Updated: 12/15/2021

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
  • ETIOLOGY
    • 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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(M2.GI.15.85) 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?

QID: 104532
FIGURES:

Radiograph A

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Radiograph B

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Radiograph C

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Radiograph D

40%

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Radiograph E

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M 7 E

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(M3.GI.13.16) 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?

QID: 102645
FIGURES:

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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M 10 E

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