J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 3/ Issue 27/July 07, 2014 Page 7547

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1 SPECTRUM OF SECONDARY PERITONITIS DUE TO HOLLOW VISCUS PERFORATION IN A TERTIARY CARE HOSPITAL Rajeshwara K. V 1, Praveen Kumar K 2, Prajwal K. Rao 3, Muhammed Sameer 4 HOW TO CITE THIS ARTICLE: Rajeshwara K. V, Praveen Kumar K, Prajwal K. Rao, Muhammed Sameer. Spectrum of Secondary Peritonitis due to Hollow Viscus Perforation in a Tertiary Care Hospital. Journal of Evolution of Medical and Dental Sciences 2014; Vol. 3, Issue 27, July 07; Page: , ABSTRACT: BACKGROUND: Peritonitis as a result of hollow viscus perforation is one of the most common surgical emergencies in India and all over the world. The etiology of perforation in India is different from Western counterpart. The objective of the study is to enlighten the spectrum of secondary peritonitis as a result of hollow viscus perforation encountered at a Tertiary care center in coastal Karnataka. METHODS: This is retrospective study of 105 cases of perforation peritonitis seen and treated over a period of 3 years. All the cases were analysed with respect to clinical presentation, operative findings and postoperative course. RESULTS: The maximum number of patients in our study was in the age group of years. There were 78 males (74.29%) as compared to 27 females (25.71%).The most commonest site of perforation in our study was gastro-duodenal (75), appendicular (13), small bowel (9), and colonic perforation (3). The complication rate (51.42%), mortality rate (0.95%). CONCLUSION: Upper gastrointestinal tract perforation constitutes majority of the cases when compared to lower gastrointestinal tract perforation which is more common in Western population. The significant rate of mortality can be attributed to delay in presentation and elder age with associated comorbidities. The traumatic gastrointestinal injury is also one of the important injuries in motor vehicle accidents which warrant early recognition and immediate prompt management to avoid morbidity and mortality. KEYWORDS: Gastro duodenal perforation, Hollow viscus perforation, Peritonitis, Exploratory Laparotomy. INTRODUCTION: Peritonitis is defined as inflammation of the serosal membrane that lines the abdominal cavity and the organs contained therein. Peritonitis can be classified as primary (hematogenous dissemination), secondary (due to perforation or trauma), or tertiary (persistent or recurrent infection after adequate initial therapy). Primary peritonitis is most often spontaneous bacterial peritonitis (SBP) caused by chronic liver disease. Secondary peritonitis is by far the most common form of peritonitis encountered in clinical practice. Tertiary peritonitis often develops in the absence of the original visceral organ pathology. Perforation peritonitis is one of the common surgical emergencies encountered in Tertiary care Centre. Despite the advances in surgical techniques, Antimicrobial therapy, intensive care support, management of secondary peritonitis continues to be difficult and challenging. 1 The gold standard treatment in suspected bowel perforation is exploratory laparotomy. Endoscopic, laparoscopic and laparoscopic assisted surgeries are now increasingly performed instead of conventional open laparotomy. The peritoneal contamination with gastrointestinal contents as a result of perforation results in peritonitis. The pathogens involved in secondary peritonitis differ in proximal to distal GI tract. Gram positive organisms predominate in upper GI tract perforation whereas gram negative is more J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 3/ Issue 27/July 07, 2014 Page 7547

2 predominant in distal GI tract perforation. The lower GI perforation peritonitis is more in Western counterpart. The gastro duodenal perforation is decreasing because of advent of proton pump inhibitor and Helicobacter Pylori eradication treatment in the management of acid peptic disease. But the duodenal ulcer perforation is one of the life threatening complications in chronic peptic ulcer disease. The patients coming to our hospital are from rural areas and belong to low socioeconomic status. Late presentation leads to high rates of morbidity and mortality. Peritonitis usually presents as an acute abdomen. Local findings include abdominal tenderness, guarding, rigidity, distension, diminished bowel sounds. Systemic findings include fever, chills or rigor, tachycardia, sweating, restlessness, tachypnea, dehydration, oliguria, disorientation and ultimately shock. The study was carried out to evaluate various etiological factors, mode of clinical presentation, morbidity and mortality pattern of different types of perforation peritonitis presented in our hospital. MATERIAL AND METHODS: This is a retrospective study of 105 cases of perforative peritonitis seen over a period of 3 years from Jan 2010 to Dec 2013 at Father Muller Medical College Hospital Mangalore. The cases due to anastomotic dehiscence were excluded from this study. In all the cases of peritonitis as a result of hollow viscus perforation resuscitation was done first and initial provisional diagnosis was made by detailed history, physical findings, presence of Pneumoperitoneum on chest x-ray. Routine blood and urine examination, serum urea, creatinine, electrolyte estimation, Blood sugar and Ultrasound abdomen was done in all cases. Exploratory laparotomy was done and necessary definitive procedures were done with adequate peritoneal irrigation. RESULTS: Fig. 1: Chart showing Age Distribution J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 3/ Issue 27/July 07, 2014 Page 7548

3 SEX DISTRIBUTION: Sex No. of Cases Percentage Male Female Table 1: Sex Distribution of cases studied CLINICAL FEATURES: Signs and Symptoms No. of cases Percentage Pain abdomen Vomiting Distension of abdomen Constipation Fever Diarrhoea Decreased urine output H/O Fall/Trauma Table 2: Clinical Features of cases studied INVESTIGATIONS: Pneumoperitoneum 75 Air fluid levels (Abdomen) 30 Hyponatraemia 40 Hypokalemia 9 Blood Urea Nitrogen 10 Serum Creatinine 8 Table 3: Investigations Reports of cases studied SITE OF PERFORATION: Site of Perforation No.(105) Percentage Gastric Duodenal Small Bowel Colon Appendicular Others (Anastomotic ulcer) Table 4: Site of Perforation Noticed in cases studied J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 3/ Issue 27/July 07, 2014 Page 7549

4 SURGICAL PROCEDURES: COMPLICATIONS: Procedures Numbers Simple closure 76 Resection with anastomosis 11 Appendicectomy 13 Definitive procedures 3 Resection without anastomosis 2 Table 5: Surgical procedures done for cases studied Complications Number Percentage Wound infection Paralytic Ileus Dehiscence Intra-abdominal abscess 0 0 Fecal fistula 0 0 Table 6: Complications seen in cases studied A total of 105 cases were studied. Male patients being predominant in this study with (74.28%). Most number of cases (21.9%) was seen in the age group of years. Clinical presentation of the patients varied according to the site of perforation and pathology. The gastro duodenal perforation patients had a predominant history of sudden onset of pain abdomen in the epigastrium with associated generalized tenderness and guarding. Most of the patients gave a history of NSAID intake for other painful conditions. The patients with small bowel perforation gave a history long standing fever followed by pain abdomen, distension of abdomen vomiting and constipation. Pneumoperitoneum on chest X-ray was evident in most of the cases (90%). Appendicular perforation patients had a characteristic pain originating in the periumbilical region later migrating to right iliac fossa. Other features like vomiting, fever, localized guarding, rebound tenderness was also seen. Erect X-ray did not show the Pneumoperitoneum. Peptic ulcer disease and NSAID consumption was the most common etiological factor for gastro duodenal perforation (70%).Small bowel perforation was due to Enteric fever and trauma. Anastomotic ulcer perforation constituted 5%. Overall there was 51.42% morbidity and 0.95% mortality. Morbidity and mortality was seen among the patients who presented at a later stage and in the elderly patients with associated comorbidities. DISCUSSION: In this study the maximum number of cases was within the age group of years. Most of them presented to our hospital at a late stage with pain abdomen. Commonest site of perforation was Gastro Duodenal. It was followed by Appendix. Other areas like colon, small bowel constituted less number of incidence. J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 3/ Issue 27/July 07, 2014 Page 7550

5 Mean age of presentation was in the study which is almost equivalent to the mean age of 49 years found by Singh G et al. 2 The other studies showed the range from 38.8 to 60 years. The incidence of perforation was higher (74.28%) in male population as compared to other studies. 3 Pain abdomen is the most common presentation with 77.14%. 4 In the present study 77.14% of the patients had pain abdomen, 39.04% had vomiting and 9.52% had history of fever which was almost similar in other studies. 4,5 Perforation of the proximal part of the gastrointestinal tract was more common, 6 which is in contrast to the studies from western countries where perforations are common in the distal part. 7-9 It was noticed in our study that proper hydration, good antibiotic cover, and simple closure of the perforation using an omentopexy significantly decreases mortality rate. 10 Gastric ulcer rarely presents with perforation peritonitis, gastric perforations are related to the widespread use of Nonsteroidal anti-inflammatory drugs (NSAIDs). 11 Perforation is a rare complication of gastric carcinoma, accounting for less than 1%. Perforated gastric ulcer has high incidence of malignancy. 12 Duodenal ulcer perforation was the most common (66.66%) and same result was shown by other studies Appendicular perforations were seen in 13(12.38%) patients comparable to other studies that showed an incidence of 3.5% to 12%. 3,9 Appendectomy, peritoneal toileting and systemic antibiotics were used in all cases. Traumatic perforations accounted for 2.85 % of all causes and it is comparable with the 9% incidence shown by Jhobta RS et al. 3 The higher incidence of wound infection may be because majority (30.47%) of patients presented late (>48hours) to the hospital with well established peritonitis and majority were in older group. 17 CONCLUSIONS: The majority of perforation peritonitis cases in the study comprised of peptic ulcer perforations followed by appendicular and small bowel perforations. The basic principles of early diagnosis prompt resuscitation and urgent surgical intervention still form the cornerstones of management in these cases. The spectrum of peritonitis in India is markedly different from that of the western world. Perforations are seen mostly in the small bowel rather than the large bowel. We have to educate the health professionals at the primary level regarding early recognition of the perforative peritonitis and early referral to tertiary centers so that morbidity and mortality can be minimized. REFERENCES: 1. Bosscha K, Van Vroonhoven TJ, Vander WC. Surgical management of severe secondary peritonitis. Br J Surg. 1999; 86: Singh G, Sharma RK, Gupta R. Gastrointestinal perforations-a prospective study of 342 cases. Gastroentrol Today Sept-Oct; 10(4): 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: Ghooi AM, Panjwani S. Acute Abdominal emergencies, Clinical overview. Ind J Surg 1978:140: Desa LA, Mehta SJ, Nadakarni KM, Bhalerao RA. Peritonitis: A study of factors contributing to mortality. Ind J Surg 1983: Agarwall N, Saha S, Srivastava A, Chumber S, Dhar A, Garg S. Peritonitis 10 years experience in a single surgical unit. Trop Gastroenterol 2007; 28 (3): J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 3/ Issue 27/July 07, 2014 Page 7551

6 7. Malangoni MA, Inui T. Peritonitis the western experience. World J Emerg Surg 2006; 1: Batra P, Gupta D, Narang R, Rao Siddarth. Spectrum of Gastrointestinal perforation peritonitis in rural central India. JMGIMS 2013; 18 (i): Dinesh Yadav, Puneet K Garg. Spectrum of Perforation Peritonitis in Delhi: 77 Cases Experience. Indian J Surg (March April 2013); 75(2): Siu WT, Leong HT, Law BK, Chau CH, Li AC, Fung KH, Tai YP, Li MK. Laparoscopic repair for perforated peptic ulcer. A randomized controlled trial. Ann Surg 2002; 235 (3): Ohene-Yeboah M, Togbe B. Perforated gastric and duodenal ulcers in an urban African population. West Afr J Med 2006; 25 (3): Franco R, Simone R, Daniele M, Giovanni DM, Corrado P, Paolo M, Giovanni C, Enrico P. Perforated gastric carcinoma; a report of 10 cases and review of the literature. World J Surg Oncol.2006; 4: Patil PV, Kamat MM, Hindalekar MM. Spectrum of perforative peritonitis-a prospective study of 150 cases. Bombay Hospital J 2012; 54(1): Sujit M Chakma, Rahul L Singh, Mahadev V Parm ekar, KH Gojen Singh. Spectrum of perforation peritonitis. JCDR 2013; Nov, Vol-7(11): Afridi SP, Malik F, Rahaman SU, Shamim S, Samo KA. Spectrum of perforation peritonitis in Pakistan: 300 cases of Eastern experiences. World J Emerg Surg. 2008; 3: Sharma L, Gupta S, Soin AS, Bikora S, Sikora S, Kapoor V. Generalized peritonitis in India-The tropical spectrum. Jpn J Surg. 1991; May; 21 (3): Mathikere Lingaiah Ramachandra, Bellary Jagadesh, Sathees B.C. Chandra. Clinical Study and Management of Secondary Peritonitis due to Perforated Hollow Viscous: Arch Med Sci 1, March/ 2007: AUTHORS: 1. Rajeshwara K. V. 2. Praveen Kumar K. 3. Prajwal K. Rao 4. Muhammed Sameer PARTICULARS OF CONTRIBUTORS: 1. Assistant Professor, Department of Surgery, Father Muller Medical College, Mangalore. 2. Associate Professor, Department of Surgery, Father Muller Medical College, Mangalore. 3. Resident, Department of Surgery, Father Muller Medical College, Mangalore. 4. Senior Resident, Department of Surgery, Father Muller Medical College, Mangalore. NAME ADDRESS ID OF THE CORRESPONDING AUTHOR: Dr. Rajeshwara K. V, Assistant Professor, Department of Surgery, Father Muller Medical College, Kankanady, Mangalore , Karnataka. rajeshwarakv@gmail.com Date of Submission: 12/06/2014. Date of Peer Review: 13/06/2014. Date of Acceptance: 24/06/2014. Date of Publishing: 05/07/2014. J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 3/ Issue 27/July 07, 2014 Page 7552