|Year : 2016 | Volume
| Issue : 1 | Page : 14-19
Acute Physiology and Chronic Health Evaluation II score as a tool to guide management strategies in ileal perforation
Sarabjeet Singh1, Amandeep Singh1, Prempal Bhatti1, Haramritpal Kaur2, Rupinder Kaur3
1 Department of Surgery, GGSM College and Hospital, Faridkot, Punjab, India
2 Department of Anaesthesia and Intensive Care, GGSM College and Hospital, Faridkot, Punjab, India
3 Department of Medicine, GGSM College and Hospital, Faridkot, Punjab, India
|Date of Web Publication||5-May-2016|
Department of Surgery, GGSM College and Hospital, Faridkot, Punjab
Source of Support: None, Conflict of Interest: None
Background: Perforation peritonitis is the common surgical emergency. Despite advances in surgical techniques, antimicrobial therapy, and intensive care support, management of peritonitis continues to be highly demanding due to associated morbidity and mortality. Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system is the best available method for risk stratification in critically ill patients. Materials and Methods : This study was conducted in the 60 patients, who were admitted from causality and surgical outpatient department with a proven diagnosis of ileal perforation peritonitis. The patients were scored using by APACHE II into either of the two groups, Group A: <10 score. Group B: ≥10 score. Patients were operated for primary closure or ileostomy formation and were divided into two groups of 30 each depending on the surgical management. Group I (n = 30): These patients were managed by primary repair of the perforation with or without resection-anastomosis. Group II (n = 30): These patients were managed by ileostomy formation with closure/resection of the perforation. The outcome was assessed by postoperative complications and duration of hospital stay as related to APACHE II score. Results : Typhoid accounted for 38.3% of ileal perforations, Tuberculosis 15%, trauma 5% and nonspecific 41.6%. The majority of the perforations were single (90%), of size <1 cm (81.66%), and located within 60 cm of terminal ileum (95%). Simple closure of perforation with or without resection anastomosis was statistically significantly (P < 0.005) more done in patients with APACHE II score <10 whereas frequency of ileostomy was statistically significantly (P < 0.005) more done in patients with APACHE II score ≥10. As the APACHE II score increases the percentage of complication rate and hence hospital stay also increases, 12.97 ± 3.50 days in patients with APACHE II <10 score and 20.96 ± 5.09 days in patients with APACHE II ≥10 score (P < 0.001). Conclusion: Enteric fever is the most common cause of perforation peritonitis. Higher APACHE II scores in secondary peritonitis correlated significantly with the higher mortality and morbidity of the patients.
Keywords: Acute Physiology and Chronic Health Evaluation II score, hospital stay, perforation peritonitis, postoperative complication
|How to cite this article:|
Singh S, Singh A, Bhatti P, Kaur H, Kaur R. Acute Physiology and Chronic Health Evaluation II score as a tool to guide management strategies in ileal perforation. Saudi Surg J 2016;4:14-9
|How to cite this URL:|
Singh S, Singh A, Bhatti P, Kaur H, Kaur R. Acute Physiology and Chronic Health Evaluation II score as a tool to guide management strategies in ileal perforation. Saudi Surg J [serial online] 2016 [cited 2022 Jan 28];4:14-9. Available from: https://www.saudisurgj.org/text.asp?2016/4/1/14/181810
| Introduction|| |
Perforation peritonitis is the common surgical emergency in the Indian subcontinent and tropical countries. This is due to high incidence of enteric fever and tuberculosis in these regions. Despite advances in surgical techniques, antimicrobial therapy, and intensive care support, management of peritonitis continues to be highly demanding due to associated morbidity and mortality.
In contrast to the Western literature, where lower gastrointestinal tract perforations predominate, upper gastrointestinal tract perforations constitute the majority of cases in India and the subcontinent. 
The postulated causes of ileal perforation include typhoid fever, tuberculosis, trauma, nonspecific enteritis, foreign bodies, Crohn's disease, ascaris worm, amoebiasis, malignancy, and radiation enteritis. Perforation of the terminal ileum constitutes the fifth most common cause of abdominal emergencies in the tropical countries. ,
Typhoid fever is an endemic disease in India and other tropical countries. Small intestinal perforations and gastrointestinal hemorrhage are the most common and dreadful complications of enteric fever.  The frequency of enteric perforation in typhoid fever has been reported from 0.8-18%. 
Of patients with tuberculosis, <1% will have gastrointestinal involvement and perhaps 10% of these may perforate leading to peritonitis. 
A "nonspecific" etiology is attributed to small bowel perforations when the perforation cannot be classified on the basis of clinical symptoms, gross examination, serology, culture and histopathological examination into any disease state such as enteric fever, tuberculosis, or malignancy. It has been proposed that submocus vascular embolism, chronic ischemia due to atheromatous vascular disease or arteritis are responsible for them. 
The increasing incidence of traumatic intestinal injuries may be due to an increase in high-speed motor vehicle accidents. Clinical evidence indicates that the most common mechanism of nonpenetrating intestinal trauma involves crushing of the bowel against the spine. A second mechanism involves tearing or shearing of bowel and its mesentery at points of fixation. Bursting of a distended or a kinked loop is a rare mode of injury. 
In contrast to these common causes of small bowel perforations in developing countries, small bowel perforations are rare in oriental countries. Apart from enteric fever and "nonspecific" ulcers, the other reported causes of such perforations from these countries include Crohn's disease, Behcet disease, radiation enteritis, adhesions, ischemic enteritis, systemic lupus erythematosus and very rarely intestinal tuberculosis. 
Various operative procedures have been advocated by different authors, such as simple repair of perforation, repair of perforation with ileo-transverse colostomy, ileostomy, exteriorization, single layer repair with an omental patch, trimming of ulcer edge and closure, wedge excision and anastomosis and segmental resection and anastomosis. Even with such a variety of procedures, enteric perforation still has a high rate of morbidity and mortality. The mortality ranges between 9% and 43%, with survivors having severe wound infection and a history of long hospital stays. Morbidity from other postoperative complications ranges 8.8-71.3%. 
Severity scoring is a valuable tool for assessing and quantification of severity of acute illness. Currently, Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system is the best available method for risk stratification in abdominal sepsis. ,,,,,,
The APACHE II system is based on the 12 acute physiological variables; the value of each variable is recorded during the first 24 h of the patient's admission and a score of 0-4 is ascribed to the variable. Combined with points for the patient's age and any chronic health problems, the APACHE II score is calculated. The important features of the APACHE II system over other systems is the increased weighting given to disorders of renal function and incorporation of score related to the patient's Glasgow Coma Score. The higher the score, the worse the likely outcome. 
The proposed study aimed to define the severity of peritonitis based on APACHE II Score, identify the cause, define the criteria for choosing a particular modality of treatment, and compare the outcomes of the various treatment modalities.
| Materials and Methods|| |
This study was conducted in the sixty patients, in the department of surgery, Guru Gobind Singh Medical College, and Hospital, over a period from March 2013 to August 2014 on patients, who were admitted from casualty and surgical outpatient department with a proven diagnosis of ileal perforation peritonitis.
The patients in the study group were subjected to detailed history, general physical examination, investigations and were scored using by APACHE II into either of the two groups Group A: <10 score and Group B: ≥10 score.
Patients were operated for primary closure or ileostomy formation and were divided into two groups of 30 each depending on the surgical management .
Group I (n = 30): These patients were managed by primary repair of the perforation with or without resection-anastomosis.
Group II (n = 30): These patients were managed by ileostomy formation with closure/resection of the perforation.
Patients with previous diagnosis of intestinal tuberculosis, children ≤12 years of age and pregnant females were excluded from the study.
The outcome was assessed by postoperative complications and duration of hospital stay.
The data collected was entered into an Excel spreadsheet and then converted into SPSS version 17 (IBM SPSS, version 17.0, SPSS Inc., Chicago) for further analysis. Chi-square tests and Student's t-tests were used for statistical analysis. P < 0.05 was taken to be significant, P < 0.0001 as highly significant and P > 0.05 was taken to be nonsignificant.
| Results|| |
A total of sixty patients were enrolled into the study. Age and sex distribution are shown in [Table 1]. Clinical features at the time of presentation are shown in [Table 2]. Time from the onset of signs and symptoms and time of reporting in the hospital, i.e., duration of perforation is shown in [Table 3]. Most of the patients, 83.3% presented within 72 h of perforation and were operated within 24 h of presentation after adequate resuscitation. Chest and abdomen radiograph was done in all patients. Pneumoperitoneum was present in 48 patients (80%). Etiology of perforation is shown in [Table 3]. Widal test was performed in all the patients except with a history of trauma. Nineteen patients had a positive Widal reaction and in four patients where clinical findings were suggestive of typhoid perforation, the test was considered as false negative. Diagnosis of tuberculosis was confirmed on lymph node biopsy examination. Rest of the patients with negative Widal test and inconclusive histopathology were considered as nonspecific.
Operative finding according to etiology is shown in [Table 4]. Operative procedure done and their correlation with APACHE II are shown in [Table 5]. Complications seen after surgery and their relation with APACHE II are shown in [Table 6]. Two patients expired due to renal failure and sepsis (APACHE ≥10). Total hospital stay is mentioned in [Table 7].
| Discussion|| |
Ileal perforation is still a common cause for peritonitis in developing countries. Surgery is the ideal treatment as it eliminates spoilage of the peritoneal cavity in an effort to lessen the toxemia and enhance the recovery of the patients. However, there is no uniformity of the standardized operative procedure that is most effective for the offending lesion.
There are also no criteria which define the type of surgical procedure based on the sepsis score. simplified acute physiology score, sepsis severity score, multiple organ failure score, Mannheim Peritonitis Index, Ransom and Imrie score, have been used to grade sepsis and prognosis. However, none of the existing scoring systems has fulfilled all expectations. Only the APACHE II score contribute independently to the prediction of outcome and has received the most attention worldwide and is thus highly validated in use. It has the advantage of being simple to use and the parameters demanded of the test are easily measured in any hospital to look after seriously ill patients. ,
Small bowel perforations most commonly affect young in the prime of their life. In the present study, male preponderance was found [Table 1] with male to female ratio of 3.28:1 that is in consistent with the ratio of 3:1 reported by Wani et al.  The mean age was 30.17 years with range of 13-70. The mean age was higher in our study as children below 12 years of age were excluded. The majority of the patients were in the age group 13-30 years (65%). The peak incidence for age was in the third decade followed by the second decade.
All the sixty patients [Table 2] presented with pain abdomen (100%), which started in the lower abdomen and later radiated to involve the whole abdomen. 80% of patients presented with fever.
The etiology of perforations [Table 3] was concluded on the basis of Widal reaction, operative findings and histopathological examination. Typhoid accounted for 38.3% of ileal perforations, Tuberculosis 15% and trauma 5%. Those patients in whom the diagnosis could not be made, and the histopathological examination revealed nonspecific inflammation were labeled as nonspecific (41.6%). The causes for nontraumatic terminal ileal perforation were enteric fever (62%), nonspecific inflammation (26%), obstruction (6%), tuberculosis (4%), and radiation enteritis (1%) as reported in a study by Wani et al.  Nadkarni et al.  found 56.6% nonspecific causes, followed by typhoid perforation (25%) and tubercular perforation.
Besides the etiology, the duration of perforation at presentation has an important bearing on the outcome of the management strategy. In our study, about 83.33% of the patient presented within 72 h of perforation [Table 3] and had a favorable outcome from those who presented late.
Two patients out of 10 (16.67%) who presented 72 h after perforation, died accounting for 20% mortality. The mortality in the delayed presentation was far less than as observed by other studies. Purohit  observed 22.2% mortality in those presenting within 48 h and 100% in those presenting after 4 days. Archampong  observed 39.6% mortality in those presenting within 48 h and 80% in those presenting after 4 days.
The majority of the perforations were single (90%), of size <1 cm (81.66%) and located within 60 cm of terminal ileum (95%) [Table 4]. Adesunkanmi et al.  observed 86% single perforations and 14% multiple perforations. Wani et al.  observed 62% had single perforation and rest had multiple perforations.
In this study, different operative procedures-simple closure of perforation with or without resection anastomosis and ileostomy [Table 5] were performed according to cause and severity of illness as per institutional protocol.
Simple closure of perforation with or without resection anastomosis was done in thirty patients [Table 5], 21 of which had APACHE II score <10 and nine patients have APACHE II score ≥ 10. These patients had single perforation, small in size (≤1 cm), located within 60 cm of terminal ileum with less peritoneal soiling. Resection-anastomosis was performed because of multiple perforations or large perforation (>2 cm) or when segment of bowel appeared unhealthy for simple closure.
Ileostomy was performed in thirty patients, 11 of which had APACHE II score <10 and 19 patients have APACHE II score ≥10. Ileostomy was done in patients of extensive contamination, perforation situated near to ileo-cecal junction, large perforations (>1 cm), intra-operative findings suggestive of strictures or caseating lymph nodes.
On analysis, we could appreciate that simple closure of perforation with or without resection anastomosis was statistically significantly (P < 0.005) more done in patients with APACHE II score <10 whereas frequency of ileostomy was statistically significantly (P < 0.005) more done in patients with APACHE II score ≥10 [Table 5]. This signifies that patients with APACHE II score ≥10 are more likely to undergo ileostomy as compared to those with APACHE II score <10.
In study done by Ahuja and Pal  18 out of 30 patients in the low risk group, i.e. APACHE 0-9, underwent primary repair with diversion ileostomy and seven patients underwent primary repair. Sahu et al.  in their study on fifty patients concluded that the most common procedure is primary closure in low risk groups. These differences in the procedure chosen reflect different institutional protocols.
Various complications and their relation to APACHE II are listed in [Table 6] and total hospital stay is mentioned in [Table 7]. It is clear from the tables that as the APACHE II score increases the percentage of complication rate and hence hospital stay also increases. Complications such as wound infection/wound dehiscence and intraabdominal collections were statistically significantly (P < 0.05) more in patients with APACHE II score ≥10. Although statistically insignificant but two patients having APACHE II score ≥10 (n = 28) expired due to due to renal failure and sepsis accounting to 7.14% mortality as compared to no mortality in patients those with APACHE II score <10. Total hospital stay was 12.97 ± 3.50 days in patients with APACHE II < 10 score and 20.96 ± 5.09 days in patients with APACHE II ≥ 10 score (P < 0.001).
Previous studies addressing APACHE II and perforation peritonitis have shown increased mortality associated with high APACHE II. ,
Similarly study by Ahuja and Pal  found that patients having high APACHE II score, i.e., more than 20, had significantly higher incidence of postoperative complications as compared to patients with APACHE II scores <10. In study done by Sahu et al.  APACHE II score was measured before the treatment of secondary peritonitis and it was found that it correlated significantly with the mortality and morbidity of the patients. Komatsu et al.,  in their study on colonic perforation found that APACHE II score 19 or more was significantly related to poor prognosis.
Although this study correlates well with high APACHE II and poor outcome, it has few limitations. This study is based on a small group of patients in a single center. Each institution has its own institutional protocols to deal with patients which can affect the surgical outcome of the patients. Further large group multicenter studies are needed to make any valediction.
| Conclusion|| |
Perforation peritonitis is a common surgical emergency, and Enteric fever is the most common cause. APACHE II is a useful score to predict the surgical outcome and complication rate. It can guide the clinician regarding choosing particular modality of treatment and comparison of outcomes of various surgical procedures.
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Conflicts of interest
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]