Table 12 Clinical pathway for patients with small bowel perforation is illustrated

Clinical signs and symptoms

• Severe, sudden-onset periumbilical pain, which can become generalized

• Abdominal tenderness

• Fever

Laboratory markers

• Increased white blood cell

• Leucocyte shift to left (> 75%)

• C-reactive protein

Imaging

• US

• CT

• Angiography (if there is suspicion of acute mesenteric ischemia)

Diagnosis

• Open or laparoscopic small bowel segmental resection and primary anastomosis.

• In the setting of perforation due to small bowel ischemia, resection and delayed anastomoses at a second look are usually needed. Also, open or endovascular mesenteric vessel reconstruction may be needed.

• Open or laparoscopic resection and stoma creation or exteriorization of the perforation as a stoma (critically ill patients or severe inflammation and edema of the bowel, resulting in friable tissue which precludes anastomosis).

• In the setting of typhoidal perforation, although closure in two layers of single perforation with relatively healthy tissue after refreshment of the edge seems an acceptable option, resection of the unhealthy tissue segment with primary anastomosis of healthy edges about 10 cm on each side of the perforation is recommended.

+

Antibiotic therapy for 4 days (immunocompetent and stable patients) (more days if there are signs of ongoing infection).

In patients with sepsis-induced tissue hypoperfusion or septic shock prompt administration of 30 mL/kg intravenous crystalloid fluid. If blood pressure is not restored after initial fluid resuscitation vasopressors should be commenced.

Treatment

Amoxicillin/clavulanate 2.2 g every 8 h +/− gentamicin 5–7 mg/Kg every 24 h

Avoid Amoxicillin/clavulanate if local Enterobacteriaceae resistances > 20%.

Piperacillin/tazobactam 6 g/0.75 g LD then 4 g/0.5 g every 6 h or 16 g/2 g by continuous infusion +/− Gentamicin 5–7 mg/Kg every 24 h (in critically ill patients)

Ceftriaxone 2 g every 24 h + metronidazole 500 mg every 8 h

Cefotaxime 2 g every 8 h + metronidazole 500 mg every 8 h

or

In patients with beta-lactam allergy

A fluoroquinolone-based regimen

Ciprofloxacin 400 mg every 8/12 h + metronidazole 500 mg every 8 h

Or

or

An aminoglycoside-based regimen

Amikacin 15-20 mg/kg every 24 h + metronidazole 500 mg every 8 h

or

In patients at high risk for infection with community-acquired ESBL-producing Enterobacteriaceae

One of the following antibiotics

Tigecycline 100 mg LD, then 50 mg every 12 h (carbapenem-sparing strategy)

Ertapenem 1 g every 24 h

Meropenem 1 g every 8 h (only in patients with septic shock)

Doripenem 500 mg every 8 h (only in patients with septic shock)

Imipenem/cilastatin 500 mg every 6 h (only in patients with septic shock)

In patients at high risk for infection from Enterococci including immunocompromised patients or patients with recent antibiotic exposure, consider the use of ampicillin 2 g every 6 h if patients are not being treated with piperacillin/tazobactam or imipenem/cilastatin (active against ampicillin-susceptible enterococci) or tigecycline.

Antibiotic therapy