Chapter 37: Intestinal Perforation

SCOPE

DISEASE/CONDITION(S)

Management of intestinal and gastric perforations.

GUIDELINE OBJECTIVE(S)

Review spontaneous intestinal and gastric perforations; recommendations for initial management, surgical involvement, and postoperative care.

DISEASE/CONDITION(S)

Spontaneous intestinal perforation

GUIDELINE OBJECTIVE(S)

Review and identify recommendations for the medical management of spontaneous intestinal perforations.

BRIEF BACKGROUND

Spontaneous Intestinal Perforation

Spontaneous intestinal perforation (SIP), also known as isolated or focal intestinal perforation, commonly presents in very low birth weight (VLBW) infants. It is characterized as isolated bowel perforation, particularly in the distal small intestines, without clinical or radiographic evidence of necrotizing enterocolitis (NEC). Presentation is typically within the first week of life and does not have a close association with enteral feedings. An association has been found between SIP and exposure to indomethacin and corticosteroids. Typically, infants with SIP lack evidence of significant intestinal or systemic inflammation. A common radiographic finding is pneumoperitoneum without pneumatosis intestinalis. Though differences exist between SIP and NEC, it can be difficult to distinguish the two entities prior to laparotomy.

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

1. An increased risk of developing SIP has been associated with administration of both a nonsteroidal anti-inflammatory agent and corticosteroids. As such, concomitant administration of these medications should be avoided if possible, particularly in VLBW infants.

2. As soon as a diagnosis of SIP is suspected, initial medical management should include bowel rest, abdominal decompression with a gastric tube, blood culture, administration of broad-spectrum antibiotics, and initiation of intravenous fluids.

3. Surgical consultation should be obtained for all infants with suspected SIP.

4. Preoperatively, it can be difficult to distinguish NEC from SIP, particularly when the only radiographic finding is pneumoperitoneum. As such, the initial management of SIP is similar to NEC and requires urgent surgical evaluation.

5. A commonly used broad-spectrum antibiotic regimen is ampicillin and gentamicin, however other antimicrobial agents such as piperacillin with tazobactam, cephalosporins, or other aminoglycosides may be used depending on local resistance patterns, renal function, or allergies. A Cochrane review demonstrated insufficient evidence from two randomized controlled trials to recommend a particular antibiotic regimen. If known, local antimicrobial resistance patterns should be taken into consideration when initiating treatment. Duration of antibiotic treatment has not been well studied, but typical practices are 7–14 days of treatment.

PRACTICE OPTIONS

Practice Option #1: Initial Management

1. Initiate bowel rest (cessation of feedings and enteral medications), abdominal decompression with gastric tube on suction, broad-spectrum antibiotics, and intravenous fluids.

2. Consult general surgery.

3. The following laboratory studies should be obtained: CBC, blood culture, electrolytes, and blood gas.

4. Initiate antibiotic regimen, commonly ampicillin and gentamicin, though other regimens may be considered based on local resistance ...