Management

1. Correct fluid and electrolyte abnormalities. Resuscitation should be prompt and aggressive and usually consists of colloid replacement plus blood to maintain Hb >7g/dl. Inotropes or vasopressors may be required to restore an adequate circulation, particularly following perforation. Early cardiac output monitoring should be considered if the circulatory status remains unstable or vasoactive drugs are required.

2. The surgeon should be informed early. A conservative approach may be adopted, e.g. with upper small bowel perforation; however, surgery is usually required for large bowel perforation. Small or large bowel obstruction may sometimes be managed conservatively as spontaneous resolution may occur, e.g. adhesions. Prompt exploration should be encouraged if the patient shows signs of systemic toxicity.

3. Both conservative and post-operative management of perforation and obstruction usually require continuous nasogastric drainage to decompress the stomach, nil by mouth and parenteral nutrition.

4. Pain relief should not be withheld.

5. Broad spectrum antibiotic therapy should be commenced for bowel perforation after appropriate specimens have been taken for laboratory analysis. Therapy usually comprises aerobic and anaerobic Gram negative cover (e.g. 2nd or 3rd generation cephalosporin, quinolone or carbapenem, plus metronidazole ± aminoglycoside).

6. Post-operative management of bowel perforation may involve repeated laparotomies to exclude collections of pus and bowel ischaemia/infarction; surgery should be expedited if the patient's condition deteriorates. Alternatively, regular imaging ± drainage of collections may be needed.

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