European Journal of Cardiovascular Medicine

Peritonitis is inflammation of peritoneum and peritoneal cavity and is most commonly due to localized or generalized infection. Perforation of a hollow viscera leads to escape of the visceral contents into the peritoneal cavity. Although the initial content may be sterile, eventually it will be contaminated due to direct bacterial invasion. Perforation peritonitis is the most common surgical emergency in India. The management of peritonitis continues to have high morbidity and mortality inspite of improved surgical techniques and antibiotics.¹ The reported mortality rate ranges between 17% to 63%.²

Perforation peritonitis is a frequently encountered surgical emergency in tropical countries like India, most commonly affecting young men as compared to the studies in the West where the mean age is between 45 to 60 years.³ The diagnosis is suspected in the absence of clinical improvement or in the presence of clinical worsening ≥24 hours after presumed adequate surgical source control, antimicrobial and medical management and exclusion of extra-abdominal sources of sepsis.⁴

The knowledge of the microbial distribution according to the anatomical site of perforation is essential, because understanding of the regional distribution and characteristics of bacteria will ensure an optimal empirical choice of antibiotic in these patients. It can be obtained by culture of peritoneal fluid obtained intraoperatively. Although some guidelines on empirical antibiotics for intraabdominal infections have been published, most studies on causative bacteria are quite old and were performed before the 2000s. The contaminating micro-organisms responsible for peritonitis with hollow viscous perforation are frequently polymicrobial and diverse.⁵ Until recently, the leading pathogens were gram negative bacilli and anaerobic bacteria.⁶ Of late, fungal micro-organisms (Candida) are being reported with increasing frequency.⁷ Different studies show that the prevalence of different micro-organisms in intestinal perforation peritonitis varies with geographical area, patient profile and location of the perforation. Until recently the leading pathogens associated with secondary peritonitis were gram negative and anaerobic bacteria. Fungal infection has become more common in recent years especially in critically ill patients in intensive care. Higher incidence of fungal isolates has been reported in gastroduodenal perforations.⁸

TABLE 1:- COMMON CAUSES OF PERITONITIS

AIMS AND OBJECTIVES

1. To evaluate the microbiological profile of intraoperative specimens of peritoneal fluid collected during exploratory laparotomy.
2. To evaluate the frequency of positive fungal cultures of intraoperative specimens of peritoneal fluid collected during exploratory laparotomy

This study was conducted prospectively in the Department of General Surgery, Government Medical College & Rajindra Hospital, Patiala. 70 patients admitted to Surgical Emergency with acute abdomen, proven to be a case of peritoneal perforation on the basis of investigations (X-ray Abdomen, USG Whole Abdomen and CECT Abdomen if needed) were selected randomly and their intraoperative findings were noted for this study. These patients were evaluated on the basis of pre operative signs and symptoms and investigations. Comorbidities, site of perforation and primary cause of perforation were studied with the help of necessary investigations and intraoperative findings.

Preoperative clinical factors recorded were include duration of fever, duration of abdominal pain and preoperative use of antibiotics, Preoperative medical conditions, pre-existing malignancy and history of drug addiction were also be recorded.

SOURCE OF DATA

Data for this prospective Study was sourced from patients admitted to surgical emergency, Rajindra Hospital, Patiala during the period of study.

INCLUSION CRITERIA

1. The patients above 18 years of age presenting with signs of peritonitis and operative findings showing peritoneal perforation.
2. Patients with gut perforated including appendix.

EXCLUSION CRITERIA

1. The patients who had been operated for perforations earlier.
2. All cases with either primary peritonitis or that due to anastomotic dehiscence were excluded.
3. Patients not willing to enroll in the study.
4. Patient who had been operated for gall bladder perforation.

PRE-OPERATIVE ASSESSMENT

History

Peritonitis typically presented as acute abdomen. In our study, abdominal pain was the most important symptom. The duration of abdominal pain is critical; pain lasting >24–48 hours often indicate sepsis or multi-organ dysfunction. Nausea and vomiting may accompany the pain.⁹

Examination

Clinical evaluation should focus on intravascular hydration, presence of shock, or multi-organ dysfunction, and adequacy of resuscitation. In our study, systemic features included fever, tachycardia, tachypnoea, and leukocytosis. The abdominal findings included distension from ileus, tenderness or rebound tenderness, guarding, and rigidity due to peritoneal irritation. Absent bowel sounds was a typical finding. Rectal and pelvic examinations revealed localized tenderness or an inflammatory mass at times.

Investigations

Recommended investigations were done including complete blood count, serum electrolytes, liver and kidney function tests, blood sugar, and ECG. In patients with systemic sepsis, coagulation profile and blood gas analysis were also warranted. Cultures of blood, urine, and peritoneal fluid were obtained prior to starting empiric antibiotics. X-ray was performed to detect pneumoperitoneum—air or gas in the peritoneal cavity. But for patients with high suspicion but no significant X-ray findings, CT was planned since it is more sensitive for diagnosis.¹⁰

Management of Perforation Peritonitis

The primary goals of surgery are elimination of contamination, reduction of bacterial load, and prevention of persistent sepsis. A midline incision was preferred to ensure complete exploration of the abdominal cavity, with meticulous hemostasis and suctioning of all fluid collections. Peritoneal fluid was sampled for Gram’s staining and fungal culture. Operative strategies varied according to site and pathology, commonly including Graham’s omental patch repair for gastroduodenal perforations, primary closure, resection with anastomosis, or stoma formation (ileostomy/colostomy) and appendectomy in selected cases.

METHODOLOGY FOR SAMPLE COLLECTION

The intraoperative specimens of peritoneal fluid were collected during surgery in sterile containers using all aseptic precautions and preserved at 4 degree celsius in case of delay. Specimens were immediately transferred to the microbiology laboratory. In the laboratory, culture for aerobic bacteria and fungi were done. For bacterial isolation, Blood agar and MacConkey agar were used and the plates were inoculated with specimens and were incubated at 37°C for 24 hours. Cultures positive for bacterial growth were identified by standard microbiological methods. Sabouraud dextrose agar (SDA) was used as a selective medium for isolation of fungi and incubation was done at 37°C for 7 days. Lactophenol Cotton Blue mount showing budding yeast cells from the colonies obtained on SDA were identified by conventional methods such as germ tube test, sugar fermentation and assimilation reactions.

STUDY DESIGN

A prospective randomized, controlled crossover study was carried out in selected patients visiting the ESW of the Department of General Surgery, Government Medical College & Rajindra Hospital, Patiala.

PERIOD OF STUDY

Over a period of 1.5 years

SAMPLING TECHNIQUES FOLLOWED

Every consecutive patient fulfilling inclusion and exclusion criteria were enrolled to complete the above calculated sample size (n=70).

Perforation peritonitis remains a major surgical emergency in India, with demographic and clinical profiles differing significantly from those reported in Western literature. (This prospective randomized, controlled crossover study done over a period of 1.5 years assessed its various aspects including the demographic distribution, clinical features, management, complications including the surgical site infections as well as mortality with the sample size of 70 as per the inclusion criteria)

 In our study, the mean age of presentation was 38.08 years, with nearly three-fourths of patients being male. This finding aligns with previous Indian series (Jindal et al., Goyal et al.)^11,12, which also reported a male predominance in younger age groups. In contrast, Western studies (Mosdell et al.)¹³ have consistently shown a higher mean age (45–60 years), reflecting geographic and lifestyle variations. (Table 2)

TABLE 2: - MEAN AGE OF PRESENTATION

The clinical presentation in our cohort was typical of generalized peritonitis, with abdominal pain, tachycardia, rigidity, and absent bowel sounds being the most consistent findings. Fever and hypotension were relatively less frequent and were consistent with the findings reported by Goyal et al.¹² and Rajender et al.¹⁴ The predominance of delayed presentation (2–3 days in nearly half of patients) is a crucial determinant of morbidity, emphasizing gaps in early recognition and referral systems in resource-limited settings. (Table 3) 

TABLE 3: - DISTRIBUTION OF PATIENTS ACCORDING TO CLINICAL PRESENTATION

Ileal perforations were the commonest site in this study (44.2%), followed closely by gastroduodenal perforations (38.5%). This contrasts with Western data (Bail et al.)⁽¹⁵⁾ where peptic ulcer perforations dominate. The higher incidence of ileal perforations in India can be attributed to endemic typhoid fever and tuberculosis, consistent with prior observations by Chaudhary et al.¹⁶ and Jhobta et al.¹⁷ Appendicular and colonic perforations were infrequent, as noted in global series. (Table 4)

TABLE 4 DISTRIBUTION OF PATIENTS ACCORDING TO ANATOMICAL SITE OF PERFORATION.

In our study, surgical treatment was based on the site and type of pathology, with most patients undergoing laparotomy with Graham’s patch (54%) or primary repair (40%), while ileostomy (20%) was reserved for selected ileal perforations. In patients having appendiceal perforation, appendectomy (10%) was done as standard care procedure. These approaches align with both national and international practices, where simple closure with or without omentopexy remains the standard of care for peptic perforations (Dandapat et al., Noorani et al.).^18,19

Postoperative complications were substantial, with surgical site infections (50%), pleural effusion (15.71%), and residual abscesses (14.29%) being the most frequent and being consistent with studies done by Jindal et al¹¹ and Goyal et al.¹² underscoring the prognostic role of intra-abdominal fungal sepsis, an area that warrants greater clinical attention. (Table 5).

TABLE 5 DISTRIBUTION OF PATIENTS ACCORDING TO POST OPERATIVE COMPLICATIONS

In our study, the peritoneal fluid culture showed bacterial growth in 56% of patients sample with E. coli (44%) being the commonest. However, this finding is in contrary with the study done by Jindal et al.¹¹ where gram positive cocci (45.7%) were being observed as the commonest ones. (Table 6).

TABLE 6: DISTRIBUTION OF PATIENTS ACCORDING TO PERITONEAL FLUID BACTERIAL CULTURE

Notably, fungal isolation from peritoneal fluid was observed in 55.71% patients, predominantly Candida albicans (37.14%). The presence of fungal positivity was strongly associated with prolonged ICU and hospital stay, higher surgical site infection rates, and increased mortality. These findings corroborate earlier studies (Sandven et al.)²⁰ (Table 7)

TABLE 7: DISTRIBUTION OF PATIENTS ACCORDING TO PERITONEAL FLUID BACTERIAL CULTURE

The microbiological profile demonstrated clear site-specific variations. Duodenal perforations showed higher bacterial culture positivity (41.3%), most commonly isolating E. coli, while fungal positivity was 30.8% with Candida albicans as the predominant organism. Ileal perforations had both substantial bacterial growth (17.4%) with E. coli as the leading isolate, and the highest fungal positivity (46.2%), again dominated by Candida albicans. Gastric perforations demonstrated the lowest bacterial (10.8%) and fungal (12.8%) positivity, but where present, E. coli and Candida species were the chief pathogens. These findings underline the importance of tailoring antimicrobial and antifungal therapy to the site of perforation, with particular vigilance for fungal coinfection in small bowel perforations.^11,12,8,20

The mortality rate in our study was 11.4%, comparable to other Indian series (Jhobta et al. – 10%). Delayed presentation and sepsis were the key contributors. In contrast, Western studies have documented both lower (5–15%) and higher (up to 50% in delayed cases) mortality rates. These variations highlight the interplay of early diagnosis, timely surgical intervention, and microbial spectrum in determining outcomes.  ^[17,3,14]

Limitations of this study include its single-centre design and relatively small sample size, which may not fully represent the heterogeneity of perforation peritonitis across diverse Indian settings. Furthermore, routine antifungal therapy was not assessed, despite high fungal isolation rates, leaving open questions regarding its therapeutic benefit.

SUMMARY

1. The mean age of presentation was 38 years, reflecting a younger demographic compared to Western literature where the average age is 45–60 years. This highlights the regional variation in disease profile and epidemiology.
2. In the present study (n=70), we found that 44.2% patients were of ileal perforation while 38.5% patients were of gastroduodenal perforation and 7.14% patients were of appendicular perforation. In 4.29% patients, jejunal perforation was seen while perforation of sigmoid colon was seen in 1.43% patients.
3. Out of 70 patients 54% patients were managed by EL + GRAHM'S Omental Repair while 40% patients were managed by EL + Primary Repair and 20% patients were managed by EL + Ileostomy.
4. Complications were frequent, with surgical site infections being the most common, followed by pleural effusion and intra-abdominal abscesses, which significantly contributed to postoperative morbidity.
5. In the present study, 44% patients sample showed growth of E.coli while 24% samples were of gram positive cocci and 18% samples were of klebsiella.
6. Out of 70 patients, 55% samples were fungal positive. Candida albicans was the most common fungal organism isolated, and fungal positivity was significantly associated with prolonged ICU stay, higher surgical site infection rates, and worse outcomes.
7. Bacterial culture positivity varied by site of perforation: 41.3% of duodenal perforations, 17.4% of ileal perforations, and only 10.8% of gastric perforations yielded positive bacterial cultures.
8. Fungal culture positivity was also site-dependent. Out of 21 duodenal perforations, 30.8% showed fungal growth, while 46.2% of ileal perforations and 12.8% of gastric perforations were fungal culture positive. These findings underline the site-specific microbiological spectrum and highlight the particularly high fungal burden associated with small bowel perforations.
9. Overall mortality was 11.4%, primarily due to delayed presentation (>48–72 hours) and sepsis at admission. Late presentation correlated with diffuse peritonitis and multi-organ dysfunction, while fungal positivity further worsened outcomes.

This study reinforces the epidemiological differences between Indian and Western populations in perforation peritonitis, with younger age at presentation, male predominance, and ileal perforations being characteristic in India. Delayed presentation remains the most significant predictor of adverse outcomes. The high prevalence of fungal infection and its association with morbidity and mortality suggests a need for further research into early antifungal strategies. Prompt surgical intervention, improved awareness, and robust critical care support remain essential for reducing mortality in this challenging surgical emergency.

1. Prakash A, Sharma D, Saxena A, Somashekar U, Khare N, Mishra A, Anvikar A. Effect of Candida infection on outcome in patients with perforation peritonitis. Indian J Gastroenterol. 2008;27(3):107-9.
2. Wacha H, Hau T, Dittmer R, Ohmann C. Risk factors associated with intra-abdominal infections: a prospective multicenter study. Langenbecks Arch Surg. 1999;384(1):24-32.
3. Tripathi MD, Nagar AM, Srivastava RD, Partap VK. Peritonitis – study of factors contributing to mortality. Indian J Surg. 1993; 55:342-9.
4. Paugam-Burtz C, Dupont H, Marmuse JP, Chosidow D, Malek L, Desmonts JM, et al. Daily organ-system failure for diagnosis of persistent intra-abdominal sepsis after postoperative peritonitis. Intensive Care Med. 2002; 28:594-8.
5. Blot S, De Waele JJ. Critical issues in the clinical management of complicated intra-abdominal infections. Drugs. 2005;65(12):1611-20.
6. Wittmann DH, Schein M, Condon RE. Management of secondary peritonitis. Ann Surg. 1996;224(1):10-18.
7. Wallace WC, Cinat ME, Nastanski F, Gornick WB, Wilson SE. New epidemiology for postoperative nosocomial infections. Am Surg. 2000;66(9):874-8.
8. Shan YS, Hsu HP, Hsieh YH, Sy ED, Lee JC, Lin PW. Significance of intraoperative peritoneal culture of fungus in perforated peptic ulcer. Br J Surg. 2003;90(10):1215-9.

2. Johnson CC, Baldessarre J, Levison ME. Peritonitis: update on pathophysiology, clinical manifestation and management. Clin Infect Dis. 1997; 24:1035-45.
3. Lee CH. Images in clinical medicine. Radiologic signs of pneumoperitoneum. N Engl J Med. 2010; 362:2410.
4. Jindal N, Singh A, Singh J, Kaur S. Spectrum of perforation peritonitis in tertiary care hospital in north India. Trop Gastroenterol. 2014;35(3):153-7.
5. Goyal S, Jindal N, Singla RL, Singla S. Perforation peritonitis: a clinical study of 77 cases. Int J Res Med Sci. 2016;4(12):5443-7.
6. Rajender A, Singh G, Kumar A. A clinical study of perforation peritonitis. J Evol Med Dent Sci. 2015;4(61):10633-41.
7. Mosdell DM, Morris DM, Voltura A, Pitcher DE, Twiest MW, Milne RL, et al. Antibiotic treatment for surgical peritonitis. Ann Surg. 1991;214(5):543-9.
8. Bail B, Greca FH, Pissaia A Jr, Biondo-Simões MLP. Peptic ulcer perforation: analysis of 215 cases. Rev Col Bras Cir. 1989; 16:135-40.
9. Chaudhary A, Agrawal R, Haran RP, Gupte P, Dhareshwar J. Perforation peritonitis: a clinical study of 46 cases. Indian J Surg. 1984; 46:94-8.
10. Jhobta RS, Attri AK, Kaushik R, Sharma R, Jhobta A. Spectrum of perforation peritonitis in India – review of 504 cases. World J Emerg Surg. 2006;1:26.
11. Dandapat MC, Mukherjee LM, Mishra SB, Kar PK. Gastrointestinal perforations. Indian J Surg. 1991; 53:189-93.
12. Noorani A, Khan A, Vohra A. Omental patch repair of perforated duodenal ulcer. J Pak Med Assoc. 2013;63(7):845-7.
13. Sandven P, Qvist H, Skovlund E, Giercksky KE. Significance of Candida recovered from intraoperative specimens in patients with intra-abdominal perforations. Crit Care Med. 2002;30(3):541-7.