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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 5
| Issue : 3 | Page : 116-121 |
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Gastrointestinal perforation peritonitis in India: A study of 442 cases
Laxmi Narayan Meena1, Sanchit Jain2, Prahlad Bajiya1
1 Department of General Surgery, SMS Medical College, Jaipur, Rajasthan, India
2 Department of General Surgery, RUHS College of Medical Sciences, Jaipur, Rajasthan, India
| Date of Web Publication | 6-Nov-2017 |
Correspondence Address:
Sanchit Jain
6, Kailash Vihar, Lal Kothi, Tonk Road, Jaipur - 302 015, Rajasthan
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ssj.ssj_33_17
Introduction: Perforation is defined as an abnormal opening in a hollow organ or viscus. Gastrointestinal perforation is one of the common surgical emergencies in developing countries. The diagnosis is mainly clinical and is aided by radiological investigations. The present study was conducted to highlight the spectrum of hollow viscus perforation peritonitis in terms of etiology, clinical presentations, site of perforation, surgical treatment, postoperative complications, and mortality encountered at SMS Medical College and Hospital, Jaipur, India.
Materials and Methods: The study was a hospital-based prospective observational study conducted from April 2012 to October 2013 in the Department of General Surgery. During the study period, a total of 442 patients underwent surgery for secondary peritonitis. The patients included in the study were patients (>12 years) presenting with gastrointestinal perforation and undergoing emergency laparotomy.
Results: Out of 442 patients, 91.2% (403) were males, with male-to-female ratio being 10.33:1. The mean age was 39.13 years. About 79.2% of the patients were below 50 years. Free gas under diaphragm on chest X-ray was noted in 86.2% cases. Duodenum was the most common site of perforation in 158 patients. The most common etiology for perforation was acid peptic disease (41.4%). Simple closure was the most common surgical procedure being performed in 63.8%. Overall morbidity and mortality recorded in this study were 42.8% and 14.7%, respectively.
Conclusion: Early diagnosis, resuscitation with fluids, and timely surgical intervention are the most important factors deciding the fate of the patient with perforation peritonitis. Keywords: Morbidity, mortality, perforation
How to cite this article:
Meena LN, Jain S, Bajiya P. Gastrointestinal perforation peritonitis in India: A study of 442 cases. Saudi Surg J 2017;5:116-21 |
| Introduction | |  |
Generalized peritonitis as a result of gastrointestinal perforation is a common surgical emergency in India.[1] In spite of advances in perioperative care, antimicrobial therapy, and intensive care support, perforation peritonitis still has high morbidity and mortality.[2],[3] Perforation is defined as an abnormal opening in a hollow organ or viscus. It is derived from the Latin perforatus, meaning “to bore through.” The spectrum of etiology of perforation is different between developing and developed countries,[4],[5] and there is a paucity of data from India regarding its etiology, prognostic indicators, morbidity, and mortality patterns.[6] Our study was designed to highlight the spectrum of hollow viscus perforation peritonitis in terms of etiology, clinical presentations, site of perforation, surgical treatment, postoperative complications, and mortality encountered by us at SMS Medical College and Hospital, Jaipur.
| Materials and Methods | | |
The study was a hospital-based prospective observational study conducted in the Department of General Surgery, SMS Medical College and Hospital, Jaipur. The study was done after permission from the Ethical Committee and Research Review Board of the institute from April 2012 to October 2013. The cases included in the study were patients (>12 years) presenting with gastrointestinal perforation and undergoing emergency laparotomy. Patients presenting with esophagus, pancreatobiliary tree, or genitourinary tract perforation or undergoing laparotomy for primary peritonitis, tertiary peritonitis (anastomotic leak and fecal fistula), or pancreatitis were excluded from the study.
All patients admitted to our hospital with acute pain abdomen or history of blunt trauma abdomen were evaluated with detailed history of their illness with onset and duration of presenting symptoms. A history of any other comorbid illness and personal habits was also taken. After a general and abdominal examination (suggesting perforation peritonitis), an X-ray abdomen upright was obtained. A diagnosis of gastrointestinal perforation was made on the basis of history, clinical examination, and presence of free gas under diaphragm on abdominal X-ray. In the rest of the cases, ultrasonography [USG]/computed tomography (CT) abdomen/paracentesis (four-quadrant aspiration – 4QA) was done to confirm the diagnosis. As soon as the diagnosis was made, resuscitation was started with large volume of crystalloids (blood transfusion if necessary), nasogastric suction to empty the stomach, and broad spectrum antibiotics were administered. Following adequate resuscitation, patients underwent exploratory laparotomy by a midline incision, and based on the intraoperative findings, the further management was decided. The operating surgeon decided the procedure to be performed. Peritoneal cavity was irrigated with warm normal saline (3-5 litres). Intra-abdominal drains were placed depending on peritoneal contamination and abdomen was closed after achieving complete hemostasis. Postoperatively, intravenous antibiotics were given for 5–10 days after the operation. The drug regimen was not uniform and was based on the cause of perforation and degree of contamination. Standard postoperative care was provided to each patient. In case of uneventful recovery, patients were discharged from the hospital when they had a good appetite; they were accepting orally and had good ambulation. If a patient had complication, they were managed accordingly. All the patients were called for follow-up 15 days after surgery and after that as per requirement.
All data related to the patient from admission to discharge was collected in a proforma after taking written consent. Data were analyzed using IBM SPSS software version 20, Chi-square test was used to compare variables, and tests were considered significant when P < 0.05.
| Results | | |
During the study period, a total of 442 participants underwent surgery for secondary peritonitis. Among these, 91.2% (403) of them were males and 8.8% (39) were females, with male-to-female ratio being 10.33. In our study, the mean age of patients was 39.13 ± 15.29 years. Three hundred and fifty (79.2%) patients were <50 years, while only 20.8% (92 patients) were >50 years. The time taken by patients between the onset of symptoms and presentation to the hospital was <48 h in 244 (55.2%) patients and >48 h in 198 (44.8%) patients. Clinical presentation of patients varied according to the site and cause of perforation [Table 1]. Abdominal pain was observed in all the patients and distension and constipation in most of the patients. Tachycardia (pulse rate >100/min) was noted in 83.5% of patients, while about 30% of patients had low urine output. A positive history of chronic smoking was noted in 106 patients (24%) and nonsteroidal anti-inflammatory drug (NSAID) abuse in 67 (15.2%) patients. Chronic obstructive pulmonary disease was the most common preexisting comorbidity seen in 6.1% patients. In our study, according to radiological investigation, Chest X-ray or X-ray flat plate abdomen showed free gas under diaphragm in a majority of perforations (86.2%), but the maximum proportion was found in acid peptic ulcer diseases (100%), followed by enteric (96.6%) and tubercular (95.5%), and the least was found in appendicular (28.6%) type. Multiple air fluid levels in X-ray abdomen erect view suggesting the presence of obstruction in association with perforation were noticed in 23.3% patients.
In our study, according to site [Table 2], gastroduodenal [205 (46.4%)] was the most common site, followed by small bowel (jejunum and ileum) [181 (41%)], appendix [36 (8.1%)], and large bowel [20 (4.5%)]. Overall duodenum was the most common site of perforation (158 patients). Among the gastroduodenal types, acid peptic disease was the most common etiology, with the site of perforation being more commonly the duodenum in >79% of peptic perforation cases. Traumatic perforations were also seen more commonly in duodenum, while all the six patients with malignant perforation had gastric perforation. Jejunal and ileal perforations were seen in 41% patients, with typhoid being the most common etiology (85 patients) followed by trauma (49 patients). Other categories [Table 2] include jejunal diverticulum, ascaris infestation in the ileum, and Meckel's diverticulum. A total of 36 patients had perforation in the appendix, of which 97.2% presented with appendicitis while only one case had malignancy. In the large intestine, the most common etiology was trauma which was the cause of perforation in 65% population. In our study according to the peritoneal fluid (exudate), clear fluid (52%) was found in maximum proportion, especially in peptic and traumatic perforation. Purulent fluid (33.5%) was observed in peptic, enteric, and appendicular perforations, while fecal type (12.7%) in enteric and traumatic perforations, and hemoperitoneum (1.8%) in traumatic perforations.
In the study, a variety of operative procedures were performed depending on the patients' general condition, peritoneal contamination, site of perforation, gut viability, and surgeons' decision [Table 3]. The most commonly executed operative procedure was the simple closure of perforation either in a single or in a double layer in 63.8% cases. Stoma surgery had to be performed in 77 patients.
In the study population, the most commonly observed postoperative complication was lung infection in 107 (24.2%) patients followed by wound infection in 89 (20.1%) patients [Table 4]. In our study, the overall morbidity rate was 42.8% (189 patients) and the mortality rate was 14.7% (65 patients). The mean hospital stay was 8.8 days with a standard deviation of 3.74 days. The maximum duration of stay was 29 days.
| Discussion | | |
Perforation peritonitis is one of the most common surgical emergencies in developing nations like India.[1] In our study among 442 patients, 91.2% (403) of them were males and 8.8% (39) of them were females. All types of perforation occurred more frequently in male patients. All studies related to perforation peritonitis show a male preponderance, although the male-to-female ratio varies from 1.34:1 to 7:1.[2],[5],[7],[8],[9],[10] A possible reason for this finding may be smoking and alcohol intake, which is more frequent among men, thus increasing the risk of perforation.
In our study, the mean age of patients was 39.13 ± 15.29 years. The overall patients reported in the younger age group <50 years (350, 79.2%) was more in comparison to the older age group >50 years (92, 20.8%). In all types of perforations, patients were reported more in the <50 years' age group except in the malignant type of perforation where it was more in >50 years' age group. Similar observations were found by Jhobta et al.,[5] Gupta et al.,[9] and Ramakrishnaiah et al.[10] This finding is in contrast to studies in the Western countries where perforation primarily occurs in the elderly.[11] This is related due to the difference in the etiology. The Western literature suggests that foreign body, ischemia, radiotherapy, diverticula, Crohn's disease, etc. are the main causes of perforation, which are more commonly seen in elderly patients. In contrast to this, infection is the most common cause for perforations in developing countries. This includes acid peptic ulcer disease related to Helicobacter pylori infection, typhoid fever, and tuberculosis, which are quite common in young.[7],[12],[13],[14]
Abdominal pain was noted in all patients presenting with perforation followed by distension in 99% and constipation in 95%. Vomiting was significantly more common in appendicular and strangulation type. Diarrhea was significantly more common in appendicular type, while fever was significantly more commonly observed in appendicular and enteric perforations. Pain abdomen was the universal presenting symptom in other studies on perforation.[9],[10] Jhobta et al.[5] found abdominal pain in 98%, while Afridi et al.[15] reported a similar history in 78% patients. Clinical presentation of the patients varied according to the site and cause of perforation.
According to personal history, in our study, NSAID usage was observed more in strangulation type, acid peptic ulcer disease, and enteric perforation patients. Higher NSAID intake in peptic ulcer diseases is for treatment of some other pain, while in enteric fever, it was for management of fever. The proportion of the patients who had a history of chronic smoking was more in peptic perforation followed by strangulation. Alcohol users were more exposed for traumatic type of perforation because of higher risk for road traffic accidents and assaults. All these findings were found significant.
In our study, generalized peritonitis (98.2%) was observed significantly more as compared to localized peritonitis (1.8%). Localized peritonitis was observed only in appendicular (20%) type and malignant (11.1%) type of perforation. Similar observations were noted in other studies, although the percentage of generalized peritonitis varies from 83% to 96%.[5],[10],[15]
In our study, according to radiological investigation, on chest X-ray or X-ray flat plate abdomen free gas under diaphragm was observed in 86.2% patients, but the maximum proportion was found in acid peptic ulcer diseases (100%), followed by enteric (96.4%) perforation, and the least was found in appendicular (28.6%) type. USG was required to diagnose 61 (13.8%) patients with mostly appendicular and traumatic type of perforation, while 4QA and contrast-enhanced CT had a role in the diagnoses of traumatic perforation. Bansal et al.[16] reported an overall positivity rate of plain radiography in detecting pneumoperitoneum at 89.20%, which was highest for stomach and duodenal perforation (94.19%) and the least for appendicular perforation (7.69%) with highly significant difference (P< 0.001). In contrast, Jhobta et al.[5] found pneumoperitoneum in 67% patients, but none of the patients with appendicular perforation showed such finding. Furthermore, only 70% of patients had an evidence of pneumoperitoneum in the study by Afridi et al.[15]
In our study according to the site, gastroduodenal type [205 (46.4%)] was the most common site, followed by small bowel [181 (41%)], appendix [36 (8.1%)], and large bowel [20 (4.5%)] [Table 2]. Similar observations were noted by Jhobta et al.[5] in their study on 504 patients. In contrast, in developed Western countries, lower gastrointestinal tract perforation peritonitis has been reported to be more common.[17],[18],[19]
In our study, clear fluid (52%) was the most common peritoneal exudate. Similar observation was made by Haque et al.[20] who found clear fluid in 57.3%. In contrast, Jhobta et al.[5] found purulent (71%) to be the most common peritoneal fluid.
In our study, a variety of operative procedures were adopted depending on the patients' general condition, peritoneal contamination, site of perforation, gut viability, and surgeon's decision. The most commonly executed operative procedure was simple closure in 63.8% cases of the perforation, resection anastomosis in 7.2%, stoma in 17.4%, appendicectomy in 7.9%, and definitive procedure in 3.6%. All gastroduodenal perforations were managed with simple closure with omental patch (majority), simple closure with omental patch and feeding jejunostomy, Billroth I/II, pancreatoduodenectomy with FJ, and simple closure with triple-tube decompression. In small-bowel perforation, simple closure, resection anastomosis with or without proximal diversion stoma, and loop ileostomy were done. In the appendix, appendectomy and peritoneal lavage with drain placement and in colorectal perforation, right/left hemicolectomy, simple closure with or without stoma, and Hartmann's procedure were done. Similar observations were noted by Jhobta et al.,[5] with simple closure being the most commonly executed operative procedure in 60% patients.
Lung infection was the most commonly observed postoperative complication followed by wound infection. Lung infection was significantly higher in proportion in malignant, tubercular, and peptic perforations. Similar observations were made by Jhobta et al.,[5] while Afridi et al.[15] found wound infection to be the most common complication in 42% patients.
In our study, the overall morbidity rate was 42.8% (189 patients) and the mortality rate was 14.7% (65 patients). Jhobta et al.[5] reported an overall morbidity rate of 50% and mortality rate of 10%, while Memon et al.[21] in their study noted the morbidity and mortality rate at 48.5% and 16.7%, respectively.
Factors having association with morbidity and mortality were evaluated. In our study, there was no significant difference found with the age in morbidity, while mortality was significantly higher in >50 years' (26.1%) age groups as compared to <50 years (11.7%). Similar observation was noted in other study by Rajesh et al.[22] Morbidity and mortality were significantly higher in those presenting with duration of symptoms >48 h (P< 0.001). Similar observations were made by Rajesh et al.[22] and Kocer et al.[23] In our study, morbidity and mortality were higher in the presence of comorbid illness, but no significant difference was observed. The presence of concomitant medical illness has been previously identified as a significant predictor of the risk of postoperative morbidity and mortality by several authors.[24],[25] In our study, morbidity and mortality were higher in the presence of tachycardia, hypotension, tachypnea, and oliguria, and these findings were statistically significant. Paryani et al.[26] also concluded that all vital parameters – heart rate, blood pressure, and relative risk – have a significant effect on mortality. Furthermore, preoperative shock has been reported as the determinant of morbidity and mortality in patients with perforation peritonitis.[5]
| Conclusion | | |
In developing countries like India, the etiology and site of perforation continues to be different from developed countries where lower gastrointestinal tract perforations predominate. The important factors clearly deciding the fate of the patient with perforation peritonitis are early diagnosis, resuscitation with fluids and electrolyte balance, timely surgical intervention, appropriate use of antibiotics, and eliminating the source of infection. Since the most important factor associated with perforation in developing countries is infection, early diagnosis and treatment can reduce the incidence further.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]
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