Bowel perforation and obstruction

Patients with bowel perforation or obstruction may be admitted to the ICU after surgery, for pre-operative resuscitation and cardiorespiratory optimisation, or for conservative management. Although rarely occurring de novo in the ICU patient, these conditions may be difficult to diagnose because of sedation ± muscle relaxation. Consider when there is:

• Abdominal pain, tenderness, peritonism

• Abdominal distension

• Increased nasogastric aspirates, vomiting

• Increasing metabolic acidosis

• Signs of hypovolaemia or sepsis

A firm diagnosis is often not made until laparotomy although supine and either erect or lateral abdominal X-ray may reveal either free gas in the peritoneum (perforation) or dilated bowel loops with multiple fluid levels (obstruction). Ultrasound is usually unhelpful though faecal fluid may occasionally be aspirated from the peritoneum following perforation.

It may be difficult to distinguish bowel obstruction from a paralytic ileus as (i) bowel sounds may be present or absent in either and (ii) X-ray appearances may be similar.

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