Treatment of Bowel Perforation Peritonitis

Initial Assessment and Diagnosis

Patients with suspected bowel perforation should be evaluated with laboratory tests including white blood cell count and C-reactive protein 3
CT scan is the preferred imaging modality to confirm perforation, as it is more sensitive than standard abdominal radiographs for detecting free air 3, 4
Double contrast enhanced CT scan can help determine if non-operative management is feasible in cases with localized peritoneal signs 5

The World Journal of Emergency Surgery recommends emergency surgery for large perforations or diffuse peritonitis 5, 6
For small bowel perforations, primary repair is recommended for small perforations, while resection with anastomosis is preferred for larger defects 2, 7
For colonic perforations, primary repair or resection depending on size and tissue viability 1, 8
Hartmann's procedure remains useful for diffuse peritonitis in critically ill patients 9, 2

Conservative management may be appropriate in selected cases, including patients with localized pain, free air without diffuse free fluids, hemodynamic stability, and absence of fever 5, 6
The World Journal of Emergency Surgery recommends serial clinical and imaging monitoring, absolute bowel rest, intravenous fluids, and intravenous broad-spectrum antibiotics for conservative treatment 6, 4

Surgical management is recommended for immunocompromised patients regardless of perforation size 6
The World Journal of Emergency Surgery recommends surgical approach over conservative management for transplant patients 6
Decision to pursue surgery should be made as early as possible after diagnosis, as delayed surgical treatment can worsen peritonitis and colonic wall inflammation 6, 4

Continuous and strict clinical and biochemical follow-up is recommended for all patients 6
Clinical improvement should gradually occur within 24 hours if conservative treatment is successful 6
Higher complication rates and longer hospital stays are associated with delayed surgical intervention after failed conservative management 6, 4