Small Bowel Perforations - Standard Treatment Guidelines

Small perforation is breach in seromuscular continuity of small intestine ie from D-J junction to ileocaecal junction. It can be single or multiple and of varying sizes depending on nature and stage of pathology causing it. It may even be associated with gangrenous segment of variable length of small intestine.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Small Bowel Perforations. Following are the major recommendations :

Incidence of the condition in our country

In India, the commonest cause of small bowel perforation is enteric fever and tuberculosis. Rapidly increasing incidence of vehicular trauma contributes to another category of perforation called traumatic perforation. Penetrating injury caused by knife, gunshot etc also adds to the etiology of these perforations. Rarely these perforations can be associated with long standing small intestinal volvulus or near the site of band compressing the gut causing ischemia and perforation. Iatrogenic perforations too can occur during conduct of various other abdominal operations and even gynecological operations.

Differential diagnosis

The common conditions that should be considered in any patient presenting with features of peritonitis (apart from small bowel perforations):-

1. Acute Pancreatitis


2. Duodenal perforation


3. Appendicular perforation with peritonitis


4. Mesenteric vascular ischemia

Prevention and counseling

Timely medical advice and treatment for conditions like enteric fever and tuberculosis. In case of injury whether blunt or penetrating, seek hospitalization without any delay. Using of seat belts during travel (wherever possible) is also a good preventive step

Optimal diagnostic criteria, Investigations, Treatment & Referral Criteria( Situation 1)

Clinical diagnosis

• Small bowel perforation is suspected clinically in any patient presenting with history of fever, trauma, abdominal pain, vomiting, distension of tummy, inability to pass flatus and feces of variable duration depending on type and duration of pathology.


• Clinical examination will reveal features of peritonitis which is mostly generalized but rarely may be localized also. Hippcratic facies will be present. The patient may be in shock ( hypovolemic or septic) or may even be having septicemia at the time of presentation.

Investigations

• Plain X-ray abdomen in erect posture shows gas under one or both domes of diaphragm


• USG evidence of fluid collection showing internal echoes


• Abdominal paracentesis , not routinely but only where X-ray provides some doubt


• Additional serological tests like Widal may be carried out.

Treatment ( Standard operating procedure )

In Patient

• Hospitalization followed by resuscitation followed by investigation followed by optimization for surgery which essentially consists of

1. Laparotomy


2. Closure of perforation/Ileostomy/resection and anastomosis depending on condition of the patient, condition of the bowel, location and multiplicity of pathology.( If single perforation with healthy bowel and condition of the patient is not bad , primary closure; otherwise ileostomy. In the event of multiple perforations with healthy bowel and good condition of the patient , resection and anastomosis ; otherwise ileostomy is advised . Once a while exteriorization may be considered if the condition of bowel and patient demands this procedure )


3. Thorough peritoneal lavage


4. Closure after providing adequate drainage tubes

Postoperative

Care in ward and involves

1. I/V fluids, antibiotics, pain killers and monitoring


2. Oral allowance after bowel movements - Stitch removal at appropriate time

Outpatient : None

Day Care : None

Referral criteria

If any of the facilities, infrastructure or expertise to carry out any of the above step is not available either at diagnostic level or treatment level or at the level of postoperative care, then the case must be referred to higher centre.

Optimal diagnostic criteria, Investigations, Treatment & Referral Criteria (Situation 2)

Clinical diagnosis

• Small bowel perforation is suspected clinically in any patient presenting with history of fever, trauma, abdominal pain, vomiting, distension of tummy, inability to pass flatus and feces of variable duration depending on type and duration of pathology.


• Clinical examination will reveal features of peritonitis which is mostly generalized but rarely may be localized also. Hippcratic facies will be present. The patient may be in shock ( hypovolemic or septic) or may even be having septicemia at the time of presentation.

Investigations

• Plain X-ray abdomen in erect posture shows gas under one or both domes of diaphragm


• USG evidence of fluid collection showing internal echoes


• Abdominal paracentesis , not routinely but only where X-ray provides some doubt


• Additional serological tests like Widal may be carried out.


• CT scan and diagnostic laparoscopy if any equivocality is involved despite already mentioned investigations.

Treatment ( Standard operating procedure )

In Patient

• Hospitalization followed by resuscitation followed by investigation followed by optimization for surgery which essentially consists of

1. Laparotomy


2. Closure of perforation/Ileostomy/resection and anastomosis depending on condition of the patient, condition of the bowel, location and multiplicity of pathology.( If single perforation with healthy bowel and condition of the patient is not bad , primary closure; otherwise ileostomy. In the event of multiple perforations with healthy bowel and good condition of the patient , resection and anastomosis ; otherwise ileostomy is advised . Once a while exteriorization may be considered if the condition of bowel and patient demands this procedure )


3. Thorough peritoneal lavage


4. Closure after providing adequate drainage tubes

Postoperative

Care in ward and involves

1. I/V fluids, antibiotics, pain killers and monitoring


2. Oral allowance after bowel movements - Stitch removal at appropriate time

Laparoscopic procedure in following situations:

1. Facilities and infrastructure available


2. Expertise is available

• Post-operative care of the patient in HDU or ICU if the patient is unstable .

Out patient – None

Day care – None

Referral criteria

If any of the facilities, infrastructure or expertise to carry out any of the above step is not available either at diagnostic level or treatment level or at the level of postoperative care, then the case must be referred to higher centre.

Who does what and Timeliness?

Doctor

The job of diagnosis, treatment including surgery, post-operative care and follow up.

Nurse

Pre-operative care, operative assistance, post-operative care, administration of treatment instructed by the doctor and monitoring as instructed.

Technician

Keeps all machines and equipments in order and assist the anesthetist during operation.

Further reading

1. Bailey & Love’s Short Practice of Surgery


2. Schwartz’s Textbook of Surgery


3. Abdominal Operations by Maingot

Resources required for one patient/procedure

Guidelines by The Ministry of Health and Family Welfare :

Dr Ajit Sinha Department of Surgery Safdarjung Hospital New Delhi