Management of Ischemic Gastritis with Peritonitis due to Perforation

Initial Assessment and Resuscitation

Patients with suspected ischemic gastritis with perforation typically present with severe abdominal pain, tenderness, distension, and signs of septic shock 3
Laboratory evaluation should include at minimum white blood cell count and C-reactive protein to assess inflammatory response 4
CT scan is the preferred imaging modality to confirm diagnosis, as it is more sensitive than standard abdominal radiographs for detecting free air 4
Aggressive resuscitation with intravenous fluids and correction of electrolyte imbalances should be initiated immediately while preparing for surgical intervention 5

For stable patients with perforation less than 1 cm, laparoscopic primary repair with omental patch is recommended as it is associated with decreased operative time, blood loss, and length of hospital stay 1, 2
During exploration, all anastomoses, the stomach, and excluded segments (if applicable in post-bariatric surgery patients) should be thoroughly assessed 2
Biopsies of the perforated ulceration should be obtained to exclude malignancy 2
If the perforation is in the gastric remnant (in post-bariatric surgery patients), options include primary suture with omental patch or stapled resection 1
Consider placement of a gastrostomy tube proximal to the perforation site if significant postoperative ileus is anticipated due to peritonitis 1
For unstable patients with diffuse peritonitis, immediate surgical exploration without delay is mandatory 2
Damage control surgery with abbreviated laparotomy and open abdomen technique is recommended in hemodynamically unstable patients 2
Planned re-laparotomies every 36-48 hours may be necessary until the abdomen is free of ongoing peritonitis 5

Broad-spectrum antibiotics should be initiated immediately, covering gram-negative, gram-positive, and anaerobic organisms 5
Antimicrobial therapy should be adjusted based on culture results and continued until clinical improvement is observed 5

Serial clinical and imaging monitoring (every 3-6 hours) should be performed in the immediate postoperative period 3

In post-bariatric surgery patients, always explore the jejuno-jejunostomy for stenosis or the gastric remnant for gastro-gastric fistula if diffuse peritonitis is due to a perforated excluded gastrointestinal segment 1
Indocyanine green (ICG) fluorescence angiography may be useful in evaluating the extent of bowel ischemia when available 6