Spectrum of perforation peritonitis in the Nepalese setting hasn’t been well documented. This study helps us to understand the different spectrum of this entity as we encounter them in our set-up. This study is a prospective descriptive study in patients presenting with a diagnosis of perforation peritonitis who underwent operative intervention from January 2010 to December 2016 at tertiary centers in central Nepal. A total of 500 patients were included in the study. The mean age of presentation was 37.02 + 19.87 years (range 2-94 years). The most common cause was, duodenal perforation, 201 cases (40.2%); followed by appendicular, 185 patients (37%). The morbidity rate was 37.2%. The mortality rate was 8.2%. 1.8% patients left against our medical advice. The scenario of perforation peritonitis is different in our setting, the most common cause being due to acid-peptic disease, then appendicular perforation and small bowel perforations. The morbidity rate and mortality rate is comparable to other series.

•    Perforation peritonitis
•    Nepal
•    Mortality
•    Morbidity 

Shakya VC , Moh Shrestha AR, Pangeni A, Byanjankar B, Pandit R, et al. (2018) Perforation Peritonitis: An Observational Study at Tertiary Centers in Central Nepal. J Surg Transplant Sci 6(1): 1063.

PL: Peritoneal Lavage; ECG: Electrocardiography; COAD: Chronic Obstructive Airway disease; Ex Lap: Exploratory Laparotomy; DIC: Disseminated Intravascular Coagulation; MODS: Multiorgan Dysfunction Syndrome

Perforation peritonitis is a relatively common surgical emergency, which is associated with a high morbidity and mortality [1]. Though advances in surgical and intensive management, results have not uniformly improved even in the last decade [2]. Peritonitis can be classified as primary, secondary or tertiary [3]; multisystem organ failure leading to death have been reported in all series [4,5]. While there have been some studies from the Indian subcontinent that highlight the differences from western studies, comprehensive data from our region regarding secondary perforation peritonitis are lacking [2,4,6-8]. Though there have been some studies and sporadic case reports from Nepal as well, spectrum of perforation peritonitis in our setting hasn’t been well documented [9-16]. This study helps us to understand the different spectrum of this entity as we encounter them in our region, and to analyze the morbidity and outcome in these patients.

This study was a prospective descriptive study in patients presenting to Surgery Department of Civil Service Hospital of Nepal, Kathmandu, Nepal and Helping Hands Hospital, Kathmandu, Nepal with a diagnosis of perforation peritonitis from January 2010 to December 2016. All patients resulting from perforation in the gastrointestinal tract was included in the study. Peritonitis secondary to anastomotic dehiscence / leak or peritonitis in postoperative patients was not included in the study. All patients following a diagnosis of peritonitis underwent adequate resuscitation and definitive treatment. A detailed clinical history, examination and relevant investigations (including hemoglobin, blood sugar, blood urea, serum creatinine, serum amylase, ECG, chest X-ray, abdominal X-ray etc.) were carried out. Based on history and physical examination, a provisional diagnosis of intestinal perforation was made which was confirmed by investigations including X-ray chest for pneumoperitoneum and abdominal X-ray for air fluid levels. Only when the diagnosis was elusive, e.g. presence of bleeding per rectum, a mass on abdominal palpation, suspected malignancy, trauma with suspicion of solid organ injury, and acute episode superimposed on chronic illness, equivocal signs on clinical examination, without evidence of pneumoperitoneum on X-ray, was a CT-scan done. All patients were resuscitated after passage of two 16-gauge cannulas, nasogastric tube and Foley’s catheter. All patients received 2-3li of Ringer’s lactate and third generation cephalosporins (ceftriaxone) or quinolones (ofloxacin) and metronidazole. With the confirmation of the initial diagnosis of intestinal perforation, the patients were subjected to emergency laparotomy. The operating decision was taken by the senior resident/consultant on duty. Perforations in the gastrointestinal tract were treated either with primary double-layered closure, segmental resection and anastomosis or loop ileostomy, depending upon the operative findings and general status of the patients. Intra-operative findings (nature of exudates- clear, purulent, fecal, and origin of source of infection etc.) were recorded. Intra-operative peritoneal lavage was done adequately with at least 2li of warm normal saline, the sources of infection were eliminated, and the lavage fluid was completely aspirated along with the purulent exudates, fecal debris, food particles, and blood. Pelvic regions, paracolic gutters and subphrenic spaces were opened and debrided. Appropriate numbers of abdominal drains were inserted according to the site of origin of infection and severity of peritonitis. Abdomen was closed either as mass closure or in layers depending upon the operator’s choice. Patients were monitored post-operatively for recovery and early detection and management of complications. Intravenous ciprofloxacin (10 mg/Kg body weight/day in 2 divided doses) and metronidazole (15 mg/Kg body weight stat followed by 7.5 mg/Kg body weight every 8 hourly) were infused initially and later switched to oral medication. Postoperative follow up was done clinically; however relevant investigations were done as desired. Data from filled performa was entered in a computer and analyzed using SPSS software for Windows. The study was given an approval by the Institutional Ethical Review Committee (ERC).

A total of 500 patients were included in the study. They were predominantly males (358 males, 142 females); the male: female ratio was 2.5:1. Maximum patients belonged to age group 41-50 years, followed by 11-20 years; the mean age of presentation was 37.02 + 19.87 years (range 2-94 years). The mean age of presentation of female patients was 36.09 + 20.03 years (range 3-86 years) and of male patients were 37.43 + 19.83 years (range 2-94 years). Presenting symptoms included abdominal pain (99.2%), vomiting (65.4%), abdominal distension (54.5%), fever (32%) and absolute constipation (80%) (Table 1). Fifty seven patients (11.4%) presented in shock. 498 patients underwent emergency laparotomy after diagnosis and resuscitation. The mean duration of presentation was 4.25 + 4.57 days (range 1-60 days). Only 107 patients (21.4%) presented in first 24 hours. One-hundred and eight patients (21.6%) presented after 3-5 days; 43.6% patients presented after 3 days of onset of the symptoms. In the investigations, the most frequent abnormality was leukocytosis. Gas under diaphragm was seen in 265 (53%) of patients. CT scan was done in 121 (24.2%) of patients. The most common co-morbidity associated was hypertension followed by respiratory diseases, especially COAD.

In 201 (40.2%) cases, duodenal perforation was the underlying cause for peritonitis which was the most common (Table 2). The second most common site of perforation was appendix, found in 185 (37%) patients. Three hundred sixty-seven (73.4%) cases were found to have generalized peritonitis while the remaining 133 patients (26.6%) had localized peritonitis. Fecal exudates was seen in 29 (5.88%) patients while 370 (74%) had purulent exudates. The most commonly performed procedure in our series was omental patch repair for ulcer perforation which was carried out in 187 (37.4%) patients, followed by laparotomy and appendectomy in 125 (25%) patients. Two patients were managed conservatively, one who had a colonic perforation due to colonoscopy, and another a small appendicular abscess which immediately resolved with an aspiration.

Postoperative complications were encountered in 186 cases (37.2%) (Table 3). The mean hospital stay was 8.93+6.63 days (range 4 to 57 days). Forty-five patients were treated in the intensive care unit for a mean period of 10.95+4.53 days (range 1-39 days). Forty-one patients (8.2%) succumbed to death. Maximum mortality occurred in patients with duodenal perforation peritonitis, which constituted 53.6% of all mortalities. The predominant cause of mortality was septicemia followed by pneumonia and renal failure. Four hundred fifty patients (90%) recovered and were discharged from the hospital, nine (1.8%) eft against our medical advice, mainly because of lack of money during the treatment and their personal or social causes.

Table 1: Preoperative data.

Table 2: Operative data.

Table 3: Morbidity, Mortality and Outcome.

Generalized peritonitis remains a significant cause of morbidity and mortality [6]. The male-female ratio was 2.5:1 in this study, which is similar to the trend worldwide, which show a male preponderance [17,18]. In a similar study conducted in another hospital in eastern Nepal in 2001, the mean age of patients was 37.4 years and majority of patients (21.7%) belonged to age group of 30-40 years though this data included tertiary peritonitis as well [10]. There was male preponderance (81.4%) with male to female ratio of 4.4:1. Majority of the patients (89; 71.7%) presented after 24 hours of onset of symptoms. The mean age hasn’t changed much in the present study, but a change has been seen in the male-female ratio. It has changed from 4.4:1 to 2.5:1; which means that more and more females are being brought to the hospital. In the present study, 78.6% of patients have been brought to the hospital after 24 hours; this may be due to many small hospitals and clinics that treat them conservatively and when the conservative management fails, they are referred late. The most common cause in that study was duodenal perforation followed by appendicular perforation and traumatic perforations. In another study of 145 patients with duodenal perforation peritonitis done in 2002-2004, there were 124 (85.52 %) males and 21 (14.48 %) females [11]. Mortality rate was 6.9%; mortality rate in our patient cohort is 11.5%. The mean age in duodenal perforation remains similar: 48.15 years versus 45.99 years in the present study. In a study in western Nepal, the commonest cause of peritonitis was also duodenal perforation, followed by small bowel perforations and perforated appendicitis [12].

The perforations of proximal gastrointestinal tract were about 2.5 times common as perforations of distal gastrointestinal tract; this is in concordance with earlier studies from India [2], but is in sharp contrast to studies from developed countries, which reported distal perforations to be more common [19-21]. Though there have been some resemblance in some aspects, there are discrepancies in other aspects as well. In another study in India by Khanna et al, he found that over half of cases were due to typhoid perforation [20].In a study from Pakistan also, the most common cause was typhoid perforation, which was found in 134 (43%) cases; this was followed by peptic ulcer disease in 56 (18%) cases [21]. These figures show the importance of infection and infestation in the third world. Meanwhile, in a study from America, Noon et al reported 430 patients of gastrointestinal perforation and found 210 cases to be due to penetrating trauma, 92 due to appendicitis and 68 due to peptic ulcer [22]. This shows the prevalence of trauma in the affluent countries. But the scenario is different in our context, the most common cause being acid-peptic disease. In a study in western Nepal, the commonest cause of peritonitis was also duodenal perforation, followed by small bowel perforations and perforated appendicitis [12]. The treatment of secondary peritonitis has also gradually changed with the advent of minimally invasive surgical techniques. Some authors have started adopted laparoscopy as preferred surgical approach for the management of secondary peritonitis [23]. We have also started laparoscopy in peritonitis patients, which has been successful in 3 patients with duodenal perforation peritonitis recently. Regarding gastro duodenal perforation, duodenal-to-gastric ulcer ratio is 30.6:1 in the present study, compared to study by Dorairajan et al., who reported a ratio of 15:1 in India [2]. This means that gastric ulcer perforations are extremely uncommon in our country. Contrary to this the ratio was 4:1 in studies from United Kingdom and United States [24,25].

There were 41(8.2%) deaths which is comparable with other published series [25-29]. The main cause of death in the present series of patients was septicemia present in 92.68% of patients with mortality. The major cause of postoperative morbidity were respiratory complications (23%), wound infection (18%), septicemia (11.8%) and electrolyte abnormalities (6.8%).

The spectrum of perforation peritonitis in our setup continues to be different from its western counterpart and even some studies in the Indian subcontinent and Nepal with duodenal ulcer perforation and perforating appendicitis being major causes.

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