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F. M. Carrano et al.
Fig. 4 Management of postoperative CD. AZA azathioprine, 6-MP 6-mercaptopurine, TNF tumor
necrosis factor. (Adapted from Sulz etal. [26])
patient should undergo examination of rectum under anesthesia (EUA) followed by
adequate drainage of the abscess. In the emergent setting, the only goal should be
the adequate drainage of the abscess while avoiding anal sphincter damage. Thus,
the search for an underlying stula should be discouraged, as local tissue conditions
(induration and sepsis) may easily lead to probing false iatrogenic tracks which will
further complicate the complexity of the disease. Only if the stula tract can be
Complicated Inammatory Bowel Disease andColonic Non-diverticular Emergencies
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clearly identied at the time of abscess drainage, a draining seton should be placed
[20]. This approach provides the best results, allowing for a precise assessment of
the perianal disease, in order to achieve an optimal outcome and avoid irreversible
damage due to incomplete or inaccurate intervention. After resolution of the acute
phase, both endoscopic ultrasonography-EUS and MRI are useful to accurately
classify the disease (low/high stulas, presence of undrained abscess, presence of
proctitis), as well as to plan the most suitable treatment and monitor its results [30].
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7 Bowel Obstruction
Bowel obstruction is characterized by nausea, vomiting, a distended abdomen, and
absence of gas or stool passage per rectum. Although can occur also in UC patients,
bowel obstruction is more frequent among CD patients, that typically undergo several episodes in their lives secondary to the development of brotic strictures combined with inammation ares that acutely reduce the bowel lumen. A contrast CT
scan should promptly be obtained. MRI may help in differentiating between a brotic
stricture, inammatory stricture, or mixed inammatory and brotic stricture resulting precious when deciding the most appropriate treatment strategy; however, its use
in the emergency setting may be limited outside referral centers. Nasogastric decompression, bowel rest, intravenous hydration, and intravenous steroids should be considered in active inammatory disease as primary treatment. However, if there are
signs of peritoneal irritation or suspected bowel ischemia, emergency surgery may be
indicated, and a resection of the diseased segment should be performed [25, 31]. In
cases of partial bowel obstruction nonresponsive to medical therapy, surgery can usually be scheduled after the patient is optimized [31]. If the patient is hemodynamically stable, a laparoscopic exploration may be considered as a routine starting point.
If intraoperative ndings allow for a safe totally laparoscopic surgery, the patient will
have all the benets of such a choice and, if a totally laparoscopic approach may not
be possible, patients could benet a lot also from hybrid procedures, in which part of
the operation is performed hand-assisted or through a mini-laparotomy [32]. In case
of need, there is always room for conversion. This event should not represent a failure for the surgeon in any circumstance and should not discourage from choosing the
minimally invasive approach. Even in an emergency setting, proper pre-operative
studies and planning are of paramount importance to choose the right intraoperative
strategies and avoid unpleasant surprises while operating [32]. In case of patients at
high risk of short bowel syndrome due to several previous resections or in case of
extensive brostenosing disease, strictureplasty may be a viable solution, with effective and durable long-term results [22]. An alternative to surgery, if there are no signs
of bowel ischemia and peritoneal irritation, endoscopic balloon dilation is an effective alternative solution, with short- term success rates of 89–91% [22]. In case of
upper abdominal pain, nausea and vomiting, weight loss, diarrhoea, hematemesis.
and anemia, a primary CD of the stomach and duodenum should be suspected. The
strictures are typically located in the distal stomach and duodenal bulb in 50–60% of
patients and are commonly treated by a distal gastrectomy with Roux-en-Y
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F. M. Carrano et al.
reconstruction. Duodenal strictures are best treated with stricturoplasty, as there is no
possibility of a blind loop, dumping, or anastomotic ulcerations [31]. For the treatment of stenotic segments up to 68 cm, the technique of choice is the HeinekeMikulicz stricturoplasty, while a Michelassi stricturoplasty should be preferred for
multiple and close strictures [25, 31]. In case of large bowel obstructions, especially
in UC, high suspicion for malignancy should be raised and, if an emergent colectomy
is required, oncologic principles should be followed.
8 Uncontrolled Intestinal Hemorrhage
Gastrointestinal bleeding is a common complication in patients with UC or CD and
is caused by inammation/ulceration of the bowel; however, uncontrolled, lifethreatening gastrointestinal bleeding occurs in less than 6% of cases [20]. Patients
with suspect ongoing bleeding or already with hemodynamic instability should
receive immediate uid resuscitation and packed red blood cells transfusions to
maintain hemoglobin levels above 7g/dL, or 9g/dL in case of massive bleeding or
if cardiovascular comorbidities are present [20].
The causes of bleeding, and related treatment, differ between UC and CD.In UC
patients, bleeding is usually caused by large areas of mucosal ulceration and hemorrhage. When massive bleeding occurs, endoscopic assessment and management of the
bleeding source may not be possible, due to the reduced visuals and considering the
ulceration extent (Fig.5). In case of ASUC, the bleeding could involve all colonic
mucosa and, after ruling out any rectal bleeding source endoscopically, an emergent
subtotal colectomy with end ileostomy should be performed [20]. Causes of bleeding
in CD patients are more insidious and complex to localize, due to the segmental nature
Fig. 5 Massive bleeding in UC patient requiring multiple blood transfusions without hemodynamic stabilization
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99
of the disease. Most of the times, bleeding comes from the erosion of an intestinal
vessel and, especially in case of massive bleeding, multiple segments of the gastrointestinal tract could be involved. For this reason, it is of paramount importance to localize bleeding sources preoperatively, thus great effort should be given to patient
stabilization rst. Subsequently, if an upper GI bleeding is suspect, an esophagogastroduodenoscopy should be promptly performed (eventually in the operating room if
there’s a serious risk that the patient cannot be stabilized for long), otherwise, if a
lower GI bleeding is suspect, a complete colonoscopy should be carried out [20]. In
case of more subtle or suspect extraluminal bleeding, CT-angiography may be useful
as a noninvasive diagnostic tool to identify bleeding at rates of at least 0.3mL/min. In
case of failure to detect the active bleeding source, a possible alternative solution is the
use of a nuclear medicine labeled red cell scans. Once the bleeding source has been
detected, if the patient is hemodynamically stable and a conservative option is feasible
(e.g., embolization, endoscopic hemostasis, etc.), it should be the preferred rst treatment approach. In case of treatment failure, or in case the patient is unstable even after
signicant resuscitation, an open surgical exploration is mandatory [20]. In this scenario, there is insufcient evidence to support the laparoscopic approach.
9 Conclusions
Acute surgical emergencies in patients with IBD may be life threatening and carry
a high degree of morbidity if not treated promptly in the appropriate way. Most
emergencies in patients with CD that are hemodynamically stable, should be initially treated conservatively, and denitive treatment postponed in the elective setting after the patient has been optimized, so that the resection would be as minimal
as possible. On the contrary, in case of UC complicated patients, surgical treatment
should be pursued earlier and with a curative intent. With sufcient expertise, the
laparoscopic approach is safe and feasible even in the emergency setting, carrying
positive benets for IBD patients. In case of hemodynamic instability and previous
history of surgeries with complicated postoperative courses, an open approach
would better serve the patient. Regardless of the underlying disease, the management of surgical emergencies in patients with IBD should be discussed in a multidisciplinary setting for optimal results.
References
1. Alatab S, Sepanlou SG, Ikuta K, Vahedi H, Bisignano C, Sari S, etal. The global, regional, and
national burden of inammatory bowel disease in 195 countries and territories, 1990–2017: a
systematic analysis for the global burden of disease study 2017. Lancet Gastroenterol Hepatol.
2020;5:17–30.
2. Kaplan GG, Windsor JW.The four epidemiological stages in the global evolution of inammatory bowel disease. Nat Rev Gastroenterol Hepatol. 2021;18:56–66.
3. Graham DB, Xavier RJ.Pathway paradigms revealed from the genetics of inammatory bowel
disease. Nature. 2020;578:527–39.
100
https://t.me/medicina_free
4. Erden A, Kuru Oz D, Gursoy Coruh A, Erden I, Ozalp Ates FS, Toruner M.Backwash ileitis in
ulcerative colitis: are there MR enterographic features that distinguish it from Crohn disease?
Eur J Radiol. 2019;110:212–8.
5. Frolkis AD, Dykeman J, Negron ME, Debruyn J, Jette N, Fiest KM, etal. Risk of surgery for
inammatory bowel diseases has decreased over time: a systematic review and meta-analysis
of population-based studies. Gastroenterology. 2013;145:996–1006.
6. Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR, et al. Toward an
integrated clinical, molecular and serological classication of inammatory bowel disease:
report of a working party of the 2005 Montreal world congress of gastroenterology. Can J
Gastroenterol. 2005;19:5A–36A.
7. Mak JWY, Ng SC. Epidemiology of brostenosing inammatory bowel disease. J Dig Dis.
2020;21:332–5.
8. Spekhorst LM, Visschedijk MC, Alberts R, Festen EA, van der Wouden EJ, Dijkstra G,
etal. Performance of the Montreal classication for inammatory bowel diseases. World J
Gastroenterol. 2014;20:15374–81.
9. Matsuoka K, Kobayashi T, Ueno F, Matsui T, Hirai F, Inoue N, etal. Evidence-based clinical
practice guidelines for inammatory bowel disease. J Gastroenterol. 2018;53:305–53.
10. Rubin DT, Ananthakrishnan AN, Siegel CA, Sauer BG, Long MD.ACG clinical guideline:
ulcerative colitis in adults. Am J Gastroenterol. 2019;114:384–413.
11. Hebuterne X, Peyrin-Biroulet L, Hausfater P.The management of emergency hospital visits
for inammatory bowel diseases: a French national expert consensus report. Dig Liver Dis.
2020;52:420–6.
12. Pabla BS, Schwartz DA. Assessing severity of disease in patients with ulcerative colitis.
Gastroenterol Clin North Am. 2020;49:671–88.
13. Carvello M, Watfah J, Wlodarczyk M, Spinelli A.The management of the hospitalized ulcerative colitis patient: the medical-surgical conundrum. Curr Gastroenterol Rep. 2020;22:11.
14. Gupta V, Mohsen W, Chapman TP, Satsangi J.Predicting outcome in acute severe colitis—
controversies in clinical practice in 2021. J Crohns Colitis. 2021;15:1211.
15. D’Amico F, Peyrin-Biroulet L, Danese S.Tofacitinib for acute severe colitis: when the going
gets tough, the tough get going. J Crohns Colitis. 2020;14:883–5.
16. Chough I, Zaghiyan K, Ovsepyan G, Fleshner P.It is not just cosmesis: straight laparoscopy
with stoma site extraction improves outcomes in ulcerative colitis patients undergoing total
colectomy. Am Surg. 2019;85:1194–7.
17. Lawday S, Leaning M, Flannery O, Summers S, Antoniou GA, Goodhand J, etal. Rectal
stump management in inammatory bowel disease: a cohort study, systematic review and proportional analysis of perioperative complications. Tech Coloproctol. 2020;24:671–84.
18. Bedrikovetski S, Dudi-Venkata N, Kroon HM, Liu J, Andrews JM, Lewis M, etal. Systematic
review of rectal stump management during and after emergency total colectomy for acute
severe ulcerative colitis. ANZ J Surg. 2019;89:1556–60.
19. Wasmann KA, van der Does de Willebois EM, Koens L, Duijvestein M, Bemelman WA,
Buskens CJ.The impact of rectal stump inammation after subtotal colectomy on pouch outcomes in ulcerative colitis patients. J Crohns Colitis. 2020;15:299.
20. De Simone B, Davies J, Chouillard E, Di Saverio S, Hoentjen F, Tarasconi A, et al. WSESAAST guidelines: management of inammatory bowel disease in the emergency setting.
World J Emerg Surg. 2021;16:23.
21. Coccolini F, Perrone G, Chiarugi M, Di Marzo F, Ansaloni L, Scandroglio I, etal. Surgery in
COVID-19 patients: operational directives. World J Emerg Surg. 2020;15:25.
22. Goldstone RN, Steinhagen RM.Abdominal emergencies in inammatory bowel disease. Surg
Clin North Am. 2019;99:1141–50.
23. Gomes CA, Podda M, Veiga SC, do Vale Cabral T, Lima LV, Miron LC, etal. Management
of inammatory bowel diseases in urgent and emergency scenario. J Coloproctol. 2021;40:
083–8.
24. DiCaprio D, Lee-Kong S, Stoffels G, Shen B, Al-Mazrou A, Kiran RP, etal. Management of
iatrogenic perforation during colonoscopy in ulcerative colitis patients: a survey of gastroenterologists and colorectal surgeons. Int J Color Dis. 2018;33:1607–16.
F. M. Carrano et al.
Complicated Inammatory Bowel Disease andColonic Non-diverticular Emergencies
https://t.me/medicina_free
25. Adamina M, Bonovas S, Raine T, Spinelli A, Warusavitarne J, Armuzzi A, et al. ECCO
guidelines on therapeutics in Crohn’s disease: surgical treatment. J Crohn’s Colitis. 2020;14:
155–68.
26. Sulz MC, Burri E, Michetti P, Rogler G, Peyrin-Biroulet L, Seibold F, etal. Treatment algorithms for Crohn’s disease. Digestion. 2020;101(Suppl 1):43–57.
27. Kristo I, Stift A, Argeny S, Mittlböck M, Riss S. Minimal-invasive approach for penetrating Crohn’s disease is not associated with increased complications. Surg Endosc. 2016;30:
5239–44.
28. Marzo M, Felice C, Pugliese D, Andrisani G, Mocci G, Armuzzi A, etal. Management of
perianal stulas in Crohn’s disease: an up-to-date review. World J Gastroenterol. 2015;21:
1394–403.
29. Lewis RT, Bleier JI.Surgical treatment of anorectal Crohn disease. Clin Colon Rectal Surg.
2013;26:90–9.
30. Spinelli A, Armuzzi A, Ciccocioppo R, Danese S, Gionchetti P, Luglio G, etal. Management
of patients with complex perianal stulas in Crohn’s disease: optimal patient ow in the Italian
clinical reality. Dig Liver Dis. 2020;52:506–15.
31. Bemelman WA, Warusavitarne J, Sampietro GM, Serclova Z, Zmora O, Luglio G, etal. ECCOESCP consensus on surgery for Crohn’s disease. J Crohns Colitis. 2018;12:1–16.
32. Spinelli A, Fiorino G, Bazzi P, Sacchi M, Bonifacio C, De Bastiani S, et al. Preoperative
magnetic resonance enterography in predicting ndings and optimizing surgical approach in
Crohn’s disease. J Gastrointest Surg. 2014;18:83–90; discussion 90–1.
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Gastroduodenal Perforation
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AmitSharma andMansoorAliKhan
1 Introduction
Learning Goals
• Be able to readily identify the causes of gastroduodenal perforation
• Have the knowledge basis to initiate immediate treatment of gastroduodenal
perforation
• Identify the spectrum of treatment modalities available dependent on physi-
ology of the patient
Acute gastroduodenal perforation can either be spontaneous or secondary to trauma.
The former is primarily due to underlying peptic ulcer disease. The incidence of
peptic ulcer disease has declined over the years due to medical treatment with histamine 2 receptor blockers (H2RBs) and proton pump inhibitors (PPI) and, the use
of eradication treatment for a Helicobacter pylori (H. pylori) infection [1]. The lifetime risk of benign gastroduodenal perforation is 10% in patients with untreated
peptic ulcer disease [2–4]. However, the need for surgical intervention for gastroduodenal perforation remains stable and may be increasing [3, 4]. This in part
related to increasing use of medications such as non-steroidal anti-inammatory
drugs (NSAIDs)/aspirin and to the ageing population [1]. Therefore, management
of peptic ulcer remains a signicant healthcare issue. Furthermore, iatrogenic duodenal perforations are becoming more common following the widespread use of
endoscopic procedures [1]. Yet there are several controversies regarding evidencebased management for acute gastroduodenal perforations including the role of nonoperative management, type of surgical approach, type of repair, and the role of
gastric diversion procedures, such as a pyloric exclusion [1, 4].
A. Sharma · M. A. Khan (*)
Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
e-mail: a.sharma1@nhs.net; mansoorkhan@nhs.net
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. Coccolini et al. (eds.), Mini-invasive Approach in Acute Care Surgery,
Hot Topics in Acute Care Surgery and Trauma,
https://doi.org/10.1007/978-3-031-39001-2_9
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A. Sharma and M. A. Khan
2 Causes ofGastroduodenal Perforation
Peptic ulcer disease accounts for the majority of acute gastroduodenal perforations.
Underlying causes of peptic ulcer disease include H. pylori infection, medications
(steroids, NSAIDs, and aspirin), and acid hypersecretion. Infection with H. pylori is
highly prevalent amongst the patients with peptic ulcer disease. As many as
90–100% of patients with uncomplicated peptic ulcer disease and 65–70% of
patients with perforated peptic ulcers are infected with H. pylori [2]. NSAIDs
related ulcer perforations occur in 30–50% of patients [2–4]. Duodenal ulcers are
four times more common than gastric ulcers below the age of 40years and are more
common in men [2]. The anterior surface of the duodenal bulb is the most common
site of disease (60%) followed by the gastric antrum (20%) and the lesser curvature
of the stomach (20%) [4]. Benign gastric ulcers occur predominantly on the lesser
curve in elderly patients. Ulcers on the greater curve, fundus, and in the antrum are
more commonly malignant [2].
Other causes of acute gastroduodenal perforation include malignancy, trauma
(blunt or penetrating), foreign body ingestion (by direct trauma or distal luminal
obstruction), iatrogenia from endoscopic procedures, marginal ulcer formation following bariatric surgery, prolonged fasting, illicit drug consumption, ZollingerEllison syndrome, stress ulcers in critically ill patients (Curling’s ulcer), and
chemotherapy with angiogenesis inhibitors such as bevacizumab [5, 6]. Blunt
trauma accounts for only 5% of hollow viscus perforations. Malignancy causes perforation by necrosis, or involution response to chemotherapy or due to distal luminal obstruction [3]. Gastric cancers account for 10–16% of perforations [4].
Iatrogenic duodenal perforations with ERCP occur in around 1% patients [1].
Gastric volvulus in setting of large hiatus hernia can cause strangulation and perforation secondary to ischaemia [2].
Duodenal perforations can also occur in people with conditions such as duodenal
diverticula, duodenal ischemia, infectious disease, and autoimmune conditions,
including Crohn’s disease, scleroderma, and vasculitis (e.g., abdominal polyarteritis
nodosa) [1]. Impacted gallstones in the duodenum have also been associated with
perforations [1]. Gastroduodenal perforation has also been reported as a complication of a variety of abdominal operations including the commonly performed laparoscopic cholecystectomy (0.015%) [1].
3 Presentation andDiagnosis
A diagnosis of gastroduodenal perforation is frequently made based on good clinical history and examination. Patients classically present with sudden onset acute
upper abdominal pain that commonly radiates to the shoulder due to diaphragmatic
irritation from free air or gastric contents. Nausea and vomiting are present in
around 50% of patients [7]. Shock is detected in 5–10% of patients [7]. A previous
history of peptic ulcer disease is present in 60–70% of patients who present with
perforation [8]. Other important risk factors in the medical history include
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105
gastroesophageal reux disease, use of NSAIDs, smoking, and a recent history of
upper GI endoscopy. A recent history of trauma should also be sought from the
medical history.
On clinical examination, patients generally show classical signs of peritonitis
due to irritation from gastric contents leakage with rigid board-like abdomen secondary to recti muscle spasm. However, only two-thirds of patients present with
frank peritonitis which might explain the diagnostic delay in some patients [6]. This
can occur when the perforation has managed to conceal or be contained to locally
surrounding tissues or into the retroperitoneal space. Examination ndings in the
obese, elderly, or immunocompromised patients can also be challengingly nonspecic and mild [1, 2]. In addition, if perforation is in the thorax as in the case of
strangulated hiatus hernia, then the patient is likely to have chest symptoms and
general signs of severe sepsis, with little or no evidence of peritonitis [2].
An upright chest X-ray is the rst choice of investigation to detect pneumoperitoneum with evidence of air under the diaphragm (Fig.1). However, pneumoperitoneum on the erect chest X-ray is absent in 20–30% of cases [2, 6]. Therefore, a
negative erect chest X-ray should prompt further investigations in the form of contrast enhanced CT scan, which has sensitivity of 98% (Fig.2). Adding water soluble
oral contrast enables further assessment of perforation [6]. In addition, CT scan
enables assessment of other synchronous intra-abdominal pathologies. Suspicious
ndings on CT scan include unexplained intraperitoneal uid, pneumoperitoneum,
bowel wall thickening, mesenteric fat stranding, and extravasation of oral contrast.
Fig. 1 Erect chest X-ray
showing bilateral air under
the diaphragm diagnostic
of pneumoperitoneum.
(Courtesy of Dr. Kewal
Arunkumar Mistry [9])
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ab
Fig. 2 Contrast-enhanced axial images of gastroduodenal perorations. (a) Double contrast-
enhanced (intravenous and oral) axial image of upper abdomen. There is evidence of free perihepatic uid and air. In addition, multiple locules of free gas are seen medial to the gallbladder. (b)
Contrast-enhanced axial image of upper abdomen with locules of free air around a thickened gastroduodenal junction. Image erect chest X-ray showing bilateral air under diaphragm diagnostic of
pneumoperitoneum. (Courtesy of Associate Professor Fran Gaillard [10])
Up to 12% of patients with traumatic perforations may have a normal initial CT
scan [6]. Although in a patient with penetrating trauma with signs of peritonitis,
surgical intervention is the key; and in both blunt and penetrating trauma patients
that are clinically stable, trauma CT scanning is the standard of care for diagnosis [3].
Other markers that help physicians in assessing a patient’s clinical state include
leukocytosis, metabolic acidosis, high lactate levels, a negative base excess, and
reduced levels of consciousness. There is usually an associated hyperamylasaemia.
Patients with reduced GCS may be difcult to assess on examination [3].
4 Management
Delays of greater than 12h result in a three-fold increase in mortality, while delays
of 24h are associated with a nine-fold increase.
4.1 Conservative Management
Also known as the Taylor method named after author who proposed this form of
management rst in 1946. Approximately half of the perforations spontaneously
seal [5]. This occurs with brin, omentum, or by fusion of the duodenum to the
underside of the liver between the gallbladder and the falciform ligament [1].
Various retrospective observational studies show variable rate of success in nonoperative management of perforated peptic ulcer disease (Table1). However, there
is a high degree of heterogeneity in methodology and selection bias in these reports.
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