European Journal of Cardiovascular Medicine

Acute gastrointestinal perforation (GIP) remains one of the most dramatic and life-threatening surgical emergencies worldwide, requiring prompt recognition and timely operative management. It constitutes a major proportion of causes of secondary peritonitis, with a wide variation in etiology depending on geography, age, lifestyle, and access to healthcare. Despite improvements in surgical techniques and perioperative care, the morbidity and mortality associated with gastrointestinal perforations remain significantly high, particularly in low- and middle-income countries [1,2].

The spectrum of causative factors is diverse and often region-specific. In developing countries, infectious diseases such as typhoid fever and tuberculosis still contribute significantly to perforation cases, especially of the terminal ileum. In contrast, in industrialized nations, non-steroidal anti-inflammatory drug (NSAID)-induced peptic ulcer perforation, diverticulitis, and colonic malignancies are more common [3,4]. The increasing use of NSAIDs, corticosteroids, and immunosuppressants has also led to a rising incidence of spontaneous intestinal perforations, particularly among the elderly [5]. Moreover, although the incidence of peptic ulcer disease (PUD) has declined with widespread use of proton pump inhibitors (PPIs), the burden of perforation as a complication of untreated or neglected ulcers continues to persist, particularly in resource-constrained settings [6].

Clinically, gastrointestinal perforations present with sudden-onset severe abdominal pain, often accompanied by signs of peritonitis such as guarding, rigidity, and rebound tenderness. However, the presentation can vary, and atypical symptoms may delay diagnosis, particularly in elderly or immunocompromised patients [7]. Imaging studies such as erect abdominal and chest X-rays remain the first-line diagnostic tools to detect free air under the diaphragm, a classical sign of perforation. However, ultrasonography and computed tomography (CT) have increasingly become important adjuncts, especially in hemodynamically stable patients or those with equivocal findings [8,9].

Surgical exploration remains the cornerstone of management. Laparotomy allows for identification and closure of the perforation, control of peritoneal contamination, and definitive treatment. In selected cases, especially in early presentations of duodenal or gastric ulcers, laparoscopic repair may be feasible. The choice of surgical technique depends on several factors including the site and size of perforation, degree of contamination, patient’s physiological status, and presence of comorbid conditions [10]. Regardless of etiology, early diagnosis, timely surgical intervention, adequate resuscitation, and postoperative care play a pivotal role in improving patient outcomes and minimizing complications.

In India, studies have shown considerable variation in the distribution and outcome of gastrointestinal perforations, with appendicular and peptic ulcer perforations being predominant in many tertiary care centers [11, 12]. Delayed presentation due to socioeconomic factors, self-medication, and lack of awareness are common contributors to poor outcomes. Postoperative complications such as wound infection, intra-abdominal abscess, and respiratory issues further prolong hospital stay and increase healthcare costs.

This study aims to evaluate the clinical presentation, etiological profile, surgical interventions, postoperative complications, and short-term outcomes of patients with gastrointestinal perforations managed at a tertiary care surgical unit over a one-year period.

This prospective observational study was conducted over a one-year period from January 2021 to December 2021 in the Department of Surgery, Andhra Medical College, a tertiary care teaching hospital that caters to a large semi-urban and rural population. The study included all adult patients aged 18 years and above who presented with acute gastrointestinal perforations and underwent emergency surgical intervention.

Patients were selected consecutively based on clinical presentation suggestive of peritonitis, including sudden-onset abdominal pain, guarding, rigidity, abdominal distension, vomiting, and altered bowel habits. Diagnostic confirmation was made using radiological imaging such as erect X-ray of the abdomen and chest to identify free gas under the diaphragm, along with ultrasonography or contrast-enhanced computed tomography (CECT) of the abdomen where appropriate. The diagnosis was further confirmed intraoperatively during exploratory laparotomy.

Patients with esophageal perforation, hepatobiliary injuries, iatrogenic gynecological perforations, and those who sustained blunt or penetrating trauma were excluded from the study. Also excluded were patients who were unfit for surgery due to refractory septic shock or severe systemic derangements, even after adequate resuscitation. A total of 46 patients fulfilled the inclusion criteria and were enrolled in the study.

Upon admission, all patients underwent initial stabilization, which included nasogastric decompression, intravenous fluid resuscitation using crystalloids (Ringer's lactate or normal saline), urinary catheterization, and administration of empirical broad-spectrum intravenous antibiotics (typically a third-generation cephalosporin with metronidazole and an aminoglycoside). Hemodynamic monitoring and oxygen support were initiated promptly, and blood samples were collected for baseline investigations including complete blood count, serum electrolytes, renal and liver function tests, and blood glucose levels.

Emergency laparotomy was performed under general anesthesia for all patients. Operative findings such as site and size of the perforation, number of perforations, nature of peritoneal contamination (purulent, bilious, feculent), and suspected etiology were noted. Surgical procedures were individualized based on the intraoperative findings. Duodenal and gastric perforations were typically managed using Graham’s omental patch technique or simple closure. Appendicular perforations were treated with appendectomy. Small bowel and colonic perforations were managed with either primary closure, resection and anastomosis, or diversion procedures such as colostomy, depending on the extent of contamination and viability of the bowel.

Peritoneal lavage with warm normal saline was routinely carried out in all cases. Drains were placed in the right paracolic gutter or pelvis as needed, and their output was monitored in the postoperative period. Postoperatively, patients were kept nil per oral and managed with intravenous fluids, analgesics, antibiotics, and supportive care. Oral intake was reintroduced gradually after confirmation of bowel sounds and passage of flatus.

Patients were followed postoperatively for immediate complications such as wound infection, burst abdomen, respiratory complications, intra-abdominal abscess, and mortality. Further follow-up was conducted at one month and three months after discharge, focusing on wound healing, nutritional status, surgical site integrity, and functional recovery.

Data were systematically recorded using a structured proforma designed for the study. All entries were compiled into a Microsoft Excel spreadsheet for analysis. Descriptive statistics were used to evaluate demographic data, clinical presentation, operative findings, procedures performed, complications, length of hospital stay, and outcomes. Categorical variables were presented as frequencies and percentages, while continuous variables were expressed as mean ± standard deviation.

A total of 46 patients presenting with gastrointestinal perforation were included in the study, with the age range spanning from 18 to 72 years. The mean age was 42.6 ± 13.8 years. There was a marked male predominance, with 30 males (65.2%) and 16 females (34.8%), giving a male-to-female ratio of approximately 2:1.

The most common sites of perforation were the duodenum and appendix, each accounting for 32.6% of cases (n=15 each). Gastric perforations contributed to 15.2% (n=7), followed by colonic (13.1%) and ileal (6.5%) perforations. Duodenal and gastric perforations were mostly attributed to peptic ulcer disease, while ileal perforations were commonly associated with enteric fever.

Table 1: Site of Perforation Distribution

Regarding clinical presentation, abdominal pain was universally present in all patients. Vomiting (73.9%), abdominal distension (60.9%), fever (50%), and signs of dehydration (63.0%) were also commonly reported. Guarding and rigidity were elicited in 78.3% of cases, indicating widespread peritoneal involvement. These findings are summarized in Table 2.

Table 2: Clinical Features at Presentation

Operative interventions included omental patch repair in 14 cases of duodenal ulcer perforation, simple closure in 7 cases of gastric perforation, and appendectomy in all 15 appendicular perforation cases. Ileal perforations were managed with primary closure, while colonic and some small bowel perforations underwent either resection and anastomosis or exteriorization with colostomy.

Table 3: Operative Procedures and Outcomes

Postoperative complications were noted in 23 patients (50%). Wound infection was the most frequent, seen in 12 cases (26.1%), followed by respiratory complications in 5 patients (10.9%). One case of burst abdomen and two cases of intra-abdominal abscess required re-exploration. Sepsis developed in 3 patients, and there was one postoperative death (2.2%) due to septic shock and multi-organ failure.

Table 4: Postoperative Complications

Most patients had an average hospital stay of 9.6 ± 3.1 days. Patients who presented within 24 hours had significantly fewer complications and shorter hospitalization periods compared to those who presented after 48 hours. Early diagnosis and intervention were associated with favorable outcomes.

Gastrointestinal perforation remains a common yet serious surgical emergency, especially in resource-constrained healthcare settings where delays in diagnosis and intervention can lead to severe complications. In our study, the mean age of patients was 42.6 years, with the highest incidence seen in the third to fifth decades of life. This is in line with findings from studies in similar Indian populations, where GIP is predominantly seen in young to middle-aged adults due to lifestyle-related risk factors such as smoking, NSAID use, and Helicobacter pylori infection [1,2]. Male predominance was observed (M:F ratio 2:1), which has been a consistent finding in other regional and global studies as well [3].

The most frequently affected anatomical sites in our cohort were the duodenum and appendix, each constituting 32.6% of cases. This closely mirrors the results from Jhobta et al., who reported that gastroduodenal and appendicular perforations were the leading causes of secondary peritonitis in northern India [1]. Similarly, Singh et al. found that appendicular and peptic ulcer-related perforations were the two most common types in their rural Indian sample [11]. While the incidence of peptic ulcer perforation has declined in many high-income countries, it continues to be a significant cause in India and Southeast Asia due to delayed diagnosis and inadequate eradication therapy for H. pylori [6].

In our study, ileal perforations accounted for 6.5% of cases and were typically associated with a history of enteric fever. Typhoid-related perforation is a well-recognized complication in endemic regions and has been reported in 8–15% of perforation peritonitis cases in multiple Indian studies [13, 5]. These findings reflect a continued public health burden of waterborne infections, highlighting the need for improved sanitation, early treatment, and vaccination.

Clinical features in our patients were consistent with those described in the literature, with abdominal pain present in all cases, followed by vomiting, abdominal distension, fever, and signs of peritoneal irritation. Guarding and rigidity were seen in 78.3% of patients, indicating diffuse peritonitis. These findings are comparable to those reported by Bandyopadhyay et al. and Francis et al., where peritonitis signs were present in over 85% of cases [2, 14].

Wound infection was the most common postoperative complication, occurring in 26.1% of our patients. This is consistent with global and Indian studies, where surgical site infection (SSI) remains a significant postoperative morbidity in gastrointestinal surgeries, especially in cases of fecal or purulent contamination [15]. Respiratory complications (10.9%) and intra-abdominal abscesses (4.3%) were also noted in our series. The use of intraoperative peritoneal lavage, adequate drainage, and early ambulation are key to reducing such complications.

Only one patient (2.2%) succumbed to postoperative complications, specifically sepsis and respiratory failure. This mortality rate is lower than that reported in many tertiary care studies, which ranges from 6% to 27% depending on delay in presentation, extent of contamination, and presence of comorbidities [1]. A major factor in our relatively lower mortality could be early operative intervention in most patients and prompt antibiotic therapy. Patients who presented after more than 48 hours had more complications, consistent with other findings that delayed presentation is a predictor of poor outcome [7].

Our study highlights the importance of early diagnosis and intervention in reducing morbidity and mortality in gastrointestinal perforation. It also underscores the regional patterns of disease, with infectious and lifestyle-related etiologies still being major contributors in India. Public health efforts toward improving hygiene, early access to care, and targeted education on NSAID use and H. pylori eradication can go a long way in reducing the burden of this condition.

Gastrointestinal perforations remain a common cause of surgical emergencies, with peptic ulcer and appendicular perforations leading in frequency. Early recognition and timely surgical intervention are critical in reducing morbidity and mortality. Focused public health strategies and better access to care can substantially improve outcomes, especially in regions with delayed presentation and infectious etiologies.

Acknowledgements: The authors would like to acknowledge the support given by the staff while conducting this study.

Conflicts of interest: None declared.

1. Jhobta RS, Attri AK, Kaushik R, Sharma R, Jhobta A. Spectrum of perforation peritonitis in India: review of 504 consecutive cases. World J Emerg Surg. 2006;1:26.
2. Bandyopadhyay D, Das S, Mandal S, et al. Spectrum of perforation peritonitis in India: review of 392 cases. Saudi J Gastroenterol. 2014;20(3):174–180.
3. Imtiaz W, Sheikh A, Khan R. Hollow viscus perforation: a study of 100 cases at a tertiary care hospital. IntSurg J. 2019;6(3):745–749.
4. Pouli, S., Kozana, A., Papakitsou, I. et al. Gastrointestinal perforation: clinical and MDCT clues for identification of aetiology. Insights Imaging 11, 31 (2020). https://doi.org/10.1186/s13244-019-0823-6
5. Sharma L, Gupta S. Gastrointestinal perforations: an overview of current surgical strategies. J ClinDiagn Res. 2013;7(4):675–679.
6. Shanker R, Akshatha AK. Trends in peptic ulcer perforation: declining or persisting? Int J Surg. 2020;82:141–146.
7. Afridi S.P., Malik F., Ur-Rahman S., et al. Spectrum of perforation peritonitis in Pakistan: 300 cases Eastern experience. World J. Emerg. Surg. 2008;3:31. doi: 10.1186/1749-7922-3-31. 
8. Khan S, Malik A, Ahmed M, et al. Role of ultrasonography and X-ray in diagnosing hollow viscus perforation. Cureus. 2021;13(9):e18359.
9. Iqbal J, Yousuf M, Hussain F. Efficacy of CT in early detection of GI perforation in non-traumatic abdomen. BMC Emerg Med. 2019;19(1):59.
10. Alves A, Panis Y, Mathieu P, et al. Emergency surgery for perforated peptic ulcer: when does laparoscopy have a role? World J Surg. 2011;35(11):2783–2788.
11. Singh G, Wadhwa R, Verma AK, et al. A clinical profile of GI perforations in rural India. J ClinDiagn Res. 2015;9(2):PC01–PC03.

12. Sahil Singla et al pattern and etiology of patients with gastrointestinal
    perforations: an observational study ijcmr.2019.6.44 April 2019, DOI:10.21276/ ijcmr.2019.6.44.
13. Capoor MR, Nair D, Chintamani MS, et al. Role of enteric fever in ileal perforations: an overstated problem in tropics? Indian J Med Microbiol. 2008;26(1):54–57.
14. Francis CA, Umeh UA. Gastrointestinal perforation in a resource-limited setting: an institutional perspective. Ann Afr Med. 2021;20(4):285–290.

15. Campbell Francis C. et al pattern of Gastrointestinal perforation in a South Nigeria Tertiary Hospital. IOSR Journal of Dental and Medical Sciences e-ISSN: 2279=0853, p-ISSN:2279-0861. Vol 19 Feb 2020. :516–525.