Perforation

Free perforation is an indication for immediate surgical intervention. Patients with perforation will often present with peritoneal signs secondary to leakage of enteric contents into the peritoneal cavity with resulting inflammation and abscesses. The most common reasons for perforation are peptic ulcer disease or diverticulitis. The history should be focused to help differentiate these. A change in bowel habits and frequent constipation can suggest a colonic source. Nonsteroidal drug use and tobacco abuse are associated with peptic ulcers. Perforation from either source can be contained or freed within the peritoneal cavity. Contained perforation may become walled off and develop into an abscess. These are often diagnosed by CT scans. Well-defined abscesses can be percutaneously drained with an interval resection of the perforated portion of bowel if indicated when the inflammation has resolved. This choice should be accompanied with antibiotics and careful follow-up to ensure that drainage is successful in controlling the infection and the patient remains hemodynamically stable. Generalized peritonitis with hemody-namic instability and free air on radiographs are indications for urgent surgical intervention following initial resuscitation.

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