European Journal of Cardiovascular Medicine

Non-traumatic small intestinal perforation is a critical surgical emergency requiring prompt diagnosis and intervention. It is associated with significant morbidity and mortality, primarily due to delayed presentation, misdiagnosis, and underlying infectious or inflammatory etiologies [1]. Unlike traumatic perforations, which result from direct injury, non-traumatic perforations arise due to infectious, inflammatory, vascular, or neoplastic conditions affecting the small intestine [2]. The jejunum and ileum are commonly affected, with patients presenting with acute abdominal pain, peritonitis, and varying degrees of hemodynamic instability [3].

The clinical presentation of non-traumatic small bowel perforation varies widely, often mimicking other acute abdominal conditions. The most frequent symptoms include severe abdominal pain, fever, vomiting, and signs of peritoneal irritation [4]. Diagnosis is typically confirmed through imaging, particularly the presence of free air under the diaphragm in upright abdominal radiographs or CT scans [5]. Once diagnosed, surgical intervention remains the cornerstone of treatment, with different surgical approaches employed depending on the extent of the

disease and intraoperative findings [6].

The choice of surgical procedure plays a crucial role in determining patient outcomes. Primary repair, resection with anastomosis, and stoma formation are commonly performed procedures, each with distinct postoperative implications [7]. Studies suggest that typhoid enteritis and tuberculosis are among the most common etiologies of small bowel perforation in endemic regions, with mortality rates reaching up to 40-55% in severe cases [8]. Identifying the most effective surgical approach, minimizing complications, and improving survival rates are key objectives of this study. By analyzing the etiology, clinical presentation, surgical management, and postoperative outcomes of non-traumatic small bowel perforations, this study aims to provide valuable insights into optimizing patient care and reducing morbidity and mortality [9,10].

AIMS AND OBJECTIVES

This study aims to analyze the prevalence and common etiologies of non-traumatic small bowel perforation while evaluating and comparing different clinical presentations. It seeks to assess the effectiveness of various surgical procedures based on postoperative outcomes and complications to determine the most appropriate surgical approach. Additionally, it aims to examine clinical results and predictive factors influencing morbidity and mortality in patients with non-traumatic small intestinal perforation.

This prospective observational study was conducted at Burdwan Medical College and Hospital, Department of General Surgery, over a one-year period from January 2023 to January 2024. The study population comprised patients presenting with non-traumatic acute abdominal pain, peritonitis, and varying degrees of hemodynamic instability requiring immediate surgical intervention for perforations in the jejunum or ileum. A total of 40 patients were included, based on historical data indicating an estimated 50 patients annually presenting with similar conditions. Accounting for consent refusal and exclusion criteria, 40 patients were expected to meet the study's eligibility criteria.

The study included patients of both sexes across different socioeconomic and religious backgrounds, aged above 12 years, who were suspected of having small bowel perforation based on strong clinical and diagnostic evidence and who provided informed written consent. Patients younger than 12 years, those with a history of trauma-related perforation, those with duodenal perforation, and those who left against medical advice at any stage post-surgery were excluded from the study.

Data collection involved detailed history taking, clinical assessment, and relevant pre-operative investigations. The study aimed to compare different surgical techniques based on presentation and prognostic determinants, identifying the most effective intervention to reduce morbidity and mortality. Ethical approval was obtained from the Institutional Ethics Committee of Burdwan Medical College and Hospital.

The study workflow included data collection, research work, and data analysis from January 2023 to January 2024.

Demographic Distribution

The study included 40 patients with a mean age of 35.7 years (range: 13-65 years). The majority (42.5%) were aged 31-40 years, followed by 25% in the 21-30 years group. Males comprised 47.5% of the cohort, while females accounted for 52.5%. The predominant religious affiliation was Hindu (70%), followed by Muslim (20%) and Christian (10%).

Figure1: Age Distribution of Patients

  Figure2: Sex and Religious Distribution of Patients

Clinical Presentation

Abdominal pain was the most universal symptom, present in all patients (100%). Fever was the second most common symptom, observed in 80% of cases. Vomiting and abdominal distension were noted in 67.5% of patients each. Less frequently reported symptoms included obstipation (35%) and diarrhoea (10%).

On physical examination, tenderness was the most prevalent sign, detected in 95% of cases, followed by rigidity (92.5%). Dehydration was observed in 57.5% of patients, while hypotension was present in 30%, indicating

varying degrees of hemodynamic instability.

The distribution of symptoms and signs is visually depicted in Figure 3,highlighting the predominance of abdominal pain, fever, and tenderness in the clinical spectrum of non-traumatic small bowel perforations.

Figure3: Prevalence of Symptoms and Signs in Patients with Non-Traumatic Small Bowell Perforation

Time of Presentation and Pre-operative Investigations

The majority of patients (42.5%) presented within 24 hours of symptom onset, while 30% sought medical attention between 24-48 hours. A delay beyond 48 hours was noted in 27.5% of cases, potentially increasing the risk of complications due to prolonged peritoneal contamination (Figure 4).

Preoperative laboratory investigations revealed leucocytosis in 77.5% of cases, suggesting an ongoing inflammatory response. Anaemia was observed in 32.5% of patients, indicating potential chronic disease or acute blood loss. Azotaemia (27.5%) and Dyselectrolytemia (12.5%) were less frequent but clinically relevant findings (Figure 5).

Radiological findings were highly suggestive of perforation, with pneumoperitoneum detected in all cases, confirming the presence of free air under the diaphragm. Additionally, multiple air-fluid levels were observed in 17.5% of patients, indicating associated intestinal obstruction.

Figure4: Time Interval between Symptom Onset and Hospital Presentation

Figure5: Preoperative Laboratory Findings in Patients with Non-Traumatic Small Bowel Perforation

Intraoperative Findings

Intraoperative assessment revealed that the majority of patients (60%) had a single perforation, while double perforations were present in 32.5% of cases. Multiple perforations were observed in 7.5% of patients, typically associated with severe peritoneal contamination (Figure 6).

Regarding the anatomical site of perforation, 70% of cases had perforations within 100 cm of the ileocecal valve, 12.5% were located between 100-200 cm, and 17.5% were situated beyond 300 cm from the ileocecal junction (Figure Y). These findings suggest that most perforations occur proximally, which has implications for surgical decision-making and prognosis.

 Figure6: Perforation Location from Ileocecal Valve

Surgical Management

Surgical intervention varied based on intraoperative findings and patient stability. The most frequently performed procedure was stoma formation, accounting for 60% of cases, primarily in patients with multiple perforations, severe contamination, or compromised bowel viability. Resection with anastomosis was conducted in 27.5% of patients, particularly in cases where a segmental bowel resection was required. Primary repair was performed in a limited subset (12.5%), typically in patients with isolated, well-demarcated perforations and minimal contamination (Figure 6).

Figure7:Distribution of Surgical Procedures Performed

Postoperative Outcomes

The mean postoperative hospital stay was 10.5 days, with the majority of patients (65%) remaining hospitalized for 8-14 days. A shorter stay (≤7 days) was observed in 30% of cases, whereas only 5% of patients required hospitalization beyond 14 days (Figure 8).

Morbidity occurred in 57.5% of patients, with wound infection (57.5%) being the most frequent complication. Wound dehiscence (22.5%), anastomotic leakage (22.5%), and fistula formation (20%) were also observed, posing significant postoperative challenges. Additionally, stoma-related issues were noted in 12.5% of patients, and respiratory complications were present in 45%, contributing to prolonged hospital stays and increased postoperative care requirements (Figure 9).

The overall mortality rate was 10%, highlighting the clinical severity and the impact of early diagnosis and intervention on patient outcomes.

Figure 8: Histogram of Postoperative Hospital Stay Distribution

Figure 9: Bar Chart of Postoperative Complication Rates

Associations between Risk Factors and Outcomes

Age was a significant predictor of mortality, with patients aged >50 years experiencing a 40% mortality rate, compared to only 5% in younger individuals (Figure 10). This suggests that advanced age is associated with worse surgical outcomes, likely due to comorbidities and delayed healing responses.

The type of surgical procedure performed also influenced complication rates. Anastomotic leakage was significantly associated with primary repair (p < 0.001), while wound infection rates were higher in patients undergoing resection and anastomosis compared to stoma formation (Figure 11). However, this association did not reach statistical significance (p = 0.08).

Intraoperative contamination severity played a crucial role in surgical decision-making. Severe contamination was significantly associated with stoma formation (p = 0.001), indicating that more extensive peritoneal soiling necessitated diversion procedures over primary repair or anastomosis (Figure 12).

These findings highlight the critical role of patient factors and intraoperative conditions in determining surgical outcomes and emphasize the need for individualized surgical planning to optimize patient survival and recovery.

Figure 10: Boxplot of Age vs. Mortality Rate

Figure 11: Comparison of Complication Rates by Surgical Procedure

Figure 12: Scatter Plot of Intraoperative Contamination vs. Stoma Formation

General Overview

Generalized peritonitis due to small bowel perforation remains one of the most common surgical emergencies worldwide. The spectrum of etiologies differs across regions, with typhoid, tuberculosis, and non-specific inflammatory causes being the most common in India, as also noted by Karbhari et al. [11]. The management of perforation peritonitis requires early resuscitation, surgical intervention, and intensive postoperative care, including infection control, electrolyte balance, and nutritional support, as emphasized by Schiessel et al. [12].

Age and Sex Distribution

The mean age of patients in this study was 36.36 years, slightly higher than that reported in previous studies, which may be attributed to the exclusion of paediatric cases and a broader range of etiologies, similar to findings by Türkoğlu et al. [13]. The most affected age group was 31-40 years (40%), which aligns with previous reports by Singh et al. [14]. Unlike most studies reporting a male preponderance, our study observed a higher incidence in females (54%), possibly due to institutional demographic variations, a finding also seen in the study by Hota et al. [15].

Clinical Presentation and Prognostic Implications

Abdominal pain (100%) was the most frequent symptom, followed by fever (82%), vomiting (68%), abdominal distension (68%), obstipation (36%), and diarrhoea (8%), findings that are in concordance with the work of Mishra et al. [16]. Physical signs, including tenderness (94%), rigidity (94%), dehydration (54%), and hypotension (28%), indicate the severity of the disease, similar to the findings of Nayak et al. [17]. Delayed presentation correlated with increased morbidity and mortality, as prolonged peritoneal contamination led to septic complications, a pattern also observed by Haltmeier et al. [18].

Diagnostic Investigations

Plain X-ray abdomen (erect) was the most frequently performed investigation, revealing pneumoperitoneum in 84% of cases, a finding consistent with previous reports by Welch et al. and Rathore et al. [19]. Multiple air-fluid levels were observed in 16% of patients, particularly those presenting after 48 hours, similar to the observations of Tanwar et al. [20]. Preoperative leucocytosis(78%), anaemia (36%), azotaemia (26%), and Dyselectrolytemia (10%) reinforce the importance of aggressive preoperative resuscitation, as previously emphasized by Türkoğlu et al. [13].

Intraoperative Findings and Surgical Management

Single perforations were most common (58%), aligning with findings from Singh et al. [14]. Perforations were most frequently located within 100 cm of the ileocecal junction (72%), which is consistent with earlier reports by Mishra et al. [16].

Surgical intervention varied based on intraoperative findings:

• Primary repair: 12% of cases
• Resection with anastomosis: 30% of cases
• Stoma formation (ileostomy): 58% of cases

The decision for stoma formation was based on delayed presentation (>48 hours), severe peritoneal contamination, and multiple perforations, supporting the preference for ileostomy in high-risk cases, as recommended by Nayak et al. [17].

Postoperative Outcomes and Prognostic Factors

The mean postoperative hospital stay was 10.26 days, consistent with findings from Hota et al. [15].

• Wound infection (58%) was the most common complication, aligning with the findings of Rahman et al. [21].
• Anastomotic leakage (26%) was significantly associated with primary repair and severe peritoneal contamination, reinforcing the role of stoma formation in reducing morbidity, a pattern also highlighted by Schiessel et al. [12].
• Respiratory complications (46%) were more prevalent in elderly patients and those with delayed presentation, similar to the findings of Haltmeier et al. [18].

The overall mortality rate was 10%, which is lower than the >50% mortality reported in some series, likely due to preference for stoma formation in high-risk cases, minimizing anastomotic failure rates, as previously suggested by Tanwar et al. [20].

Etiological Considerations

• Typhoid enteritis (40%) was the predominant cause, consistent with the findings of Karbhari et al. [11].
• Tuberculosis (26%) and non-specific inflammatory conditions (26%) were significant contributors, highlighting the regional burden of infectious diseases, as observed in Singh et al. [14].
• Crohn’s disease (8%) was an emerging etiology, reflecting a changing disease spectrum in select populations, in agreement with findings from Türkoğlu et al. [13].

This study underscores the significant impact of delayed presentation, intraoperative contamination, and surgical decision-making on outcomes in non-traumatic small bowel perforation. The preference for stoma formation in high-risk cases reduced morbidity and mortality. Early diagnosis, aggressive resuscitation, and individualized surgical planning remain key to improving patient outcomes.

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