INFECTION & SEPSIS • SENIOR RESIDENT / SURGEON

Fecal Peritonitis

Gross enteric contamination is the endpoint of multiple ACS diseases; the operative problem is rapid source control in a physiologically threatened patient.

PROTOTYPE REVIEW REQUIRED

The Call

Older adult with abrupt worsening abdominal pain

Diffuse peritonitis, systemic toxicity and imaging consistent with hollow-viscus perforation. At exploration there is widespread feculent contamination.

T 39.0 C • HR 126 • BP 88/52

The diagnosis is no longer subtle: this is uncontrolled intra-abdominal sepsis.

Read the Image • Clinical DataACS VISUAL

Fecal peritonitis operative image from the ACS image archive.

Make the Decision • Commit to a Plan

Fecal Peritonitis

Older adult with abrupt worsening abdominal pain

A patient arrives in profound septic shock with free perforation and feculent peritonitis. What is the operative priority?

After resection the patient is hypothermic, acidotic and coagulopathic. Best next step?

At re-look 24 hours later the patient is warmer and off high-dose pressors. Bowel ends are healthy. What now?

Control the leak, remove nonviable tissue and simplify when physiology is failing.

Source control must be followed by aggressive critical care.

Surgical Pearls

Pitfalls

After resection of the perforated segment, the patient remains acidotic, hypothermic and vasopressor-dependent. Which strategy is most appropriate to consider?