**3. Early recognition of perforation by simple bedside examination**

In a patient who has undergone small bowel endoscopy the diagnosis of small bowel perforation should be suspected if the patient has acute pain in the abdomen. The severity of pain will progressively increase. The patient will lie still as any movement will exacerbate the pain. Even the respiration will be shallow for this reason. This differentiates it from other acute pathologies like acute pancreatitis in which the patient is restless and changes posture to find relief. The physical examination will reveal a sick look, tachycardia, and features of dehydration along with the signs of peritonitis. Perforation causes third space loss of body fluid. This along with bacteremia and systemic inflammatory response leads to hypotension and decreased urine output. The abdomen will be very tender and guarding will be present. A board-like rigidity may be felt. Loss of liver dullness on percussion will further confirm the presence of free air in the peritoneal cavity. Bowel sounds will be absent due to paralytic ileus caused by peritonitis. After 4–6 hours of perforation (gastro-duodenal perforation), the peritoneal cavity acid becomes diluted and there is a decrease in pain and guarding. It may seem that the patient is improving but, in reality, is deteriorating [12].

Making the diagnosis of perforation may be difficult in the early period because of subtle signs and symptoms. The classical peritoneal signs may fail to elicit in a morbidly obese patient. Thus a high index of suspicion should be kept in mind for patients complaining of undue pain following endoscopy. Any patient with difficult endoscopy should have close post procedure monitoring for early detection of complications. Tachycardia, dehydration, or decreased urine output should alarm the clinician. Repeated abdominal examination can detect any new abdominal signs. Lessons can be learnt from trauma surgery. In a hemodynamically stable patient with an anterior abdominal stab wound with the peritoneal breach, serial abdominal examination is a standard technique for picking the peritonitis early.

### **4. Role of basic laboratory investigation like TLC and serum lactate in early diagnosis**

Laboratory workup will confirm the diagnosis of small bowel perforation apart from a careful history and physical examination. It is particularly helpful in elderly or seriously ill patients in whom signs and symptoms are less reliable. An elevated (>12,000/ cumm) or decreased white blood cells (< 4000/cumm) confirms inflammation or infection [13]. If TLC is normal, an increase in the number of neutrophils in differential counts or bandemia (> 10% band forms) is indicative of infection. The hemoglobin level will help in deciding the blood transfusion requirement. Serum electrolytes, blood urea nitrogen and, serum creatinine measurements will provide information about the fluid losses associated with third space loss, vomiting, delayed presentation, etc. Lactate level serves as a surrogate marker for tissue perfusion and correlates with anaerobic metabolism. A raised lactate level indicates bowel ischemia, shock, and sepsis. Lactate levels have been more specific than leukocyte count in diagnosing abdominal sepsis [14]. However, lactate levels can also be elevated in hepatic

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**Figure 1.**

*Early Recognition and Management of Small Bowel Perforation*

failure, dehydration, and drug abuse. Metabolic acidosis will be present in sepsis. Coagulation profiles such as platelet count, prothrombin time, international normalized ratio, etc. are important in the preoperative assessment of patients with liver disease or those on anticoagulants. These may also be deranged due to sepsis. Other biochemical markers of inflammation include C-reactive protein and pro-calcitonin which when used in adjunct with complete blood count and other clinical signs help in making the diagnosis, assessing severity and prognosis, and guiding treatment.

**5. Role of X-ray abdomen and CT scan in confirming the diagnosis**

Plain radiography remains the most frequently ordered examination in patients with suspected perforation. Pneumoperitoneum is present in the rupture of any hollow viscous. It may also be observed following recent abdominal surgery, paracentesis, and pneumatosis intestinalis. Benign pneumoperitoneum may rarely develop following endoscopy due to transmural passage of insufflated air without bowel perforation [15]. Plain radiography can detect about 55–85% of patients with pneumoperitoneum [16]. It can detect as little as 1–2 ml of free air [17]. Upright lateral chest radiograph has better sensitivity than upright postero-anterior chest radiograph [18]. Upright positions including left lateral decubitus are uncomfortable in critically ill patients in the emergency setting. In such patients supine decubitus anteroposterior view of the thorax and anteroposterior or lateral view of

Free air can be visualized in different shapes, sizes, and locations in the abdominal cavity. On upright postero-anterior chest or abdominal radiography, free air is visualized as a translucent crescent below the diaphragm (**Figure 1**). These free-air signs can be categorized as bowel-related, right-upper-quadrant, peritoneal ligament- related, or other signs [20]. Rigler sign is the visualization of both sides of the bowel wall in a supine abdominal radiograph (**Figure 2**). The presence of normal gas

*X-ray abdomen showing A-Giant pneumoperitoneum appearing as an air-fluid level in the peritoneal cavity.* 

*B-pneumoperitoneum on the left side may be confused with fundal gas.*

*DOI: http://dx.doi.org/10.5772/intechopen.96435*

the abdomen are generally requested [19].

*Early Recognition and Management of Small Bowel Perforation DOI: http://dx.doi.org/10.5772/intechopen.96435*

*Endoscopy in Small Bowel Diseases*

all indications (1.1 per 1000 procedures) [11].

with inflammatory bowel disease (IBD) as compared to non-IBD patients, with disease severity and steroid use being the two of the strong predictors for perforation [7–10]. In a systematic review, the total rate of perforation with enteroscopy in Crohn's disease was 4.27 per 1000 procedures (diagnostic and therapeutic procedures) and it was nearly 4 times that of diagnostic balloon assisted enteroscopy for

**3. Early recognition of perforation by simple bedside examination**

nal examination is a standard technique for picking the peritonitis early.

**4. Role of basic laboratory investigation like TLC and serum lactate** 

Laboratory workup will confirm the diagnosis of small bowel perforation apart from a careful history and physical examination. It is particularly helpful in elderly or seriously ill patients in whom signs and symptoms are less reliable. An elevated (>12,000/ cumm) or decreased white blood cells (< 4000/cumm) confirms inflammation or infection [13]. If TLC is normal, an increase in the number of neutrophils in differential counts or bandemia (> 10% band forms) is indicative of infection. The hemoglobin level will help in deciding the blood transfusion requirement. Serum electrolytes, blood urea nitrogen and, serum creatinine measurements will provide information about the fluid losses associated with third space loss, vomiting, delayed presentation, etc. Lactate level serves as a surrogate marker for tissue perfusion and correlates with anaerobic metabolism. A raised lactate level indicates bowel ischemia, shock, and sepsis. Lactate levels have been more specific than leukocyte count in diagnosing abdominal sepsis [14]. However, lactate levels can also be elevated in hepatic

In a patient who has undergone small bowel endoscopy the diagnosis of small bowel perforation should be suspected if the patient has acute pain in the abdomen. The severity of pain will progressively increase. The patient will lie still as any movement will exacerbate the pain. Even the respiration will be shallow for this reason. This differentiates it from other acute pathologies like acute pancreatitis in which the patient is restless and changes posture to find relief. The physical examination will reveal a sick look, tachycardia, and features of dehydration along with the signs of peritonitis. Perforation causes third space loss of body fluid. This along with bacteremia and systemic inflammatory response leads to hypotension and decreased urine output. The abdomen will be very tender and guarding will be present. A board-like rigidity may be felt. Loss of liver dullness on percussion will further confirm the presence of free air in the peritoneal cavity. Bowel sounds will be absent due to paralytic ileus caused by peritonitis. After 4–6 hours of perforation (gastro-duodenal perforation), the peritoneal cavity acid becomes diluted and there is a decrease in pain and guarding. It may seem that the patient is improving but, in reality, is deteriorating [12]. Making the diagnosis of perforation may be difficult in the early period because of subtle signs and symptoms. The classical peritoneal signs may fail to elicit in a morbidly obese patient. Thus a high index of suspicion should be kept in mind for patients complaining of undue pain following endoscopy. Any patient with difficult endoscopy should have close post procedure monitoring for early detection of complications. Tachycardia, dehydration, or decreased urine output should alarm the clinician. Repeated abdominal examination can detect any new abdominal signs. Lessons can be learnt from trauma surgery. In a hemodynamically stable patient with an anterior abdominal stab wound with the peritoneal breach, serial abdomi-

**110**

**in early diagnosis**

failure, dehydration, and drug abuse. Metabolic acidosis will be present in sepsis. Coagulation profiles such as platelet count, prothrombin time, international normalized ratio, etc. are important in the preoperative assessment of patients with liver disease or those on anticoagulants. These may also be deranged due to sepsis. Other biochemical markers of inflammation include C-reactive protein and pro-calcitonin which when used in adjunct with complete blood count and other clinical signs help in making the diagnosis, assessing severity and prognosis, and guiding treatment.
