain, no rigidity and a near-normal abdomen — the perforation is found on the CT, not the examination
Meet the patient
A 64-year-old man on ibuprofen for osteoarthritis sits bolt upright on the trolley, afraid to move, breathing in shallow sips. Four hours ago, in the small hours, an agony burst through his epigastrium "like a hot knife" — he can time it to the minute. His abdomen is rigid and board-like, the bowel sounds are absent, and the loss of hepatic dullness tells you gas has replaced the liver’s dull note. The registrar is already on the phone to surgery while the cannulae go in.[1]
The two questions that govern the first hour are the two the Fellowship candidate must hold: is there a perforation, and is the patient septic or shocked? (the imaging confirms the first, the lactate and the physiology answer the second) and what resuscitation, antibiotics, and operation does the site demand? (peptic ulcer, appendix, diverticulum, or colon). Resuscitation and antibiotics run in parallel with the imaging — never in sequence before it.[1][2]
References5ShowHide
- [1]Tarasconi A, Coccolini F, Biffl WL, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg, 2020.PMID 31921329
- [2]Sermonesi G, Tian BWCA, Vallicelli C, et al. Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma. World J Emerg Surg, 2023.PMID 38066631
- [3]Pinto A, Miele V, Schillirò ML, et al. Spectrum of Signs of Pneumoperitoneum. Semin Ultrasound CT MR, 2016.PMID 26827732
- [4]Chiu YH, Chen JD, Tiu CM, et al. Reappraisal of radiographic signs of pneumoperitoneum at emergency department. Am J Emerg Med, 2009.PMID 19328377
- [5]Pavlidis ET, Pavlidis TE. Current Aspects on the Management of Perforated Acute Diverticulitis: A Narrative Review. Cureus, 2022.PMID 36176861