Perforated viscus and peritonitis
Sudden pain and a rigid belly. Resuscitate, give antibiotics, image if stable, and get to theatre. Typhoid perforation is still common in Pakistan.
A 45-year-old man has sudden, severe upper abdominal pain that started 3 hours ago and is now everywhere. He lies very still. He takes diclofenac for back pain. Board-like rigid abdomen, pulse 116, BP 104/68, temperature 37.6 °C. Erect chest X-ray: air under the right hemidiaphragm.
What do you do in the next 30 minutes, and does a normal X-ray rule this out?
- Peritonitis with shockResuscitate, surgeons now.
- Nil by mouth, 2 large cannulasBloods: FBC, U&E, LFT, amylase or lipase, CRP, lactate, clotting, group and save, cultures.
- Erect chest X-rayFree air under the diaphragm. Sit upright 10 minutes first.
- CT abdomenIf the X-ray is normal but suspicion remains, or the cause is unclear.
- IV fluids, analgesia, antiemeticMorphine titrated.
- Broad-spectrum antibioticsWithin 1 hour if septic.
- NG tube and catheterDecompress, monitor urine output. IV PPI if peptic.
- Generalised peritonitis
- Shock or lactate above 2
- Free air on imaging
- Elderly or steroid users with abdominal pain (signs masked)
- Increasing pain after endoscopy or surgery
- Perforation in the elderly or on steroids (few signs)
- Pancreatitis mimic
- Inferior MI
- Ruptured AAA
- Mesenteric ischaemia
- Boerhaave's (oesophageal rupture)
| Erect chest X-ray | Sit upright 10–15 minutes first, misses about 1 in 4 to 1 in 3 perforations |
| CT | Most sensitive for free air and the source |
| Antibiotics | Within 1 hour in sepsis |
| Urine output | 0.5 mL/kg/hour or more |
| Omeprazole | 40 mg IV (suspected peptic perforation) |
| Risk scoring | Older, shock, delay and comorbidity worsen outcome |
Check every dose against a current drug reference and your hospital protocol.
On this page
Causes
| Site | Common causes |
|---|---|
| Stomach and duodenum | Peptic ulcer (NSAIDs, H. pylori, smoking, steroids) |
| Small bowel | Typhoid (terminal ileum), trauma, Crohn's, foreign body |
| Appendix | Delayed appendicitis |
| Colon | Diverticulitis, cancer, obstruction (caecum), colitis, endoscopy |
| Oesophagus | Boerhaave's after vomiting, endoscopy |
Pakistan: typhoid ileal perforation is an important cause, usually in the second or third week of fever.
Clinical picture
- Sudden severe pain, often starting in one place then spreading.
- Lying still (movement worsens peritonitis).
- Board-like rigidity, guarding, rebound tenderness, absent bowel sounds.
- Shock develops with time.
- Elderly, steroids, immunosuppressed, diabetics: few signs. Have a low threshold for CT.
Diagnosis
Surgeons now
CT abdomen and pelvis
Plan surgery or, in selected cases, non-operative care
Management
- ResuscitateOxygen, 2 large cannulas, Ringer's lactate, bloods, lactate.
- AntibioticsBroad-spectrum IV within 1 hour.
- AnalgesiaIV morphine titrated. Pain relief doesn't mask signs.
- DecompressNG tube, catheter, nil by mouth.
- IV PPIIf peptic.
- SurgeonsLaparotomy or laparoscopy for most. Non-operative only in selected stable patients with sealed perforation.
Differential diagnosis
| Condition | Clues |
|---|---|
| Acute pancreatitis | Epigastric pain to the back, high lipase or amylase (can rise a little in perforation) |
| Inferior MI | ECG changes, troponin |
| Ruptured AAA | Older, back pain, pulsatile mass, shock |
| Mesenteric ischaemia | AF, pain out of proportion, high lactate |
| Biliary colic or cholecystitis | Right upper quadrant, ultrasound |
| Lower lobe pneumonia | Cough, chest signs |
Investigations
| Test | Why |
|---|---|
| Erect chest X-ray | Free air |
| CT abdomen and pelvis | Free air, source, collection |
| Lactate, gas | Perfusion |
| Amylase or lipase | Pancreatitis |
| ECG and troponin | MI mimic |
| Blood cultures | Sepsis, typhoid (Widal is unreliable) |
Treatment
See sepsis and peptic ulcer and GI bleed.
After surgery
- H. pylori testing and eradication.
- Stop NSAIDs.
- Endoscopy at 6–8 weeks for gastric ulcers to exclude cancer.
Common mistakes
- Ruling out perforation with a normal chest X-ray.
- Withholding analgesia "until the surgeon sees".
- Missing perforation in steroid users or the elderly.
- Delaying antibiotics.
- Missing typhoid perforation in a feverish young patient.
- Forgetting an ECG.
Frequently asked questions
What is the first imaging test for suspected perforation?
An erect chest X-ray, taken after sitting upright for 10–15 minutes. CT is more sensitive if the X-ray is normal.
Does a normal chest X-ray rule out perforation?
No. CT is needed if suspicion remains.
What is the most common cause of a perforated viscus?
Peptic ulcer, often linked to NSAIDs, H. pylori and smoking.
Should analgesia be withheld until the surgeon examines the patient?
No. Analgesia does not hide the diagnosis and should be given.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A man on daily diclofenac has sudden severe epigastric pain and a rigid abdomen. What is the most likely diagnosis?
Answer: Perforated peptic ulcer. NSAIDs cause peptic ulcers that can perforate, causing sudden pain and generalised peritonitis.
- Biliary colic: No rigid abdomen.
- Acute pancreatitis: Possible but less likely with NSAID use and board-like rigidity.
- Renal colic: No peritonism.
- Gastritis: No peritonism.
2. A patient with typhoid fever in the third week develops sudden abdominal pain and peritonism. Which antibiotic is appropriate where XDR typhoid is common?
Answer: Meropenem. Typhoid perforation needs surgery and antibiotics active against XDR typhoid, such as meropenem.
- Co-trimoxazole: Resistant.
- Ceftriaxone alone: XDR strains are resistant.
- Oral amoxicillin: Inadequate.
- Ciprofloxacin: XDR strains are resistant.
3. An elderly patient on long-term steroids has abdominal pain but a soft abdomen and raised lactate. What is the best next step?
Answer: CT abdomen. Steroids and old age can mask peritonism. CT is the most sensitive test for perforation.
- Stool test: Not helpful.
- Repeat examination next week: Delay.
- Endoscopy first: Contraindicated if perforation.
- Discharge with antacids: Steroids blunt peritoneal signs.
4. A 20-year-old was slapped on the ear 2 days ago and has a small clean slit-like perforation of the drum with mild conductive loss; no discharge or vertigo. What is the management?
Answer: Keep ear dry; most heal spontaneously. Traumatic perforation (slap, blast, cotton bud, barotrauma): most small perforations heal spontaneously within 6–8 weeks; keep ear dry, avoid drops/syringing, analgesia; antibiotics only if infection. Review hearing; refer if no healing (myringoplasty), or urgently if vertigo, SNHL, facial palsy (ossicular/inner ear injury). Document carefully in assault cases (medicolegal).
- Immediate myringoplasty: Most traumatic perforations heal without surgery.
- Antibiotic ear drops containing aminoglycoside: Drops are not needed, and aminoglycosides are ototoxic.
- Syringe the ear: Syringing is contraindicated.
5. A 16-year-old in Sindh with 3 weeks of fever develops generalised peritonitis and free gas under the diaphragm. Blood culture grew XDR Salmonella Typhi. After resuscitation, what is the definitive management?
Answer: Laparotomy + meropenem. Typhoid ileal perforation (3rd week, Peyer’s patches of terminal ileum) is managed with fluid resuscitation, broad IV antibiotics covering the resistant organism (meropenem for XDR typhoid, plus anaerobic cover) and early laparotomy — primary closure of the perforation after freshening the edges, or segmental resection/ileostomy if multiple perforations or severe contamination. Delay increases mortality markedly. Wound infection rates are high.
- Conservative care, oral azithromycin: A perforation needs surgery.
- Laparoscopic cholecystectomy: This is the wrong organ; the ileum is perforated.
- Percutaneous drain only: A drain alone is inadequate for a free perforation.
6. From which spinal roots does the phrenic nerve arise?
Answer: C3, C4 and C5. The phrenic nerve (mainly C4) supplies motor fibres to the diaphragm and sensory fibres to the central diaphragm, pericardium and mediastinal pleura. Irritation of the diaphragm (blood, pus) refers pain to the shoulder tip (C4 dermatome). It descends on scalenus anterior.
- C1, C2 and C3: Cervical plexus branches, not phrenic.
- C5, C6 and C7: Brachial plexus.
- C2, C3 and C4 only: Misses C5.
- T1 and T2: Upper thoracic roots.
7. After a blow to the upper abdomen, a pancreatic injury leaks pancreatic juice. Where does the fluid collect, forming a pseudocyst?
Answer: Lesser sac (omental bursa). The pancreas lies behind the stomach, forming much of the floor of the lesser sac. Fluid from pancreatic injury or pancreatitis collects in the lesser sac. If it persists for more than 4 weeks with a fibrous wall (no epithelial lining), it is a pseudocyst.
- Right paracolic gutter: Fluid may track there later, but the lesser sac is first.
- Pelvis: Not the usual first site.
- Left subphrenic space: Possible later.
- Morison's pouch: The hepatorenal pouch, lowest in the supine position; not the first site here.
References and dose sources
- WSES guidelines for management of intra-abdominal infections (2017)
- NELA
- NICE NG180 — perioperative care in adults
- Ringer's lactate (Hartmann's solution) dosing: Drugs.com: Lactated Ringer's dosage (see also our ringer's lactate (hartmann's solution) dose page)
- Piperacillin-tazobactam dosing: Drugs.com: Piperacillin/tazobactam dosage (see also our piperacillin-tazobactam dose page)
- Ceftriaxone dosing: Drugs.com: Ceftriaxone dosage (see also our ceftriaxone dose page)
- Omeprazole dosing: Drugs.com: Omeprazole dosage (see also our omeprazole dose page)
- Morphine dosing: Drugs.com: Morphine dosage (see also our morphine dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.