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Perforated viscus
A rigid abdomen with free air is a surgical emergency and a sepsis emergency at once. Recognise peritonitis, resuscitate and treat sepsis, confirm free air (CT is best), find where it came from, and get the patient to theatre with a NELA risk assessment. Built for revision, not live patient decisions.
Settle them, and check the basics
resuscitate · antibioticsRed flags — what each should make you think
The elderly, immunosuppressed and anyone on steroids can perforate with very few abdominal signs. Tachycardia, confusion or a rising lactate may be all you see. A soft abdomen on examination does not exclude perforation in these patients.
First actions
- O₂Oxygen
- IVTwo cannulas, bloods
- ℞IV antibiotics
- flFluids
- NGNG tube, NBM, catheter
- CTCT abdomen/pelvis
- ☎Surgical registrar + NELA
Understand the patient
where from?Common causes
- Perforated peptic ulcer — NSAIDs, steroids, smoking, H. pylori; sudden epigastric pain becoming generalised
- Perforated diverticulitis — LIF pain, older, purulent or faecal peritonitis
- Perforated appendicitis
- Colorectal cancer (at the tumour or caecal blow-out from obstruction)
- Boerhaave syndrome — oesophageal rupture after vomiting: chest pain, surgical emphysema, sepsis
- Iatrogenic — after endoscopy/colonoscopy
Erect CXR vs CT
- Erect CXR (sitting up for 10 min) shows air under the diaphragm in many but not all perforations
- CT abdomen/pelvis is more sensitive and shows the source, contamination and collections
- Don't delay resuscitation or senior review waiting for imaging if the patient is peritonitic and shocked
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Sudden severe epigastric pain, rigid abdomen, NSAIDs/steroids.
CT / erect CXR.
Resuscitate, IV PPI, antibiotics, surgery (laparoscopic repair/omental patch); selected cases managed non-operatively by senior decision.
Older patient, LIF pain, septic shock.
CT.
Emergency laparotomy (often Hartmann's), critical care.
Forceful vomiting followed by severe chest/epigastric pain, surgical emphysema, effusion, sepsis.
CT chest with oral contrast.
NBM, broad antibiotics + antifungal, upper GI/thoracic surgery.
Severe pain with few signs, AF, vascular disease, raised lactate.
CT angiogram.
Vascular and general surgery emergency.
Investigate — what to order, when, and what it tells you
test with a question in mindBloods
Imaging
Risk
How the plan comes together
disposition · handovertheatre / critical care
Most perforations: emergency laparotomy/laparoscopy with consultant surgeon and anaesthetist present for high-risk patients; post-op critical care if NELA risk is high (5% or more).
Hand over: source, CT findings, antibiotics given, lactate, NELA score.
non-operative (selected)
Contained perforations or very high-risk patients after senior discussion; ceilings of care documented.
Rigid abdomen? Resuscitate, antibiotics, CT, surgeon. And remember that the elderly and the immunosuppressed may perforate with a soft-looking abdomen. Nicely done getting here.
Clerking template
copy or downloadPerforated viscus — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 10 knownFrequently asked questions
quick answersWhat are the red flags for a perforated viscus?
- Sudden severe pain, board-like abdomen — think perforated viscus
- Shock, high lactate — think septic shock / faecal peritonitis
- Vomiting then chest pain + surgical emphysema — think Boerhaave (oesophageal rupture)
- Elderly on steroids, few signs — think masked perforation
- Pain out of proportion, AF — think mesenteric ischaemia (mimic)
- Pulsatile mass, shock — think ruptured AAA (mimic)
What is the initial management of a perforated viscus?
- Oxygen — to target
- Two cannulas, bloods — FBC, U&E, LFT, lipase, clotting, G&S, lactate, cultures
- IV antibiotics — broad-spectrum per local intra-abdominal sepsis policy
- Fluids — balanced crystalloid bolus, reassess
- NG tube, NBM, catheter — fluid balance
- CT abdomen/pelvis — most sensitive for free air and source
- Surgical registrar + NELA — emergency laparotomy pathway
Always alongside senior support and your local guideline.
What diagnoses must you not miss in a perforated viscus?
- Perforated peptic ulcer — epigastric · sudden
- Faecal peritonitis — colonic perforation
- Boerhaave syndrome — vomit → chest pain
- Mesenteric ischaemia (mimic) — pain out of proportion
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for a perforated viscus?
- Bloods — FBC, U&E, LFT, lipase/amylase, CRP, clotting, G&S, cultures.
- Imaging — Free air, source, collections.
- Risk — Mortality risk to guide consent and critical care.
Admit or discharge: how is the plan decided for a perforated viscus?
- Theatre / critical care — Most perforations: emergency laparotomy/laparoscopy with consultant surgeon and anaesthetist present for high-risk patients; post-op critical care if NELA risk is high (5% or more).
- Non-operative (selected) — Contained perforations or very high-risk patients after senior discussion; ceilings of care documented.
Is there a clerking template for a perforated viscus?
Yes — there is a free clerking template for a perforated viscus on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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