Small bowel perforation: Is urgent surgery necessary?

Background: Controversies regarding how urgent bowel perforation should be diagnosed and treated exist in recent reports. The approach for early diagn osis is also debatable, The purposes of this study were to evaluate the rel ationship between treatment delay and outcome of small bowel perforation af ter blunt abdominal trauma and to determine the best assessment plan for th e diagnosis of this injury, Methods: One hundred eleven consecutive patients with small bon el perforat ions caused by blunt abdominal trauma were retrospectively reviewed. The pa tients were divided into four groups according to the time interval between injury and surgery, Hospital stay, time to resume oral intake, and mortali ty and morbidity rates were compared between groups. Physical signs, labora tory and computed tomographic findings, and the results of diagnostic perit oneal lavage were analyzed to find the most sensitive and specific test for early diagnosis of small bowel perforation, Results: Delay in surgery for mole than 24 hours did not significantly incr ease the mortality with modern method of treatment; however, complications increased dramatically. Hospital stay and time to resume oral intake increa sed significantly when surgery was delayed for more than 24 hours. Abdomina l tenderness was a common finding, but it was not specific for bowel perfor ation, Only 40% of the computed tomographic scans were diagnostic for bowel perforations: 50% of them showed suggestive signs, and 10% were considered as negative. Persistence of abdominal signs indicated peritoneal lavage, B S using cell count ratio in diagnostic peritoneal lavage and/or increased l avage amylase activity, presence of particulate matter and/or bacteria in t he lavage fluid, all patients with intraperitoneal bowel perforation were d iagnosed accurately before operation, Conclusion: Small bowel perforation has low mortality and complication rate s if it is treated earlier than 24 hours after injury. The principle of "ru shing to the operation suite" for a stable blunt abdominal trauma patients without detailed systemic examination is not justified. The priority of tre atment for the small bowel perforation should be lower than the limb-threat ening injuries. Diagnostic peritoneal lavage provides high sensitivity and specificity rates for the diagnosis of small bowel perforation if a special ly designed positive criterion is applied.