Updated: 10/30/2019

Bowel Perforation

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Snapshot
  • A 45-year-old man presents to the emergency department after a fight. He has 2 stab wounds in his abdomen. A FAST exam is negative for intra-abdominal fluid. A chest radiography shows free air under the diaphragm. He is immediately given 2 liters of crystalloid fluid, broad-spectrum antibiotics, and taken to the operating room for surgical exploration.
Introduction
  • Overview
    • bowel perforation often occurs due to penetrating injury from trauma or iatrogenic causes
  • Epidemiology
    • risk factors
      • penetrating trauma > blunt abdominal trauma
      • acute diverticulitis
      • malignancy
      • inflammatory bowel disease
      • ischemic bowel
  • Pathogenesis
    • mechanism
      • blunt abdominal trauma
        • deceleration and acceleration injuries
        • compressive injuries
        • increased luminal pressure
      • penetrating trauma
        • direct tissue disruption
Presentation
  • Symptoms
    • common symptoms
      • location
        • abdominal pain
  • Physical exam
    • inspection
      • hypotension
      • tachycardia
      • shock
      • bruising
    • motion
      • tenderness to palpation
        • rebound tenderness
    • provocative tests
      • peritoneal signs
        • guarding
        • rigidity
Imaging
  • Chest or abdominal radiograph
    • indications
      • all patients
    • findings
      • free air
        • sudden onset pain and free air = bowel perforation which is an emergency
        • a normal finding post-operatively
          • manage expectantly 
  • Abdominal CT
    • indications
      • hemodynamically stable patients
    • findings
      • intraperitoneal fluid
      • bowel wall discontinuity
      • extraluminal air
      • extraluminal contrast
  • Abdominal ultrasound
    • FAST exam
      • focused abdominal sonography for trauma
    • indications
      • at bedside for all trauma patients
    • findings
      • intra-abdominal free fluid
Studies
  • Serum labs
    • leukocytosis
    • anemia
    • lactic acid
      • may indicate ischemic bowel
Differential
  • Splenic laceration
    • key distinguishing factor     
      • splenic bleeding or hematoma on imaging
Treatment
  • Medical
    • resuscitation
      • indications
        • all patients
    • broad-spectrum antibiotics
      • indications
        • all patients
  • Surgical
    • exploratory laparotomy
      • indications
        • hemodynamically unstable patients
        • bowel perforation
Complications
  • Intra-abdominal abscess
  • Sepsis
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.GI.16) A 60-year-old man with a history of chronic back pain presents to the emergency department with abdominal pain. He states his back pain has been worsening recently requiring more pain medications. His temperature is 97.6°F (36.4°C), blood pressure is 122/80 mmHg, pulse is 120/min, respirations are 12/min, and oxygen saturation is 98% on room air. The patient is laying still on his back and is moaning in pain. There is notable tenderness in all quadrants with rebound tenderness. The patient's heart rate is 90/min after receiving hydromorphone. A radiograph is performed as seen in Figure A. Which of the following is the most likely diagnosis? Review Topic

QID: 102645
FIGURES:
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Gastritis

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Peptic ulcer disease

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Perforated viscus

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Pneumothorax

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Ruptured abdominal aortic aneurysm

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(M2.GI.85) A 24-year-old male is brought in by fire rescue after being the restrained driver in a motor vehicle accident. There was a prolonged extraction. At the scene, the patient was GCS 13. The patient was boarded and transported. In the trauma bay, vitals are T 97.2 F, HR 132 bpm, BP 145/90 mmHG, RR 22 rpm, and O2 Sat 100%. ABCs are intact with a GCS of 15, and on secondary survey you note the following (Figure F). FAST exam is positive at Morrison's pouch. Abdominal exam shows exquisite tenderness to palpation with rebound and guarding. Which of the following radiographs is most likely to be present in this patient? Review Topic

QID: 104532
FIGURES:
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Radiograph A

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Radiograph C

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Radiograph D

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Radiograph E

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