Perforated viscus — Hinchey and free gas

Hinchey. Reproduce grades I–IV: I pericolic abscess, II distant pelvic abscess, III generalised purulent peritonitis, IV faecal peritonitis — grades III–IV need resection, typically a Hartmann procedure for faecal peritonitis. The WSES references cover complicated peptic ulcer (prompt recognition, resuscitation, appropriate antibiotics, timely surgical/radiological treatment).^[1][2]

First hour (generalised peritonitis + sepsis).

• ABCDE; large-bore access; crystalloid; cultures; early vasopressors if needed after fluid.
• Immediate broad-spectrum antibiotics — piperacillin-tazobactam 4.5 g IV first line — appropriate antibiotic therapy is a WSES principle.^[1]
• NBM, NG, analgesia, surgical referral for emergency source control.
• CT if stable enough and it will not delay theatre; free gas + shock + generalised peritonitis may go straight to theatre after resus.

Likely operation. For Hinchey III–IV diverticular perforation, Hartmann procedure is the classic exam answer.