**7. The indication of laparoscopy in the diagnosis and management of intestinal perforation**

Laparoscopy has a role in the diagnosis of perforations that are sometimes not detected by imaging tools. It allows complete visualization and exploration of the abdominal cavity. Laparoscopy is considered safe and a valid diagnostic tool and has a diagnostic benefit of 89–100% in the acute abdomen [30]. However, in cases of small bowel perforation, it is more of a therapeutic modality. Patients treated with laparoscopy have smaller incisions (**Figure 6**), reduced post-operative pain, early return of bowel movements, shorter hospital stay, and faster return to normal activity. Various factors limit the role of laparoscopy in patients with perforation peritonitis. Respiratory and hemodynamic stability is necessary before performing laparoscopy. Pneumoperitoneum affects the respiratory and cardiovascular parameters, thus patients with comorbidities

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after a timely repair.

**8. Conclusion**

**Figure 6.**

*Early Recognition and Management of Small Bowel Perforation*

should be properly evaluated before the procedure. The presence of dense intraabdominal adhesions and the expertise of the surgeon are other parameters that affect

as well as the bowel. Primary suture repair can be done for small perforation. Resection of the involved bowel with anastomosis is required if the surrounding bowel is unhealthy or the perforation is large (more than 50% of the bowel circumference). The primary repair/anastomosis is at risk in conditions that impair healing. An obstructed, irradiated, inflamed, or ischemic intestine is traditionally considered high risk. Other than this, systemic factors like malnutrition, hypotension, diabetes, renal failure, chronic liver disease, anemia, steroid use, and other conditions causing immunocompromise lead to an increased risk of anastomotic failure [32]. If there are multiple risk factors for anastomotic leak then exteriorization of the perforated bowel as a stoma may be a safer option. It is followed by stoma closure after two to three months. However, in proximal jejunum, a stoma will lead to serious nutritional loss and if possible should be avoided. Complete lavage of all the abdominal recesses must always be done to prevent post-operative intra-abdominal collection (tertiary peritonitis). The patients have a good recovery

The choice of bowel repair technique depends upon the condition of the patient

In a patient who has undergone small bowel endoscopy the diagnosis of small bowel perforation should be suspected if the patient is presenting with an acute

The physical examination will reveal a sick look, tachycardia, and features of

pain abdomen, especially after a therapeutic procedure.

dehydration along with the abdominal signs of peritonitis.

the feasibility of laparoscopic procedure [30, 31].

*Small incisions of laparoscopic surgery.*

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

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

*Endoscopy in Small Bowel Diseases*

diagnosis of intestinal perforation (**Figure 5**).

site of perforation [25].

Furthermore, the logistic regression showed that extra-luminal air, segmental bowel wall thickening, and focal defect of the intestinal wall were strong predictors of the

Signs present in plain radiography are also seen in scout view in CT. When contrast is contraindicated, then even plain CT is of help, in diagnosing perforation. The European Society of Gastrointestinal Endoscopy (ESGE) recommends that clinical features suggestive of perforation after an endoscopy should be rapidly and carefully evaluated and documented with a CT scan [26]. See flowchart for the

**6. Resuscitation, supportive measures, and preparation for surgery**

and the elderly. Foley's catheterization is needed to measure urine output.

stomas, postoperative ICU care, and expected complications of surgery.

**7. The indication of laparoscopy in the diagnosis and management** 

Laparoscopy has a role in the diagnosis of perforations that are sometimes not detected by imaging tools. It allows complete visualization and exploration of the abdominal cavity. Laparoscopy is considered safe and a valid diagnostic tool and has a diagnostic benefit of 89–100% in the acute abdomen [30]. However, in cases of small bowel perforation, it is more of a therapeutic modality. Patients treated with laparoscopy have smaller incisions (**Figure 6**), reduced post-operative pain, early return of bowel movements, shorter hospital stay, and faster return to normal activity. Various factors limit the role of laparoscopy in patients with perforation peritonitis. Respiratory and hemodynamic stability is necessary before performing laparoscopy. Pneumoperitoneum affects the respiratory and cardiovascular parameters, thus patients with comorbidities

indicated or changed according to culture and sensitivity.

**of intestinal perforation**

Evaluation and resuscitation should go hand in hand. The intravascular fluid deficit should be corrected considering systemic diseases in acutely ill patients. Warmed crystalloids (normal saline or lactated Ringer solution) should be started using wide-bore IV cannula. Fluid therapy should be guided according to physical signs (pulse rate, blood pressure), urine output, lactate levels, CVP, etc. Patients who are not responsive to adequate fluid therapy should be started on vasopressors. Nasogastric tube insertion prevents aspiration in patients with altered mental status

Parenteral analgesics (tramadol, paracetamol, NSAID, etc) should be started in an adequate dose in combination, keeping in mind the renal function of the patient. We generally avoid diclofenac in bowel repair as animal studies have shown an increased risk of post-surgery leak [27]. Broad-spectrum antibiotic therapy (piperacillin + tazobactum or meropenem, etc. along with metronidazole) should be started to control on-going sepsis. The antibiotics can later be continued as

The anesthetic evaluation would include the American Society of Anesthesiologists (ASA) classification system to stratify patients according to the degree of perioperative risks [28]. Thromboprophylaxis should be started in high-risk patients that include mechanical devices (thromboembolic deterrent stocking and pneumatic compression boots) and drugs (heparin and LMWH) [29]. Risk factors for deep vein thrombosis include increased age, obesity, chronic diseases (diabetes, COPD, malignancy), corticosteroid therapy, and past or family history of thromboembolic disease. Written consent for surgery is taken and the patient and the family should be explained about the possibility of multiple staged surgeries, temporary

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**Figure 6.** *Small incisions of laparoscopic surgery.*

should be properly evaluated before the procedure. The presence of dense intraabdominal adhesions and the expertise of the surgeon are other parameters that affect the feasibility of laparoscopic procedure [30, 31].

The choice of bowel repair technique depends upon the condition of the patient as well as the bowel. Primary suture repair can be done for small perforation. Resection of the involved bowel with anastomosis is required if the surrounding bowel is unhealthy or the perforation is large (more than 50% of the bowel circumference). The primary repair/anastomosis is at risk in conditions that impair healing. An obstructed, irradiated, inflamed, or ischemic intestine is traditionally considered high risk. Other than this, systemic factors like malnutrition, hypotension, diabetes, renal failure, chronic liver disease, anemia, steroid use, and other conditions causing immunocompromise lead to an increased risk of anastomotic failure [32]. If there are multiple risk factors for anastomotic leak then exteriorization of the perforated bowel as a stoma may be a safer option. It is followed by stoma closure after two to three months. However, in proximal jejunum, a stoma will lead to serious nutritional loss and if possible should be avoided. Complete lavage of all the abdominal recesses must always be done to prevent post-operative intra-abdominal collection (tertiary peritonitis). The patients have a good recovery after a timely repair.

#### **8. Conclusion**

In a patient who has undergone small bowel endoscopy the diagnosis of small bowel perforation should be suspected if the patient is presenting with an acute pain abdomen, especially after a therapeutic procedure.

The physical examination will reveal a sick look, tachycardia, and features of dehydration along with the abdominal signs of peritonitis.

Perforation is confirmed by x-ray abdomen, leucocytosis, and an increase in serum lactate. Computed tomography scan is very sensitive and specific for perforation of the gastrointestinal tract.

Early diagnosis should be the goal with prompt surgical correction, and the patients have a good recovery after timely repair.
