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 ETIOLOGY Pathogenesis mechanism blunt abdominal trauma login to view 3 more bullets penetrating trauma login to view 1 more bullet Presentation Symptoms common symptoms location login to view 1 more bullet Physical exam inspection hypotension tachycardia shock bruising motion tenderness to palpation login to view 1 more bullet provocative tests peritoneal signs login to view 2 more bullets Imaging Chest or abdominal radiograph indications all patients findings free air login to view 3 more bullets 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 login to view 1 more bullet broad-spectrum antibiotics indications login to view 1 more bullet Surgical exploratory laparotomy indications login to view 2 more bullets Complications Intra-abdominal abscess Sepsis