Small Bowel Perforations

Abstract

Small bowel perforation is a common cause of secondary peritonitis in the developing countries and seen less often in the West. Typhoid fever is the commonest cause of small bowel perforation followed by tuberculosis in third world countries, whereas in the developed countries, it is mostly due to mesenteric ischemia, trauma, or Crohn’s disease. Other causes include primary and metastatic tumors, worms, diverticular disease, foreign bodies, drugs, and iatrogenic perforations. Unsafe abortion is a major and significant iatrogenic cause of small bowel perforation bearing high mortality in developing countries, and its incidence is increasing. However, most cases go unreported due to its medicolegal implications. Several new causes of small bowel perforations are added to the list in recent years such as enteroscopy, laparoscopy, and drug-induced perforations due to newer anticancer drugs.

The diagnosis of small bowel perforation is usually based on clinical presentation and radiological imaging. The cornerstones of effective treatment are early diagnosis, prompt resuscitation, adequate source control, treatment of underlying pathology, and appropriate antimicrobial therapy. The surgical treatment of perforation ranges from primary closure, resection-anastomosis to bowel exteriorization depending upon condition of the patient and operative findings. In cases presenting with severe peritonitis and multi-organ failure, repeated peritoneal lavage is indicated, and there is high risk of abdominal compartment syndrome. These cases are best managed with laparostomy, and re-laparotomy is performed whenever indicated.

This chapter reviews the various etiologies of small bowel perforation and their management.