European Journal of Cardiovascular Medicine

Gastrointestinal (GI) perforation is a critical medical condition with significant global and regional variations in its prevalence. Worldwide, it is a common cause of acute abdominal emergencies, with an estimated incidence ranging between 1.2 to 4 cases per 100,000 individuals annually. The underlying causes differ based on geographic and socioeconomic contexts. In developed nations, GI perforations are often linked to conditions such as diverticulitis and complications from medical procedures. On the other hand, in developing regions, infections like typhoid fever and tuberculosis, as well as obstructive pathologies and trauma, are leading causes [1]. Certain groups, including the elderly, immunocompromised individuals, and those with existing health issues like diabetes and chronic liver disease, face an elevated risk of developing this condition.

The study of GI perforation in tribal populations is particularly significant due to the unique challenges they encounter. Limited access to healthcare services often results in delayed diagnosis and treatment, worsening the prognosis. Geographic isolation and transportation difficulties further compound these delays, while cultural and socioeconomic barriers sometimes discourage seeking timely medical care. Infections such as typhoid fever, tuberculosis, and parasitic diseases are more common in tribal regions, increasing the risk of perforations. Additionally, poor nutrition and inadequate sanitation contribute to the population's overall vulnerability to gastrointestinal issues [2].

Healthcare disparities play a significant role in shaping outcomes for tribal populations with GI perforations. Diagnostic tools and surgical facilities are often unavailable or insufficient in these remote areas, leading to prolonged suffering and higher mortality rates. Unregulated use of medications like nonsteroidal anti- inflammatory drugs (NSAIDs) also contributes to the prevalence of peptic ulcers, which can progress to perforations [3]. These disparities highlight the urgent need for targeted public health interventions in these communities.

Understanding the burden of GI perforation in tribal populations can provide valuable insights into the impact of healthcare inequities on acute medical emergencies. This understanding can guide the development of region-specific strategies aimed at improving early detection and healthcare delivery. Initiatives to address malnutrition, prevent infections, and raise awareness about early symptoms can significantly reduce the incidence of perforations. Training local healthcare providers and enhancing surgical capabilities in tribal areas could also improve survival rates. By addressing these challenges, public health efforts can make meaningful progress in mitigating the risks and improving outcomes associated with GI perforations in underserved populations [4].

Hence, this study was undertaken to study the etio-clinico-pathological profile of GI perforation in a tertiary care center located in a tribal region of Central India.

This study was prospective observational study, meticulously planned to evaluate the etiology, clinical presentation, operative findings, and outcomes in patients with gastrointestinal (GI) perforation. done at our hospital from January 1, 2024, to December 31, 2024. The study adhered to the tenets of the Declaration of Helsinki, and approval from the institutional research ethics board was obtained for the study.

Participants were selected with a non-probability convenience sampling technique and data collection commenced. . The hospital serves as a critical healthcare center for a geographically vast and socioeconomically diverse population, predominantly comprised of rural and tribal communities. Its status as a referral center makes it a suitable setting for studying acute surgical emergencies such as gastrointestinal perforations, which often present late and with significant complications.

A purposive sampling method was employed, with an estimated sample size of 60 patients at the study's inception. However, during the actual course of the study, 105 eligible patients were included based on their fulfillment of the inclusion criteria and willingness to provide informed consent. The increased sample size was due to the high incidence of perforation cases presenting to the emergency unit and the researchers’ intent to include a broader dataset to improve the generalizability and statistical power of the findings.

Inclusion Criteria

Patients were included in the study based on the following criteria:

Ø  Clinically and radiologically diagnosed cases of gastrointestinal perforation.

Ø  Willingness to participate, evidenced by written informed consent.

Ø  Exclusion Criteria

Ø  Patients with the following characteristics were excluded:

Ø  Hepatobiliary perforations, as their pathophysiology and management differ significantly.

Ø  Traumatic and iatrogenic perforations, including those secondary to endoscopic or surgical procedures.

Ø  Anastomotic leaks occurring post-operatively were excluded to ensure homogeneity of primary pathology

All data collected were coded and entered into a secure database. Analysis was performed using SPSS (Statistical Package for Social Sciences) software. Descriptive statistics were applied to calculate mean, median, standard deviation, and frequency distribution. Inferential analysis included:

Ø   Chi-square and Fisher exact test: For categorical variables.

Ø   P-values < 0.05 were considered statistically significant.

A total of 105 patients were studied. Males represent the majority of the study population, accounting for 76.2 % of cases. Females constitute 23.8 % of the total study population. The highest number of patients falls within the 21-30 years age group, making up 23% of the cohort. This is followed by the 51-60 years group (20%) and 11-20 years (15.3%).

Table 1 showing demographic profile of patients.

Table 2 showing clinical features in the patients

Figure 1: clinical features in gastrointestinal perforation patients

Table 3: showing mean duration of symptoms

Table 4: Risk factors and site of perforation

Table 5: Showing Etiology of gastrointestinal perforations

Figure 2: Etiology of gastrointestinal perforations

Pain was the most prevalent symptom, reported by 100% of the patients. Anorexia (68.6%) and vomiting (67.6%) were also commonly reported. Fever was present in 60%, and constipation in 44.8% of the patients. Less common symptoms included abdominal distension (21.9%), breathlessness (21.9%), bleeding per rectum (11.4%), and diarrhoea (11.4%). Weight loss was observed in 6.6% of cases.

The mean duration was 1.66 ± 0.72 days, representing the largest group with 52 patients. 3–5 days group: Patients in this group had a mean symptom duration of 3.63 ± 0.62 days (41 patients). 6–10 days group: The mean duration was 7.21 ± 1.66 days among 11 patients. >10 days group: Only 1 patient fell in this category, with a mean (and SD) of 15.0 ± 0.0 days.

The most common co-morbidity observed was a history of tuberculosis (28 patients, 26.7%), followed closely by hypertension (27 patients, 25.7%). A history of diabetes was present in 21 patients (20.0%). Additionally, history of previous surgeries was noted in 20 patients (19.0%), and history of peptic ulcer disease (PUD) was found in 22 patients (19.8%).

Alcohol consumption emerges as the leading risk factor, followed by the Use of Pain Medication and smoking. Patients with a history of Use of Pain Medication or smoking should be monitored closely for gastric complications. These findings emphasize the need for risk factor modification strategies, such as alcohol and smoking cessation programs, and the judicious Use of Pain Medication to reduce the risk of perforation.

Out of the total 105 patients, Prepyloric perforation and appendicular perforation were the most commonly observed sites, with prepyloric perforation observed in 40 patients (38.1%), and appendicular perforation was noted in 40 patients (38.1%), suggesting a significant incidence related gastric perforation and acute appendicitis. Duodenal perforations were seen in 14 patients (13.3%), reflecting their consistent presence in peptic ulcer complications.

Peptic ulcer is the most common cause of gastrointestinal perforation, accounting for 60% of all cases. Appendicitis follows closely with 32.4%, contributing to appendicular perforations. Enteric fever, tuberculosis, and malignancy were rare causes. Unknown etiology was recorded in 2 patients (1.9%).

Perforation is defined as an abnormal opening in a hollow organ or viscus, leading to the leakage of its contents into the peritoneal cavity and resulting in peritonitis. This condition represents one of the most common surgical emergencies worldwide, including in India, where it poses significant challenges due to variations in etiology, delayed presentation, and limited healthcare access in rural and tribal regions. Despite advancements in surgical techniques, critical care, and antibiotics, perforation peritonitis remains associated with high morbidity and mortality, particularly in elderly patients and those with delayed intervention [5] .

The causes of gastrointestinal perforation are diverse, with peptic ulcer disease being the most prevalent, especially duodenal and gastric ulcers. Other contributing factors include trauma, both blunt and penetrating; iatrogenic causes such as endoscopic or surgical instrumentation; inflammatory conditions like appendicitis and diverticulitis; infections including typhoid and tuberculosis; malignancies leading to bowel erosion; ischemic events due to mesenteric vascular occlusion; and obstructive pathologies such as volvulus or strictures[6]. In the Indian context, the etiology differs notably from Western countries, where diverticulitis and malignancies are more common. Here, infections like typhoid and tuberculosis, along with peptic ulcer disease, dominate the causes of perforation, particularly in rural and tribal populations where healthcare access is limited [7].

In our study, the age distribution of gastrointestinal perforation cases revealed the highest incidence in the 21–30 years age group (22.8%), followed by 51–60 years (20%), and 11–20 years (15.2%). This pattern indicates a significant burden among young adults and middle-aged individuals. Comparatively, a study by Sivaram P et.al; 2018. in reported the maximum number of patients in the 31–40 years age group (23%), with a mean age of 40.29 years, highlighting a similar trend of younger age group predominance. Additionally, a study Panteris V et.al; 2009 observed that 33.6% of patients were over 50 years of age, suggesting a shift towards older age groups in certain regions. These variations in age distribution across different studies may reflect regional differences in risk factors such as pain medicine usage, dietary habits, and prevalence of infections like typhoid and tuberculosis. Understanding these demographic patterns is crucial for developing targeted prevention and management strategies for gastrointestinal perforations in diverse populations [8] [9].

In our study, abdominal pain was reported in 100% of cases, vomiting in 67.6%, fever in 60%, constipation in 44.8%, abdominal distension in 21.9%, and breathlessness in 21.9%. These findings are consistent with other studies. For instance, a study by Kim HC et.al; 2014 observed abdominal pain in 100% of patients, vomiting in 96.1%, fever in 80.7%, and abdominal distension in 67.3% of cases. Similarly, Panteris V et.al; 2009 reported abdominal pain in all patients, vomiting in 54.5%, abdominal distension in 89.3%, and fever in 9.1%. These variations may be attributed to differences in study populations, etiologies, and healthcare-seeking behaviors. Nonetheless, abdominal pain remains the most consistent symptom across studies, underscoring its importance in the clinical assessment of gastrointestinal perforations [9] [10].

In our study, the majority of patients (49.5%) presented within 2 days of symptom onset, with a mean duration of 1.66 ± 0.72 days. This early presentation likely contributed to better outcomes. Comparatively, Njume C, et.al; 2012, reported that 53% of patients presented more than 24 hours after symptom onset, indicating a trend of delayed presentation in that cohort. Similarly, Discolo AC et.al; 2019 found that only 30% of patients presented within 24 hours, with a mean duration of presentation being 54.7 hours. These differences in presentation times may be attributed to factors such as accessibility to healthcare facilities, awareness levels, and socioeconomic status of the populations studied. Early presentation, as observed in our study, is crucial for prompt surgical intervention and improved patient outcomes in cases of gastrointestinal perforation [11] [12].

In our study, diabetes (20%), hypertension (25.7%), history of previous surgeries (19%), tuberculosis (26.7%), and peptic ulcer disease (19.8%) were notable comorbidities among patients with gastrointestinal perforation. Similarly, a study by Discolo AC, et.al; 2019 found that 22% of their patients had a history of peptic ulcer disease, and comorbidities like diabetes and hypertension were also common contributors. Another study by Kastl Jr AJ et.al; 2020 from a tertiary center reported a significant association of gastrointestinal perforations with tuberculosis and prior abdominal surgeries. [12] [13].

In our study, major risk factors associated with gastrointestinal perforation included the use of pain medication (42.9%), smoking (46.7%), and alcohol consumption (47.6%). These findings are comparable to the study by Trikes T, et.al; 2012 where nonsteroidal anti-inflammatory drug (NSAID) use and smoking were significantly associated with an increased risk of perforations. Similarly, a Kastl Jr AJ et.al; 2020 study reported that chronic alcohol consumption and smoking were prevalent risk factors among their patients. The high rates of alcohol and smoking in our tribal population may reflect lifestyle factors that predispose individuals to gastrointestinal mucosal damage and subsequent perforation [13] [14].

In our study, the most common sites of perforation were prepyloric (38.1%) and appendicular (38.1%), followed by duodenal (13.3%) and ileal (4.8%) perforations. This distribution is consistent with the findings of Sealock RJ, et.al; 2021 where perforations most frequently involved the gastroduodenal region, particularly the prepyloric and duodenal areas. They also noted the gastroduodenal region as the predominant site, although ileal perforations were more common in their study population. The relatively high number of appendicular perforations in our study may reflect delayed presentation and limited healthcare access in the tribal region [15]

In our study, peptic ulcer disease was the most common cause of gastrointestinal perforation (60%), followed by appendicitis (32.4%), which aligns closely with the findings of KriwanekS et.al; 1994, where peptic ulcers accounted for 45% and appendicitis 19% of perforations. Similarly, they reported peptic ulcers and appendicitis as the leading etiologies. This consistent pattern across studies highlights the predominance of acid-peptic disease and appendicitis as key contributors to gastrointestinal perforations in different populations [16].

The present study revealed that gastrointestinal perforation in tribal populations remains a surgical challenge characterized by delayed presentation, underlying risk factors, and a high rate of postoperative complications. Peptic ulcer disease and appendicitis are the primary causes.

1.      Machicado, Jorge D., et al. "Epidemiology of Gastrointestinal Diseases." Geriatric Gastroenterology, 2020, pp. 1–21.

2.      Khokha, V. "Large Bowel Perforation." Textbook of Emergency General Surgery: Traumatic and Non-traumatic Surgical Emergencies, edited by [Editor if available], Springer International Publishing, 7 June 2023, pp. 1131–42.

3.      Modlin, I. M., M. Kidd, and K. D. Lye. "From the Lumen to the Laparoscope." Archives of Surgery, vol. 139, no. 10, 2004, pp. 1110–26.

4.      Torres, C. M., et al. "Exploring Rural-Urban Differences in the Receipt of Nonelective Cancer-Specific Gastrointestinal Surgery Using a Multilevel Mixed-Effects Approach." Journal of Gastrointestinal Surgery, 16 Oct. 2024, p. 101858.

5.      Rosenthal, M. E. "Gastrointestinal Infections." Geriatric Gastroenterology, 2021, pp. 1655–74.

6.      Di Saverio, Salomone, et al. "Diagnosis and Treatment of Perforated or Bleeding Peptic Ulcers: 2013 WSES Position Paper." World Journal of Emergency Surgery, vol. 9, 2014, p. 1.

7.      Sengupta, T. K., et al. "Surgical Management of Peptic Perforation in a Tertiary Care Center: A Retrospective Study." Nigerian Medical Journal, vol. 61, no. 6, 2020, pp. 328–33.

8.      Sivaram, P., and A. Sreekumar. "Preoperative Factors Influencing Mortality and Morbidity in Peptic Ulcer Perforation." European Journal of Trauma and Emergency Surgery, vol. 44, Apr. 2018, pp. 251–57.

9.      Panteris, V., J. Haringsma, and E. J. Kuipers. "Colonoscopy Perforation Rate, Mechanisms and Outcome: From Diagnostic to Therapeutic Colonoscopy." Endoscopy, vol. 41, no. 11, 2009, pp. 941–51.

10.   Kim, H. C., et al. "Gastrointestinal Tract Perforation: Evaluation of MDCT According to Perforation Site and Elapsed Time." European Radiology, vol. 24, June 2014, pp. 1386–93.

11.   Njume, Collise, and Nceba I. Goduka. "Treatment of Diarrhoea in Rural African Communities: An Overview of Measures to Maximise the Medicinal Potentials of Indigenous Plants." International Journal of Environmental Research and Public Health, vol. 9, no. 11, Nov. 2012, pp. 3911–33.

12.   Discolo, A. C., et al. "2019 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Baltimore, Maryland, USA, 3–6 April 2019: Podium Abstracts." Surgical Endoscopy, vol. 33, 2019, pp. S1–77.

13.   Kastl, Arthur J., Jr., et al. "The Structure and Function of the Human Small Intestinal Microbiota: Current Understanding and Future Directions." Cellular and Molecular Gastroenterology and Hepatology, vol. 9, no. 1, 1 Jan. 2020, pp. 33–45.

14.   Tirkes, T., et al. "Peritoneal and Retroperitoneal Anatomy and Its Relevance for Cross-Sectional Imaging." Radiographics, vol. 32, no. 2, Mar. 2012, pp. 437–51.

15.   Sealock, R. J., M. Othman, and K. Das. "Endoscopic Diagnosis and Management of Gastrointestinal Trauma." Clinical Gastroenterology and Hepatology, vol. 19, no. 1, 1 Jan. 2021, pp. 14–23.

16.   Kriwanek, S., et al. "Prognostic Factors for Survival in Colonic Perforation." International Journal of Colorectal Disease, vol. 9, Aug. 1994, pp. 158–62.