European Journal of Cardiovascular Medicine

Peritonitis is a condition which signifies the inflammation of the peritoneum which is a tissue that supports and covers the organs of the abdomen and lines the inner wall of the abdomen. Perforation peritonitis is condition that signifies the most common surgical emergency reported worldwide including in India and poses a high burden on the healthcare system in countries with limited healthcare resources as India. Perforation peritonitis usually affects the subjects in younger age and more commonly encountered in male subjects compared to females. However, in the Western countries, the mean age of perforation peritonitis is 45-60 years.¹

In most of the affected subjects, the cases are presented in the late stages to the institute and have well-established generalized peritonitis with fecal or purulent contamination along with septicemia of various degrees. The symptoms and signs of nearly all the subjects with perforation are particular and clinical diagnosis of peritonitis can be made in all the affected subjects. CT (computed tomography), abdomen ultrasound, and X-ray abdomen are the common investigations done in subjects with perforation peritonitis to confirm the diagnosis. However, in few subjects with perforation peritonitis, diagnostic laparoscopy can be helpful to reach the diagnosis.²

Peritonitis is usually seen as an acute abdomen. Local findings of perforation peritonitis are decreased bowel sounds, abdominal distension, rigidity, guarding, and/or generalized abdominal tenderness, whereas, systemic findings of the condition include disorientation, oliguria, dehydration, tachypnea, tachycardia, restlessness, fever with rigor or chills which can ultimately result in shock. Factors that affect the prognosis in subjects with perforation peritonitis are contamination in peritoneal cavity, site of origin of peritonitis, cause of infection, malignoma, serum albumin, preoperative status, alcoholism and drug abuse, habits of smoking, malnutrition, metabolic acidosis, vitals, and age of the subjects. Untreated peritonitis can spread rapidly to blood causing sepsis and to other organs leading to multiple organ failure and death.³

In cases of gastrointestinal perforation, clinical trend depicts a significant variation based on the geographical regions. In western countries having high predilection for lower gastrointestinal perforations compared to upper gastrointestinal perforations seen in developing nations as India. The etiological factors for perforation peritonitis in India are multiple and shows a high variation compared to Western countries. Majority of subjects with perforation peritonitis present in late stages and have septicemia and purulent peritonitis. Hence, surgical management of perforation peritonitis becomes vital, complex, and demanding. Combine use of intensive care support, improved surgical technique, and anti-microbial therapy can help to improve outcomes in these subjects.⁴ The present study was aimed to assess the clinical spectrum of perforation peritonitis in Indian context and to assess the demographic data, etiological factors, intraoperative factors, operative parameters, and postoperative outcomes in Indian subjects with perforation peritonitis

The present prospective clinical study was aimed to assess the clinical spectrum of perforation peritonitis in Indian context and to assess the demographic data, etiological factors, intraoperative factors, operative parameters, and postoperative outcomes in Indian subjects with perforation peritonitis.  The study was done at Department of General Surgery, ESIC Medical Colleges and Hospital, K. K. Nagar, Chennai, Tamilnadu after the clearance was taken by the concerned Institutional Ethical committee. The study subjects were from Department of General Surgery of the Institute. Verbal and written informed consent were taken from guardians/parents of all the subjects before study participation.

The study assessed 434 subjects with perforation peritonitis that presented to the Institute within the defined study period. The inclusion criteria for the study were subjects with perforation peritonitis with confirmed clinical diagnosis and further confirmed on radiographic assessment on X-ray as Gas Under Diaphragm and free fluid in the peritoneal cavity as noted on the abdominal ultrasonography. The exclusion criteria for the study were subjects aged <14 years and subjects that had perforation peritonitis from the blunt trauma to the abdomen.

After final inclusion of the subjects, detailed history was recorded for each participant followed by comprehensive clinical assessment of the perforation. For perforation peritonitis, the spectrum was assessed following the intraoperative assessment of the perforation site. Based on the perforation site, hemodynamic status and intra-abdominal contamination was assessed and surgery was performed. Other parameters assessed were outcomes in the study subjects.

The data collected were statistically analyzed with the chi-square test, Fisher’s exact test, Mann Whitney U test, and SPSS (Statistical Package for the Social Sciences) software version 24.0 (IBM Corp., Armonk. NY, USA) using ANOVA, chi-square test, and student's t-test. The significance level was considered at a p-value of <0.05

The present prospective clinical study was aimed to assess the clinical spectrum of perforation peritonitis in Indian context and to assess the demographic data, etiological factors, intraoperative factors, operative parameters, and postoperative outcomes in Indian subjects with perforation peritonitis.  The study assessed 434 subjects with perforation peritonitis that presented to the Institute within the defined study period. Concerning the demographic and disease characteristics in study subjects preoperatively, there were 82.9% (=360) male and 17.1% (n=74) females in the study. The mean age of the study subjects was 44.34±18.28 years and there were 64.97% (n=282) subjects aged <50 and 35% (n=152) subjects were >50 years of age. There were 6.5% (n=14) subjects from urban and 93.5% (n=406) subjects from the rural background (Table 1).

Table 1: Demographic and disease characteristics in study subjects preoperatively

Table 2: Operative data in study subjects with perforation peritonitis

Table 3: Postoperative data in study subjects with perforation peritonitis

For the disease characteristics in study subjects, most common personal habit was smoking seen in 73% (n=316) subjects followed by NSAIDs in 67.7% (n=294), alcohol in 58.5% (n=254), opioid intake in 23% (n=100), spicy foods in 20.7% (n=94), and stress in 11.5% (n=50) study subjects respectively. Chief complaint in study subjects was constipation, nausea and vomiting, abdominal distension, and abdominal pain in 35.94% (n=156), 88% (n=382), 64% (n=276), and 1005 (n=434) study subjects respectively. On abdominal X-ray, gas under diaphragm was seen in 94.5% (n=410) subjects and abdominal USG showed mild and moderate free fluid in 65.4% (n=284) and 34.6% (n=150) study subjects respectively (Table 1).

It was seen that for operative data in study subjects, the site of peritoneal perforation was duodenal as most common site seen in 33.6% (n=146) subjects followed by ileal, Pre pyloric and gastric, appendicular, jejunal, and colonic site in 25.8% (n=112), 24.4% (n=106), 7.8% (n=34), 4.6% (n=20), and 3.6% (n=16) study subjects respectively. The surgical procedure being done in study subjects was Gastrojejunostomy in 0.9% (n=4) subjects, resection and anastomosis in 2.3% (n=10) subjects, colostomy in 3.3% (n=14) subjects, appendectomy in 4% (n=18) subjects, ileostomy in 14% (n=60) subjects, simple closure and primary repair in 20% (n=86), and Grahm’s patch repair in 56% (n=242) study subjects respectively (Table 2).

The study results showed that on assessing the postoperative data in study subjects with perforation peritonitis, mortality was recorded in 5.5% (n=24) study subjects. For morbidity, anastomotic leak, acute renal failure, burst abdomen, septicemia, abdominal collection, pneumonia, and wound infection was seen in 0.9% (n=4), 1.4% (n=6), 3.7% (n=16), 4.1% (n=18), 6.9% (n=30), 8.8% (n=38), and 11% (n=48) study subjects respectively.

The present study assessed 434 subjects with perforation peritonitis that presented to the Institute within the defined study period. Concerning the demographic and disease characteristics in study subjects preoperatively, there were 82.9% (=360) male and 17.1% (n=74) females in the study. The mean age of the study subjects was 44.34±18.28 years and there were 64.97% (n=282) subjects aged <50 and 35% (n=152) subjects were >50 years of age. There were 6.5% (n=14) subjects from urban and 93.5% (n=406) subjects from the rural background. These data were comparable to the previous studies of Bali RS et al⁵ in 2014 and Jhobta RS et al⁶ in 2006 where authors assessed subjects with demographic data comparable to present study in their respective studies for subjects with perforation peritonitis.

Concerning the disease characteristics in study subjects, most common personal habit was smoking seen in 73% (n=316) subjects followed by NSAIDs in 67.7% (n=294), alcohol in 58.5% (n=254), opioid intake in 23% (n=100), spicy foods in 20.7% (n=94), and stress in 11.5% (n=50) study subjects respectively. Chief complaint in study subjects was constipation, nausea and vomiting, abdominal distension, and abdominal pain in 35.94% (n=156), 88% (n=382), 64% (n=276), and 1005 (n=434) study subjects respectively. On abdominal X-ray, gas under diaphragm was seen in 94.5% (n=410) subjects and abdominal USG showed mild and moderate free fluid in 65.4% (n=284) and 34.6% (n=150) study subjects respectively. These findings were in agreement with the results of Agarwall N et al⁷ in 2007 and Malangoni MA et al⁸ in 2006 where disease data, chief complaint, and radiographic features reported by the authors in their studies were comparable to the results of the present study.

The study results showed that for operative data in study subjects, the site of peritoneal perforation was duodenal as most common site seen in 33.6% (n=146) subjects followed by ileal, Pre pyloric and gastric, appendicular, jejunal, and colonic site in 25.8% (n=112), 24.4% (n=106), 7.8% (n=34), 4.6% (n=20), and 3.6% (n=16) study subjects respectively. The surgical procedure being done in study subjects was Gastrojejunostomy in 0.9% (n=4) subjects, resection and anastomosis in 2.3% (n=10) subjects, colostomy in 3.3% (n=14) subjects, appendectomy in 4% (n=18) subjects, ileostomy in 14% (n=60) subjects, simple closure and primary repair in 20% (n=86), and Grahm’s patch repair in 56% (n=242) study subjects respectively. These results were consistent wit the findings of Chakma SM et al⁹ in 2013 and Ross JT et al¹⁰ in 2018 where operative results in subjects with perforation peritonitis comparable to the present study were also reported by the authors in their studies.

It was seen that on assessing the postoperative data in study subjects with perforation peritonitis, mortality was recorded in 5.5% (n=24) study subjects. For morbidity, anastomotic leak, acute renal failure, burst abdomen, septicemia, abdominal collection, pneumonia, and wound infection was seen in 0.9% (n=4), 1.4% (n=6), 3.7% (n=16), 4.1% (n=18), 6.9% (n=30), 8.8% (n=38), and 11% (n=48) study subjects respectively. These findings were in line with the results of Bali RS et al¹¹ in 2014 and Agbonrofo PI et al¹² in 2018 where postoperative data in study subjects with perforation peritonitis reported by the authors in their studies were comparable to the results of the present study.

Considering its limitations, the present study concludes that perforations of UGI (upper gastrointestinal) is a common finding in subjects with perforation peritonitis in India. NSAIDs, smoking, and alcohol abuse are main etiological factors associated with perforation peritonitis. It is vital to prevent the abuse associated with these substances can remarkably reduce the incidence of upper gastrointestinal perforations. However, further studies with larger sample size and longer monitoring are needed to reach a definitive conclusiom.

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