Jejunal Perforation

Jejunal perforation is full thickness disruption of the jejunal wall with leakage of enteric content into the peritoneum.

Causes include blunt or penetrating trauma, foreign body, bowel ischaemia, jejunal diverticulitis, Crohn disease, malignancy and iatrogenic injury.

Because jejunal contents are liquid and bacterial contamination increases distally, free perforation can rapidly produce diffuse peritonitis and sepsis.

Presentation is usually acute abdominal pain with progressive tenderness and guarding.

Traumatic perforation may initially be subtle and become apparent hours later as contamination progresses.

Persistent tachycardia, increasing pain, ileus or unexplained inflammatory deterioration after abdominal trauma should raise concern even when initial imaging was reassuring.

CT abdomen with IV contrast: identify the perforated segment and associated free fluid, contamination or other injuries.

A deteriorating patient with convincing peritonitis should proceed to surgery without waiting for repeated imaging.

Keep fasting, establish IV access and resuscitate according to physiological deficit.

Start broad intra abdominal antimicrobial coverage:

Ceftriaxone 2 g IV every 24 hours plus metronidazole 500 mg IV every 12 hours.

Use piperacillin tazobactam 4.5 g IV every 8 hours by extended infusion for severe sepsis, extensive contamination or significant resistant organism risk.

Small isolated traumatic perforations with healthy surrounding bowel can often undergo primary transverse repair.

Segmental jejunal resection with primary anastomosis is preferred for:

• Large defects
• Devitalised edges
• Multiple adjacent perforations
• Ischaemic bowel
• Perforated tumour or diverticulitis involving a diseased segment

In severe shock or questionable perfusion, defer anastomosis or use staged reconstruction when necessary.

After adequate source control, approximately 4 days of antimicrobial therapy is usually sufficient for the secondary intra abdominal infection.