European Journal of Cardiovascular Medicine

Perforation peritonitis is a life-threatening surgical emergency resulting from a breach in the gastrointestinal tract, leading to contamination of the peritoneal cavity with intestinal contents and subsequent diffuse peritonitis. It remains a significant cause of acute abdomen in developing countries, often associated with considerable morbidity and mortality despite advancements in surgical and critical care [1,2]. The etiological spectrum of perforation peritonitis varies across regions, influenced by geographical, socioeconomic, and dietary factors, as well as the prevalence of infectious diseases [1,3].

In low- and middle-income countries such as India, peptic ulcer perforation remains the most common etiology, followed by appendicular and ileal perforations, particularly due to typhoid and tuberculosis [2,4]. In contrast, Western nations report higher incidences of perforations due to diverticular disease and malignancy [5]. The clinical presentation is typically acute and severe, with symptoms including sudden-onset abdominal pain, vomiting, and signs of peritonitis such as guarding, rigidity, and rebound tenderness [1,3,6].

Management hinges on prompt diagnosis, aggressive fluid resuscitation, early administration of broad-spectrum antibiotics, and timely surgical intervention. Exploratory laparotomy remains the cornerstone of treatment in most cases, although laparoscopic approaches are gaining traction in selected patients [2]. The prognosis is strongly influenced by the patient’s physiological status at the time of presentation, the underlying cause of perforation, the extent of peritoneal contamination, and the timeliness of surgical management [1,4,6].

Given the variability in etiologies and outcomes based on local factors, this study was undertaken to analyze the spectrum of causes, types of surgical procedures performed, and the clinical outcomes of patients presenting with perforation peritonitis at a tertiary care teaching hospital in South India. The findings aim to inform clinical decision-making and highlight areas for improving patient care and prognosis.

Study Design and Setting:
This was a retrospective observational study conducted in the Department of General Surgery, Government Medical College and General Hospital, Suryapet.

Study Period:
The study was carried out over a period of eight months, from September 2023 to April 2024.

Study Population:
All patients diagnosed with perforation peritonitis and managed surgically at the hospital during the study period were included. A total of 100 patients who met the inclusion criteria were enrolled in the study.

Inclusion Criteria:

Patients aged 18 years and above.

Patients diagnosed with perforation peritonitis based on clinical, radiological, and intraoperative findings.

Patients who underwent exploratory laparotomy.

Exclusion Criteria:

Patients managed conservatively without surgery.

Perforations secondary to trauma with associated multi-organ injuries.

Incomplete medical records or loss to follow-up before discharge.

Data Collection:
Data were collected retrospectively from patient case records, operative notes, and discharge summaries. Information regarding demographic details, clinical presentation, etiology of perforation, type of surgical procedure performed, postoperative complications, duration of hospital stay, ICU requirement, and in-hospital mortality was recorded in a structured proforma.

Statistical Analysis:
Descriptive statistics were used to summarize the data. Categorical variables were expressed as frequencies and percentages, while continuous variables were presented as mean ± standard deviation. Data analysis was performed using Microsoft Excel and SPSS version 25.0.

Ethical Consideration:
Necessary permission was obtained from the concerned authorities before starting the study.

A total of 100 patients diagnosed with perforation peritonitis were included in this retrospective observational study. The mean age of the study population was 41.3 ± 16.4 years, with a male predominance (70%). The most common presenting symptoms were abdominal pain (100%), vomiting (78%), abdominal distension (64%), and fever (52%). Clinical signs of peritonitis such as guarding and rigidity were observed in 92% of the patients (Table 1).

Table 1: Demographics and Clinical Presentation (n = 100)

Peptic ulcer disease was identified as the most frequent cause of perforation, accounting for 40% of cases, followed by appendicular perforation (20%), ileal perforation due to typhoid or tuberculosis (18%), and traumatic bowel injury (8%). Other etiologies included malignancy-related perforation (5%), postoperative anastomotic leaks (3%), and ischemic or diverticular causes (6%) (Table 2).

Table 2: Etiology of Perforation (n = 100)

Figure 1. Etiology of Perforation

All patients underwent exploratory laparotomy as the definitive surgical intervention. Graham’s omental patch repair was the most commonly performed procedure (38 cases), particularly for peptic ulcer perforations. Other surgical interventions included appendectomy (20%), ileostomy with or without resection (16%), primary closure of traumatic perforations (8%), right hemicolectomy for malignant perforations (5%), and peritoneal lavage with drainage in selected cases (5%). Eight patients required re-exploration for postoperative complications (Table 3).

Table 3: Surgical Procedures Performed

Figure 2. Surgical Procedures Performed

Postoperative complications were noted in several patients, with surgical site infection (28%) being the most common. Sepsis occurred in 14% of cases, followed by prolonged ileus in 11%, wound dehiscence in 5%, and anastomotic leaks in 4%. Reoperation was required in 6% of patients. ICU admission was necessary for 20% of cases. The mean hospital stay was 10.2 ± 3.9 days. The in-hospital mortality rate was 10%, predominantly due to septic shock and multi-organ dysfunction (Table 4).

Table 4: Postoperative Complications and Outcomes

Figure 3. Postoperative Complications and Outcomes

Perforation peritonitis remains one of the most challenging surgical emergencies, particularly in resource-limited settings. Despite advancements in surgical techniques and perioperative care, it continues to contribute significantly to morbidity and mortality [7,8]. This study analyzed 100 patients with perforation peritonitis, focusing on etiology, surgical management, and outcomes in a tertiary care hospital in South India.

The mean age of presentation was 41.3 years, with a male predominance (70%), consistent with studies highlighting the higher risk among males due to lifestyle factors such as smoking, alcohol use, and delayed healthcare-seeking behavior [8]. Peptic ulcer perforation was the most common etiology (40%), followed by appendicular (20%) and ileal perforations (18%), which correlates with regional patterns reported in the developing world, where infections like typhoid and tuberculosis are still prevalent [8,10]. In contrast, colonic perforations due to malignancy and diverticular disease are more common in Western populations [7].

All patients in our study underwent exploratory laparotomy, and Graham’s omental patch repair was the most frequently performed procedure (38%), reflecting standard surgical practices in emergency settings [9]. Postoperative complications such as surgical site infections (28%), sepsis (14%), and prolonged ileus (11%) were observed, particularly in patients with delayed presentation or comorbidities.

The in-hospital mortality rate was 10%, comparable to findings from multicenter studies in low-resource and elderly populations [11]. The mean hospital stay was 10.2 ± 3.9 days, which is consistent with other regional data and reflects the burden of postoperative recovery [10,12].

Our findings highlight the need for early diagnosis, rapid referral, and access to surgical intervention, particularly in peripheral settings. Additionally, adopting minimally invasive approaches, where feasible, may help reduce morbidity, as shown in recent multicenter data from left colonic perforation management [12].

The study emphasizes the importance of public awareness, infrastructure development, and multidisciplinary care involving surgeons, intensivists, and infectious disease specialists to improve outcomes in patients with perforation peritonitis.

Limitations of our study include its retrospective design and single-center data, which may limit generalizability. A prospective multicenter study could offer more robust insights into evolving patterns of disease and outcomes.

Perforation peritonitis remains a major surgical emergency with diverse etiologies and significant morbidity and mortality. In our study, peptic ulcer disease emerged as the most common cause, followed by appendicular and ileal perforations. Prompt surgical intervention, particularly Graham’s omental patch repair and appendectomy, played a pivotal role in managing these cases. Despite appropriate surgical care, complications such as surgical site infections and sepsis were frequently observed. Mortality was primarily associated with delayed presentation and severe sepsis. Early diagnosis, timely surgical management, and improved perioperative care are essential to optimize outcomes. Strengthening healthcare infrastructure and public awareness can help reduce the burden of this condition.

1. Mabewa A, Seni J, Chalya PL, Mshana SE, Gilyoma JM. Etiology, treatment outcome and prognostic factors among patients with secondary peritonitis at Bugando Medical Centre, Mwanza, Tanzania. World J Emerg Surg. 2015 Oct 6;10:47. doi: 10.1186/s13017-015-0042-5. PMID: 26448784; PMCID: PMC4595331.
2. Harvitkar RU, Gattupalli GB, Najmu S, Joshi A. Emergency Laparoscopic Management of Perforative Peritonitis: A Retrospective Study. Cureus. 2021 Dec 2;13(12):e20121. doi: 10.7759/cureus.20121. Erratum in: Cureus. 2022 Mar 10;14(3):c58. doi: 10.7759/cureus.c58. PMID: 34873564; PMCID: PMC8640191.
3. Samuel JC, Qureshi JS, Mulima G, Shores CG, Cairns BA, Charles AG. An Observational Study of the Etiology, clinical presentation and outcomes associated with peritonitis in Lilongwe, Malawi. World J Emerg Surg. 2011 Nov 8;6(1):37. doi: 10.1186/1749-7922-6-37. PMID: 22067899; PMCID: PMC3223493.
4. Neupane S, Koirala DP, Kharel S, Silwal S, Yadav KK. Clinical profile and management of perforation peritonitis in Bharatpur hospital, Nepal: A prospective study. Ann Med Surg (Lond). 2022 Sep 11;82:104528. doi: 10.1016/j.amsu.2022.104528. PMID: 36268443; PMCID: PMC9577425.
5. Shahi R, Siddiqui NH, Khan IA, Bashar MA. Etiologies and Outcomes Following Duodenal Perforation in Acute Peritonitis: A Systematic Review. Cureus. 2024 Nov 28;16(11):e74707. doi: 10.7759/cureus.74707. PMID: 39741604; PMCID: PMC11685785.
6. Doklestić SK, Bajec DD, Djukić RV, Bumbaširević V, Detanac AD, Detanac SD, Bracanović M, Karamarković RA. Secondary peritonitis - evaluation of 204 cases and literature review. J Med Life. 2014 Jun 15;7(2):132-8. Epub 2014 Jun 25. PMID: 25408716; PMCID: PMC4197493.
7. Cirocchi R, Afshar S, Di Saverio S, Popivanov G, De Sol A, Gubbiotti F, Tugnoli G, Sartelli M, Catena F, Cavaliere D, Taboła R, Fingerhut A, Binda GA. A historical review of surgery for peritonitis secondary to acute colonic diverticulitis: from Lockhart-Mummery to evidence-based medicine. World J Emerg Surg. 2017 Mar 9;12:14. doi: 10.1186/s13017-017-0120-y. PMID: 28293278; PMCID: PMC5345194.
8. Hameed T, Kumar A, Sahni S, Bhatia R, Vidhyarthy AK. Emerging Spectrum of Perforation Peritonitis in Developing World. Front Surg. 2020 Sep 15;7:50. doi: 10.3389/fsurg.2020.00050. PMID: 33102512; PMCID: PMC7522547.
9. Ordoñez CA, Puyana JC. Management of peritonitis in the critically ill patient. Surg Clin North Am. 2006 Dec;86(6):1323-49. doi: 10.1016/j.suc.2006.09.006. PMID: 17116451; PMCID: PMC3413265.
10. Shakya VC, Pangeni A, Karki S, Sharma LR. Evaluation of Mannheim's Peritonitis Index in Prediction of Mortality in Patients with Non-traumatic Hollow Viscus Perforation Peritonitis. J Nepal Health Res Counc. 2021 Apr 23;19(1):179-184. doi: 10.33314/jnhrc.v19i1.3258. PMID: 33934156.
11. Ogbuanya AU, Ugwu NB, Enemuo VC, Nnadozie UU, Eni UE, Ewah RL, Ajuluchuku UE, Umezurike DA, Onah LN. Emergency laparotomy for peritonitis in the elderly: A Multicentre observational study of outcomes in Sub-Saharan Africa. Afr J Emerg Med. 2023 Dec;13(4):265-273. doi: 10.1016/j.afjem.2023.08.005. Epub 2023 Sep 27. PMID: 37790994; PMCID: PMC10542594.
12. Ceresoli M, Ferro CAP, La Greca A, Cioffi SPB, Biloslavo A, Podda M, Coccolini F; Study Collaborative Group. Minimally invasive approach to peritonitis from left colonic perforation: a retrospective multicenter observational study. Surg Endosc. 2025 Apr;39(4):2370-2379. doi: 10.1007/s00464-025-11611-w. Epub 2025 Feb 18. PMID: 39966134; PMCID: PMC11933178