European Journal of Cardiovascular Medicine

Perforative peritonitis is a serious and potentially fatal surgical emergency that arises from the perforation of a hollow viscus, resulting in contamination of the peritoneal cavity by gastrointestinal contents. It continues to pose a major challenge to surgeons due to its acute presentation, rapid progression, and high risk of complications. Despite advances in diagnostic imaging, anesthesia, antibiotics, and intensive care, perforative peritonitis remains associated with significant morbidity and mortality, particularly in resource limited settings [1,2].

The epidemiology of perforative peritonitis shows marked geographical variation. In developed countries, lower gastrointestinal perforations related to diverticular disease, malignancy, or ischemia are more commonly reported. In contrast, developing countries, including India, continue to report a predominance of upper gastrointestinal and small bowel perforations [3,4]. This difference is attributed to factors such as higher prevalence of peptic ulcer disease, enteric infections, tuberculosis, delayed healthcare access, and socioeconomic constraints [5].

Peptic ulcer disease remains a leading cause of gastroduodenal perforation, even in the era of proton pump inhibitors and Helicobacter pylori eradication therapy [6]. The continued use of non steroidal anti inflammatory drugs, alcohol consumption, smoking, and stress related mucosal injury contribute significantly to ulcer perforation, particularly among elderly patients [7]. Small bowel perforations are frequently associated with enteric fever, intestinal tuberculosis, trauma, and nonspecific inflammatory conditions in tropical regions [8,9]. Appendicular perforation also remains a common cause, especially in younger patients, often due to delayed presentation or atypical symptoms [10].

The pathophysiology of perforative peritonitis involves an initial chemical insult to the peritoneum, followed by bacterial contamination that leads to widespread inflammation. The ensuing cascade of inflammatory mediators can rapidly progress to systemic inflammatory response syndrome, sepsis, and multiorgan dysfunction if not promptly managed [11]. The severity of peritoneal contamination, virulence of organisms, host immune status, and presence of comorbid conditions play a crucial role in determining outcomes [12]. Advanced age, diabetes mellitus, chronic liver disease, renal dysfunction, and malnutrition have been identified as important predictors of poor prognosis [13].

Clinically, patients with perforative peritonitis typically present with acute abdominal pain, abdominal distension, vomiting, fever, and features of peritoneal irritation. However, classical signs may be absent or subtle in elderly individuals and immunocompromised patients, leading to diagnostic delays [14]. Plain erect abdominal and chest radiographs demonstrating free intraperitoneal air remain a useful initial investigation, particularly in emergency settings [15]. Ultrasonography and computed tomography have further improved diagnostic accuracy by identifying the site of perforation, extent of contamination, and associated complications [16].

Emergency surgical intervention remains the cornerstone of management. The primary objectives of surgery are source control, removal of contaminated material, and restoration of gastrointestinal continuity wherever feasible [17]. The choice of surgical procedure depends on factors such as the site and size of perforation, degree of peritoneal contamination, hemodynamic stability of the patient, and intraoperative findings [18]. Commonly performed procedures include primary closure with or without an omental patch, resection with anastomosis, and stoma formation. In critically ill patients or those with extensive contamination, staged procedures and damage control strategies may be required [19].

Postoperative management plays a vital role in influencing outcomes. Early administration of broad spectrum antibiotics, aggressive fluid resuscitation, adequate nutritional support, and close monitoring for complications are essential components of care [20]. Despite optimal management, postoperative complications such as surgical site infection, respiratory complications, intra abdominal abscess, anastomotic leak, and septicemia remain common [21]. These complications significantly increase hospital stay, healthcare costs, and mortality.

Reported mortality rates for perforative peritonitis vary widely, ranging from 5 percent to more than 20 percent, depending on etiology, timing of presentation, and patient related factors [22]. Prognostic scoring systems such as the Mannheim Peritonitis Index and APACHE II score have been developed to stratify risk and predict outcomes, although their routine application in emergency settings is limited [23].

In India, several studies have documented a predominance of gastroduodenal and ileal perforations, with peptic ulcer disease and enteric fever being the most common etiological factors [24,25]. However, regional variations exist, and tertiary care centres often receive patients with advanced disease referred from peripheral hospitals. Continuous evaluation of etiological trends, management practices, and outcomes is therefore essential to improve patient care.

The present study was undertaken to analyze the etiological spectrum, clinical profile, surgical management, and outcomes of perforative peritonitis in a tertiary care centre. Understanding these factors may help identify areas for early intervention, optimize surgical decision making, and ultimately improve patient outcomes.

Study Design and Setting

This hospital based observational study was conducted in the Department of General Surgery at Government Medical College and General Hospital, Jagtial. The hospital functions as a tertiary care referral centre and caters to a large population from surrounding rural and semi urban areas. A substantial number of emergency surgical cases are managed on a daily basis, making it an appropriate setting to study the clinical profile and outcomes of patients with perforative peritonitis.

Study Period

The study was carried out over a period of twenty one months from March 2024 to November 2025. This duration allowed adequate patient recruitment and provided sufficient data to assess etiological patterns, management strategies, and clinical outcomes.

Study Population

The study population comprised patients presenting to the emergency department with features suggestive of perforative peritonitis who subsequently underwent emergency surgical intervention. Patients were enrolled consecutively during the study period to minimize selection bias. Only those with intraoperative confirmation of gastrointestinal perforation were included in the final analysis.

Inclusion Criteria

Patients aged eighteen years and above of either sex were included in the study if they were clinically suspected and intraoperatively confirmed to have perforative peritonitis and underwent emergency exploratory laparotomy. Patients who were hemodynamically stabilized and provided informed consent, either personally or through legally authorized representatives, were considered eligible for participation.

Exclusion Criteria

Patients with primary peritonitis without evidence of hollow viscus perforation were excluded from the study. Cases of postoperative peritonitis, anastomotic leaks, and traumatic perforations were also excluded to maintain etiological uniformity. Patients managed conservatively without surgical intervention and those unwilling to provide informed consent were not included in the study.

Sample Size

All eligible patients fulfilling the inclusion criteria during the study period were included. A convenient sampling method was adopted, as the study aimed to evaluate the entire spectrum of perforative peritonitis cases presenting to the institution rather than a predefined sample size.

Data Collection

After obtaining informed consent, data were collected prospectively using a predesigned structured proforma. Demographic variables such as age and sex were documented. A detailed clinical history was obtained, including presenting symptoms, duration of symptoms prior to hospital admission, and history of previous gastrointestinal disease. Information regarding comorbid conditions such as diabetes mellitus, hypertension, chronic liver disease, chronic kidney disease, and history of non steroidal anti inflammatory drug intake was recorded. Clinical examination findings including signs of generalized peritonitis, abdominal distension, and hemodynamic status at presentation were carefully noted.

Baseline laboratory investigations were performed for all patients and included complete blood count, renal and liver function tests, serum electrolytes, and random blood glucose levels. Radiological evaluation with erect abdominal and chest radiographs was performed to detect free intraperitoneal air. Ultrasonography of the abdomen was used to identify free fluid, bowel wall thickening, or localized collections. Computed tomography of the abdomen was performed in selected cases where the diagnosis was uncertain or to better delineate the site of perforation.

Operative Findings

All patients underwent emergency exploratory laparotomy under general anesthesia after adequate preoperative resuscitation. Intraoperative findings were documented in detail, including the anatomical site of perforation, number and size of perforations, and degree of peritoneal contamination. The nature of peritoneal fluid, whether purulent, feculent, or bilious, was noted. Perforations were categorized based on their location as gastroduodenal, small bowel, appendicular, or colonic. Any associated pathology such as bowel ischemia, strictures, or inflammatory masses was also recorded.

Surgical Management

The choice of surgical procedure was individualized based on intraoperative findings, patient condition, and surgeon judgment. Primary closure with or without an omental patch was performed in cases of gastroduodenal perforation with minimal contamination. Resection and anastomosis were undertaken in selected small bowel or colonic perforations where bowel viability was adequate. Stoma formation was preferred in cases with extensive contamination, poor bowel condition, or hemodynamic instability. Appendicectomy was performed for appendicular perforations. Thorough peritoneal lavage with warm saline was carried out in all cases, and abdominal drains were placed where indicated.

Postoperative Management and Follow Up

Postoperative care was provided according to institutional protocols. All patients received broad spectrum intravenous antibiotics initiated preoperatively and continued postoperatively, with modifications based on clinical response and culture sensitivity reports. Supportive care included fluid management, pain control, respiratory physiotherapy, and nutritional support. Patients were closely monitored for postoperative complications such as surgical site infection, respiratory complications, wound dehiscence, intra abdominal abscess, anastomotic leak, and septicemia. The duration of hospital stay and final outcome at discharge were documented.

Outcome Measures

Primary outcome measures included the etiological spectrum, anatomical site of perforation, type of surgical procedure performed, postoperative complications, and in hospital mortality. Secondary outcome measures included duration of hospital stay and the association of outcomes with delayed presentation and presence of comorbid conditions.

Statistical Analysis

All collected data were entered into Microsoft Excel and analyzed using Statistical Package for the Social Sciences software. Continuous variables were summarized as mean with standard deviation or median with interquartile range depending on data distribution. Categorical variables were expressed as frequencies and percentages. Appropriate statistical tests were used to assess associations between clinical variables and outcomes. A p value of less than 0.05 was considered statistically significant.

Ethical Considerations

The study protocol was reviewed and approved by the Institutional Ethics Committee of Government Medical College, Jagtial. Written informed consent was obtained from all participants or their legally authorized representatives. Patient confidentiality was maintained throughout the study, and data were used solely for academic and research purposes.

Demographic Characteristics

A total of 120 patients diagnosed with perforative peritonitis and managed surgically during the study period were included in the analysis. The age of patients ranged from 18 to 78 years, with a mean age of 46.3 ± 14.2 years. The highest incidence was noted in the 41 to 60 years age group, accounting for 47 patients (39.2 percent). There was a marked male predominance, with 84 males (70 percent) and 36 females (30 percent), resulting in a male to female ratio of 2.3:1. The association between age group and sex distribution was not statistically significant (Chi square = 1.86, p = 0.60) (Table 1).

Table 1: Age and Sex Distribution of Patients

Clinical Presentation and Duration of Symptoms

Abdominal pain was the predominant presenting symptom and was reported by 118 patients (98.3 percent). Other common symptoms included abdominal distension in 72 patients (60 percent), fever in 78 patients (65 percent), vomiting in 66 patients (55 percent), and constipation in 44 patients (36.7 percent). Generalized abdominal tenderness with guarding and rigidity was present in 92 patients (76.7 percent) at the time of admission.

The duration of symptoms before hospital presentation varied considerably. Early presentation within 24 hours was observed in 54 patients (45 percent), whereas 66 patients (55 percent) presented after 24 hours. Patients presenting after 24 hours were significantly more likely to have signs of generalized peritonitis (Chi square = 6.94, p = 0.008).

Etiological Spectrum of Perforative Peritonitis

Peptic ulcer disease was identified as the most common etiology, accounting for 42 cases (35 percent). Enteric perforation was the second most common cause, seen in 36 patients (30 percent). Appendicular perforation and colonic perforation accounted for 24 patients (20 percent) and 18 patients (15 percent), respectively. The distribution of etiological factors showed a statistically significant predominance of upper gastrointestinal perforations (Chi square = 9.72, p = 0.021) (Table 2).

Table 2: Etiological Distribution

Anatomical Site of Perforation

The duodenum was the most common site of perforation, observed in 38 patients (31.7 percent). Ileal perforations were noted in 34 patients (28.3 percent). Appendicular perforations accounted for 24 cases (20 percent), while colonic perforations were seen in 18 cases (15 percent). Gastric perforations were relatively uncommon, with 6 cases (5 percent). A significant association was observed between site of perforation and etiology (Chi square = 18.46, p = 0.005).

Surgical Procedures Performed

Primary closure with omental patch was the most frequently performed surgical procedure and was carried out in 48 patients (40 percent). Resection with anastomosis was performed in 36 patients (30 percent), particularly in ileal and colonic perforations. Stoma formation was required in 24 patients (20 percent) due to extensive contamination or poor bowel condition. Appendicectomy alone was sufficient in 12 patients (10 percent). The choice of surgical procedure was significantly influenced by the degree of peritoneal contamination (Chi square = 12.68, p = 0.013) (Figure 1).

Figure 1: Distribution of surgical procedures performed in patients with perforative peritonitis. Primary closure with omental patch was the most commonly performed procedure, followed by resection with anastomosis, stoma formation, and appendicectomy alone. The choice of surgical procedure showed a significant association with the degree of peritoneal contamination (Chi square = 12.68, p = 0.013).

Postoperative Complications

Postoperative complications were observed in 54 patients (45 percent). Surgical site infection was the most common complication, occurring in 32 patients (26.7 percent). Respiratory complications such as pneumonia and atelectasis were seen in 18 patients (15 percent). Septicemia developed in 14 patients (11.7 percent), while wound dehiscence occurred in 10 patients (8.3 percent). The occurrence of complications was significantly higher in patients presenting after 24 hours (Chi square = 10.84, p = 0.001) (Table 3).

Table 3: Postoperative Complications

Association between Duration of Presentation and Complications

Among patients who presented within 24 hours, postoperative complications were observed in 16 patients (29.6 percent). In contrast, 38 patients (57.6 percent) who presented after 24 hours developed complications. This difference was statistically significant (Chi square = 10.84, p = 0.001) (Table 4).

Table 4: Duration of Symptoms and Postoperative Complications

Mortality and Final Outcome

The overall in hospital mortality rate was 10 percent, with 12 deaths recorded during the study period. Mortality was significantly higher among patients with delayed presentation beyond 24 hours (15.2 percent) compared to those presenting early (3.7 percent) (Chi square = 5.21, p = 0.022). Patients with associated comorbidities such as diabetes mellitus and chronic liver disease also had a significantly higher mortality rate (Chi square = 4.92, p = 0.026).

The mean duration of hospital stay was 11.6 ± 4.3 days, which was significantly longer in patients who developed postoperative complications (t = 4.18, p < 0.001) (Figure 2).

Figure 2: Survival and mortality outcomes among patients with perforative peritonitis. The majority of patients survived following surgical management, while a smaller proportion succumbed to the disease, reflecting the overall in hospital mortality observed in the study population (n = 120)

Perforative peritonitis continues to represent a major surgical challenge in emergency care, particularly in developing countries where delayed presentation and limited access to healthcare significantly influence outcomes. The present study provides a comprehensive analysis of the etiological spectrum, clinical presentation, surgical management, and outcomes of perforative peritonitis in a tertiary care setting. The findings of this study are largely consistent with previously published Indian and international literature and reinforce the continued burden of this life threatening condition.

The demographic profile observed in the present study showed a clear male predominance, with males accounting for nearly seventy percent of cases. Similar male preponderance has been consistently reported in earlier studies from India and other developing regions [3,4,24]. This trend may be attributed to greater exposure of males to risk factors such as smoking, alcohol consumption, non steroidal anti inflammatory drug use, and occupational stress, which predispose to peptic ulcer disease and subsequent perforation [7]. The majority of patients belonged to the middle aged group, which aligns with findings reported by Jhobta et al. and Gupta and Kaushik, who noted a peak incidence in the fourth and fifth decades of life [4,24].

Abdominal pain was the most common presenting symptom, observed in almost all patients, followed by fever, vomiting, and abdominal distension. These findings are in accordance with the classical clinical presentation of perforative peritonitis described in earlier studies [1,14]. However, a significant proportion of patients in the present study presented after twenty four hours of symptom onset. Delayed presentation remains a major concern in developing countries and has been attributed to lack of awareness, delayed referral from peripheral centers, and socioeconomic barriers [5]. The present study demonstrated a statistically significant association between delayed presentation and increased postoperative complications, highlighting the critical importance of early diagnosis and timely surgical intervention.

With respect to etiology, peptic ulcer disease emerged as the most common cause of perforative peritonitis, followed by enteric perforation. This pattern is consistent with several Indian studies that report gastroduodenal perforations as the predominant cause [4,24,25]. Despite advances in medical management of peptic ulcer disease, factors such as widespread availability of non prescription analgesics, poor treatment compliance, and late presentation continue to contribute to ulcer related perforations [6,7]. Enteric perforation remains a significant cause in the Indian subcontinent, reflecting the persistent burden of enteric fever and related infections [8].

The anatomical distribution of perforations in the present study showed a predominance of duodenal and ileal perforations. Similar distributions have been reported by Dorairajan et al. and Jhobta et al., who observed that upper gastrointestinal and small bowel perforations are more common in tropical regions compared to colonic perforations seen in Western populations [3,4]. The relatively lower incidence of colonic perforations in the present study may reflect differences in dietary habits, disease prevalence, and referral patterns.

Surgical management remains the cornerstone of treatment for perforative peritonitis. In the present study, primary closure with omental patch was the most commonly performed procedure, particularly for gastroduodenal perforations. This approach has been widely accepted as an effective and safe technique for managing perforated peptic ulcers, as supported by earlier studies [6,7]. Resection and anastomosis were performed in selected cases of small bowel and colonic perforations where bowel viability was adequate, while stoma formation was reserved for patients with extensive contamination or poor general condition. The choice of surgical procedure showed a significant association with the degree of peritoneal contamination, which is in line with established surgical principles [17,18].

Postoperative complications were observed in nearly half of the patients, with surgical site infection being the most common complication. High rates of wound infection have been reported in several studies on perforative peritonitis and are often attributed to gross peritoneal contamination, prolonged operative time, and compromised patient immunity [21]. Respiratory complications and septicemia were also frequently encountered, underscoring the need for meticulous postoperative monitoring and supportive care. The present study demonstrated a significant association between delayed presentation and higher complication rates, reinforcing findings reported in earlier literature [12,13].

The overall mortality rate in the present study was ten percent, which falls within the range reported in previous studies, where mortality rates vary from five to twenty percent depending on patient profile and disease severity [22]. Mortality was significantly higher among patients with delayed presentation and those with associated comorbidities such as diabetes mellitus and chronic liver disease. Similar observations have been made by Koperna and Schulz, who emphasized the role of host factors and systemic response in determining outcomes in peritonitis [13]. These findings highlight the importance of early risk stratification and aggressive management of high risk patients.

The duration of hospital stay was significantly longer in patients who developed postoperative complications. This finding is consistent with reports that complications not only increase morbidity and mortality but also place a substantial burden on healthcare resources [21]. Although prognostic scoring systems such as the Mannheim Peritonitis Index and APACHE II score have been shown to predict outcomes, their routine application in emergency settings remains limited [22,23]. Nevertheless, awareness of clinical predictors such as delayed presentation, extent of contamination, and comorbidities can aid surgeons in identifying patients at increased risk.

Overall, the findings of the present study reaffirm that perforative peritonitis in developing countries continues to be dominated by peptic ulcer and enteric perforations, with delayed presentation playing a pivotal role in adverse outcomes. Early diagnosis, prompt surgical intervention, appropriate choice of operative procedure, and vigilant postoperative care are essential to reduce morbidity and mortality. Strengthening referral systems, improving public awareness, and optimizing perioperative management protocols may further improve outcomes in patients with perforative peritonitis.

The present study highlights that perforative peritonitis continues to be a major surgical emergency associated with significant morbidity and mortality in tertiary care settings. Peptic ulcer disease and enteric perforation were identified as the leading etiological factors, with a clear predominance among middle aged male patients. Delayed presentation to the hospital emerged as a critical determinant of adverse outcomes, including higher rates of postoperative complications and mortality. The choice of surgical procedure was largely influenced by the site of perforation, extent of peritoneal contamination, and overall patient condition. Early diagnosis, prompt surgical intervention, appropriate selection of operative technique, and vigilant postoperative care were found to be essential for improving patient outcomes. Strengthening referral systems, improving public awareness regarding early symptoms, and optimizing perioperative management protocols may contribute to further reduction in morbidity and mortality associated with perforative peritonitis.

Limitations of the Study

This study was conducted at a single tertiary care centre, which may limit the generalizability of the findings to other healthcare settings. The use of a hospital based observational design and convenience sampling may have introduced selection bias. Long term follow up after discharge was not included, and therefore late complications and long term outcomes could not be assessed.

Author Contributions

All authors contributed to the conception and design of the study. Data collection, clinical management, and surgical procedures were performed by the authors. Data analysis and interpretation were carried out collectively. The manuscript was drafted and critically revised by the authors, and all authors approved the final version of the manuscript.

Conflict of Interest

The authors declare that there are no conflicts of interest related to this study.

Source of Funding

This study did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors. All investigations and treatments were carried out as part of routine institutional practice.

Acknowledgements

The authors express their sincere gratitude to the patients who consented to participate in this study. The authors acknowledge the support and cooperation of the faculty and residents of the Department of General Surgery, Government Medical College and General Hospital, Jagtial, for their assistance in patient management and data collection. The authors also thank the nursing staff and operation theatre personnel for their invaluable contribution to patient care. Support from the Department of Radiology and the Department of Anaesthesiology is gratefully acknowledged.

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