Acute small bowel ulcers complicated by perforation in patients with widespread purulent peritonitis of gunshot etiology

Levchuk A.L., Grin N.A.

In modern armed conflicts, various complications occur in 78.6% of patients with abdominal injuries. From the first minutes after a gunshot wound, one of the most severe syndromes of peritonitis begins to develop – enteral insufficiency, which manifests as the spontaneous and often asymptomatic occurrence of acute perforating ulcers in various parts of the small intestine. The relevance of this issue is associated with a significant increase in their incidence and the poorly studied psychophysiological reasons for their formation.

Objective: To study the frequency of development, possible predisposing factors, and morphological characteristics of acute perforating ulcers of the small intestine that arise in the postoperative period after surgical interventions on the abdominal and pelvic organs due to gunshot wounds.

Materials and Methods. A retrospective analysis was conducted on the treatment of 264 patients with abdominal firearm injuries. Among them, 27 (10.2%) patients were diagnosed with acute perforations appearing as ‘punch-like’ holes in various sections of the small intestine against the backdrop of widespread peritonitis at the stage of specialized medical care. The most optimal method for diagnosing this complication was contrast-enhanced spiral CT. Endoscopic examinations (EGD, colonoscopy, double-balloon and capsule enteroscopy) were performed in 19.4% of the patients, among whom manifestations of ischemic and erosive-ulcerative enteritis were diagnosed. The time range for the occurrence of acute small bowel perforations was 2 to 26 days. All injured patients underwent emergency surgery for this complication.

Results. During relaparotomies, 24.7% of the wounded were found to have both foci of ischemia and necrosis of the small intestine, as well as perforation holes measuring 0.1–0.3 cm. Morphological studies confirmed a severe disruption of microcirculation in areas where acute perforating ulcers had formed. To assess the overall condition of patients with widespread gunshot peritonitis, the Mannheim Peritonitis Index was used alongside an evaluation of functional organ-system dysfunction according to the SOFA scale. Marked hemostatic changes were detected in 72.4% of the victims, leading to significant suppression of regional blood flow, impaired regeneration, and biological integrity of the small intestine. The risk group for the development of this severe complication includes victims with multiple and combined abdominal gunshot injuries, prolonged nasointestinal drainage, prolonged mechanical ventilation, and those requiring frequent scheduled relaparotomies. The incidence of abdominal sepsis and multiple organ failure in the study group was 64.3%, with a mortality rate of 3.7%. The main therapeutic measures for this category of wounded were carried out in the intensive care unit using extracorporeal detoxification methods aimed at eliminating circulatory hypoxia, endogenous microbial intoxication, and intestinal paresis.

Conclusion. The occurrence of acute perforations of small intestine ulcers in the postoperative period in patients with gunshot wounds to the abdomen is a highly unfavorable complication, indicating a decompensation of enteral insufficiency, which serves as an integral indicator in the progression of widespread gunshot peritonitis and the formation of small bowel fistulas.

1. Levchuk AL, Ignatiev TI, Vinogradov AV. Widespread peritonitis in penetrating gunshot wounds of the abdomen with damage to internal organs. Bulletin of the N.I. Pirogov National Medical Center. 2025; 20(1): 74-79. (In Russ.)

2. Peredov SN, Zubritskiy VF, Levchuk AL, Gardashov NT, Kovalev AS. The place of enteral insufficiency in the pathogenesis of abdominal sepsis in gunshot abdominal injury: the current state of the problem. Medical Bulletin of the Ministry of Internal Affairs. 2025; 3: 13-18. (In Russ.)

3. Zemlyanoi VP, Singaevensky AB, Nesvit EM, et al. Сlinical features and diagnostic possibilities of acute perforated ulcers of the small intestine in the postoperative period. Bulletin of the NMCC named after N.I. Pirogov. 2019; 14(3): 43-46. (In Russ.)

4. Golbraich VA, Maskin SS, Bobyrin AV, et al. Acute performative ulcers of the small intestine in patients with widespread purulent peritonitis. Bulletin of Experimental and Clinical Surgery. 2012; 5: 51-53. (In Russ.)

5. Bensignor T, Lefevre J, Creavin B, et al. Postoperative peritonitis after digestive tract surgery: surgical management and risk factors for morbidity and mortalily, a cohort of 191 patienty. World J. Surg. 2018; 42: 3589-3598.

6. Zharikov AN, Lubensky VG, Kanteeva YuL, et al. The effect of disorders of regional hemodynamics and microcirculation of the intestinal wall on the occurrence of acute perforations of the small intestine. Bulletin of Experimental and Clinical Surgery. 2015; 8(5): 34-44. (In Russ.)

7. Nesvit EM. features of the clinical course of acute perforated ulcers of the small intestine in the postoperative period. [abstract of the dissertation] 2022. (In Russ.)

8. Levchuk AL, Abdullaev AE. Intra–abdominal hypertension is an intergral indicator of the progression of peritonitis with the development of abdominal compartment syndrome. Bulletin of the NMCC named after N.I. Pirogov. 2025; 20(3): 74-82. (In Russ.)

9. Cheatham ML. Abdominal compartment syndrome: pathophysiology and definitions. Scand. J. Trauma Resusc. Emerg. Med. 2009; 17: 10-14.