International Surgery Journal

Mukherjee S et al. Int Surg J. 2016 Nov;3(4):2074-2078

http://www.ijsurgery.com pISSN 2349-3305 | eISSN 2349-2902

DOI: http://dx.doi.org/10.18203/2349-2902.isj20163576
Original Research Article

A retrospective study of perforation peritonitis in a tertiary care

hospital in Uttar Pradesh, India
Sujoy Mukherjee*, Mohd. Arshad Raza, Rishi Jindal, Ratnakar

1
Department of Surgery, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

Received: 30 June 2016

Accepted: 05 August 2016

*Correspondence:
Dr. Sujoy Mukherjee,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Perforation peritonitis is a common surgical emergency encountered by surgeon’s world over. The
spectrum of this disease including its etiology differs in various countries. The present study was carried out to study
the various modes of presentation, clinical features morbidity and mortality of perforation peritonitis in a tertiary care
hospital in Uttar Pradesh, India.
Methods: This study was conducted on 221 consecutive patients of perforation peritonitis who presented in a period
of 2 years (March 2014 to February 2016) in department of surgery, Rohilkhand medical college and hospital,
Bareilly, Uttar Pradseh, India. These patients were assessed with respect to clinical presentations, causes, site of
perforation, surgical management, postoperative complications and mortality if any. Following resuscitative
measures, all patients underwent emergency exploratory laparotomy, where the cause of perforation was explored and
controlled.
Results: A total of 221 cases of perforation peritonitis were included in the study with mean age of 39.8 years (range
= 10 - 70 years). Majority of patients were male with female ratio of 4.02:1. 62% came with complaints of distension
and 42% gave positive history of chronic NSAID use. Most common complications were wound infection, septicemia
and dyselectrolylemia (49, 40 and 46% respectively). The overall mortality was 12.2%.
Conclusions: In the present study, most common site of perforation was the duodenum, the cause being acid peptic
disease as a consequence of NSAIDs use. Early recognition, prompt intervention might lead to better outcomes and
curtail mortality and morbidity associated with this disease. Highest percentage of perforation was noted in upper part
of gastrointestinal tract.

Keywords: NSAIDs, Perforation peritonitis

INTRODUCTION highly demanding despite advances made in diagnosis,

surgical management, antibiotics therapy, correction of
Perforation peritonitis is the peritoneal inflammation due electrolyte balance and intensive care support.
to reaction of peritoneal cavity to the contents of
perforated viscus, namely, gastro intestinal tract, the Thus the management remains challenging through
biliary system, pancreas or genitourinary tract. improvements in outcomes of such cases in respect to
Gastrointestinal perforations constitute one of the morbidity and mortality has been achieved. The causes of
commonest surgical emergency encountered by perforation are wide apart between Asian populace and
surgeons.1,2 Since the perforations could be because of their western counter parts.3-5 Majority of patients
injury or lesions of viscus, these are amenable to surgical reported to hospital fairly late often with complications
therapy. Management of these patients continues to be such as purulent peritonitis and septicemia.2

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 Mukherjee S et al. Int Surg J. 2016 Nov;3(4):2074-2078

METHODS Amongst comobrid conditions NSAIDs intake and COPD

were more commonly encountered.
This retrospective study was conducted from March 2014
to February 2016 for a period of 2 years in patients of Table 2: Symptomatology and comorbid conditions in
perforation peritonitis in the department of surgery, cases of perforation peritonitis.
Rohilkhand medical college and hospital, Bareilly, Uttar
Pradesh, India. All 221 consecutive cases of peritonitis Comorbid
Symptoms No. (%) No. (%)
due to perforation of a viscus were included in the present conditions
study. The exclusion criteria included all cases of primary Distension 137 (61.99) COPD 106 (48)
peritonitis, trauma, corrosive and post-operative Tenderness/ NSAIDs
peritonitis due to anastomosis leakage. 86 (38.91) 93 (42)
pain intake
Vomiting 66 (29.86) Hypertension 22 (9.9)
All enrolled cases were studied with respect to clinical Constipation 62 (28.05) TB 22 (9.9)
features at the time of presentations and based on history, Fever 22 (9.9) Diabetes 7 (3.16)
physical examination, a provisional diagnosis of
Shock 19 (8.6) Malignancy 4 (1.81)
intestinal perforation was made which was confirmed by
X-ray abdomen and chest, Routine investigations
including haemoglobin, renal functions tests, liver Table 3: Time taken to reach hospital and admission
functions tests and electrolytes were also assessed. On to operation time.
performing exploratory laparotomy, the source of
Variable Time Patients no.
peritonitis was found and managed accordingly followed
by peritoneal lavage and drain instillation. Parenteral Time taken to <24 hours 44
broad spectrum antibiotics and fluids were administered reach hospital >24 hours 177
and electrolyte balance was maintained. Patients were Admission to <12 hours 46
allowed orally after return of bowel sounds and passage operation time >12 hours 175
of flatus and stools. Early ambulation was ensured. If
required blood transfusion was given. Table 3 shows time taken to reach hospital and time taken
from admission to operation. It has been noted that a
RESULTS great majority of patients (177) took more than 24 hours
to reach hospital after the appearance of the symptoms.
In this retrospective study spanning a period of 2 years a 20% of patients presented to hospital within 2 hours of
total of 221 patients were included. Mean age was onset of symptoms. Only 44 patients reached hospital
39.8±13.31 years. within 24 hours and majority of these patients were city
dwellers. Further, in great majority of cases (175), the
Table 1 shows number of patients and their age groups. admission to operation time took more than 12 hours.
The highest number (96) patients belonged to the age This much time was taken for resuscitation, diagnosis and
group of 31-40 years. preparing the patient for surgery. In only 46 cases the
exploratory laparotomy was performed within 12 hours
Table 1: The age and number of patients in cases of owing to prompt resuscitation and early clinching of
perforation peritonitis. diagnosis.

Age Numbers Table 4 depicts positive findings on investigations,

<10 5 Radiological pictures and dyselectrolytemia were the two
11-20 4 foremost positive investigative findings.
21-30 12
31-40 96 Table 4: Positive findings on investigations.
41-50 42
Investigations No.
51-60 39
X-Ray chest 174
61-70 15
X-Ray abdomen 62
>70 8
Dyselectrolytemia 91
Total 221
Raised renal function 46
Table 2: Shows presenting symptoms and comorbid
Table 5: Shows different sites of perforation, the most
conditions in cases of perforation peritonitis.
common being duodenum (54%) followed by ileal
perforation (23%). Gall bladder was involved in only 2
A single case may exhibit several symptoms
out of 221 cases.
simultaneously. It may be noted that distention and pain
in abdomen were the most frequent symptoms observed.
Table 6: Shows the surgical procedures undertaken in
cases of perforation peritonitis. It could be noted that

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 Mukherjee S et al. Int Surg J. 2016 Nov;3(4):2074-2078

omentopexy and ileostomy were the commonest antibiotics and maintenance of proper electrolyte balance,
procedures undertaken. only then an improved outcome will be achieved

Table 5: Sites of perforation. Approximately 62% cases had distension of abdomen,

and 39% had pain and tenderness. Almost similar type of
Site No. (%) symptomatology was also noted by other investigations
Duodenum 119 (53.6) and thus corroborated our observations.6-8
Gall bladder 2 (0.9)
Gastric anterior 18 (8.1) In our study large number of cases had associated
Gastric posterior 4 (1.8) comorbid conditions. Common associated comorbid
Jejunum 5 (2.3) conditions included chronic obstructive pulmonary
disease (COPD) followed by NSAID intake,
Ileum 50 (22.6)
hypertension, diabetes, TB and malignancy. Bali et al in
Appendix 11 (4.9)
their study also observed COPD, renal disease, diabetes
Colon 7 (3.2) and hypertension as comorbidities.6
Caecum 5 (2.3)
Majority of patients in present study exhibited positive
Table 6: Surgical procedures undertaken. findings on investigations such as evidence of
pneumoperitoneum on X-ray chest and air fluid levels on
Procedure No. (%) X-ray chest and air fluid levels on X-ray abdomen and
Omentopexy 199 (53.6) dyselectryrolemia. Memon et al contested our
Ileostomy 55 (24.9) observations and noted that investigations have dubious
Colostomy 7 (3.2) reliability.8 Supporting our observations in respect to
Resection with anastomosis 5 (2.3) investigations results, other investigations have also
Appendicectomy 11 (4.9) observed a positive role reporting 50% of cases had
Graham’s patch 22 (9.9) pneumoperitoneum. We observed positive findings in
Cholecystectomy 2 (0.9) various investigations conducted. Consistent with our
observations, Bali et al also noted that 79% patients had
pneumoperitoneum on chest x-ray and multiple air fluid
Table 7 enumerates various complications which arose
levels on abdominal X-rays.6 Similar to our findings,
during the course of management. The most common
these authors also noted altered electrolyte balance.
being wound infection, septicaemia and
dyselectrolytemia. Intraoperatively, there was purulent
Most patients (177) took more than 24 hours to reach
exudate in 143, faecal in 63, clear in 13 and bilious in 2
hospital despite onset of symptoms. Memon et al in their
patients.
series also observed that majority of patients presented
late from 12 hours to 6 days with average 3.5 days.8 Kaur
Table 7: Complications encountered in these patients.
et al also observed a delay in seeking surgical treatment
as an important cause of high morbidity.9 We observed
Complications No. (%)
that the diagnosis of peritonitis could be clinched
Wound infection 49 (22.1)
clinically. Abdominal distention, pain, tenderness,
Septicemia 40 (18) vomiting were some important symptoms. Other
Burst abdomen 15 (6.7) investigations also noted similar symptomatology in their
Abdominal collection 28 (12.6) studies.8,10
Chest infection 30 (13.5)
Dyselectrolytemia 46 (20.8) More commonly the perforations involved the proximal
Anastomotic leaks 1 (0.4) part of gastrointestinal tract.6,11-13 This observation was in
Mortality 27 (12.2) contrast to observations of Memon et al, Quereshi et al
and Dorairajan et al who noted distal gastrointestinal tract
There was a total 27 mortality out of 221 cases. Wound was the common site of perforation.8,14,15 Our
infections, septicaemia and dyselectolytemia were observations are also in contrast to studies from western
responsible for prolonged stay in the hospital and countries where perforations were more common in the
comorbidities. distal part.16,17

DISCUSSION It may be noted that then spectrum of perforation

peritonitis in India continues to be different from western
Peritonitis as results of perforation of a viscus is one of counterparts. Although there is a paucity of data from our
the commonest emergencies seen in surgical department. country about perforation peritonitis with respect to
Management of perforation peritonitis not only requires etiological factors, prognostic indicators, morbidity and
prompt resuscitation measures and improved surgical mortality patterns yet with passage of time one could
strategies but also intensive medicare including specific clearly observe the changing patterns with wide

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 Mukherjee S et al. Int Surg J. 2016 Nov;3(4):2074-2078

geographical variations even in our own country mortality range between 6-27%.6,23,26,27 The main cause of
regarding etiology etc. If earlier studies pattern are death in the present series was wound infection and
compared with the present studies. septicemia a problem of infection, and electrolyte
imbalance. Hence early surgical intervention curtails
Khanna et al in their study of 204 consecutive cases of further contamination by removing the source of
gastrointestinal perforation from UP reported that over infection through final outcome depends upon general
half (108) cases were due to perforation of typhoid fever host resistance, maintaining proper electrolyte balance
as also with amoebiasis and tuberculosis, thus and control of septicemia by resorting to antibiotic
emphasizing a major role played by infection at that era sensitivity of the organism. Our observations are well
of time.18 Bali et al also noted that 22% of cases were due supported by Nadkarni et al and Bali et al.5,6
to typhoid and tuberculosis.6 In contrast Bose et al from
PGIMER Chandigarh reported blunt trauma to be a major CONCLUSION
cause (21% cases) probably due to high speed road traffic
accidents on national highway near Chandigarh.4 Spectrum of perforation peritonitis is quite different
between India and western countries. Upper
Noon et al also reported penetrating trauma to be major gastrointestinal perforation (duodenal mainly) are fairly
cause. These observations are contrary to our common in India. In present study, NSAIDs consumption
observations wherein major cause is chronic NSAIDs is the most important cause of perforation. Wound
consumption (42%) cases.19 Moreover, blunt abdominal infection and septicaemia are the major causes of
trauma also poses diagnostic dilemma for the concerned mortality. Early surgical intervention, undercover of
surgeon. broad spectrum antibiotics, preceded by prompt
resuscitation measures and correction of electrolyte
Acid peptic disease is the commonest cause of imbalance are the cornerstone in achieving good
perforation peritonitis consequent to NSAIDs outcomes and reducing morbidity and mortality rate.
consumption. In 53.6% of cases duodenum is the site of
perforation, followed by ileum in 22.6% cases, and ACKNOWLEDGEMENTS
gastric ulcers-gastric anterior (8.1%) and gastric posterior
(1.8%). In 4.9% cases peritonitis developed secondary to Authors would like to thank our patients who participated
perforated appendix. Our observations are in line with in this study. Also Authors thankful to our colleagues,
those of Dandapat et al who noted an incidence of 6.4% seniors and paramedical staff who helped and supported
of perforated appendix, whoever there was much variance us throughout the study.
in the findings of Memon et al reporting 15%
appendicular perforations.8,20 Funding: No funding sources
Conflict of interest: None declared
Duodenal and gastric ulcers are present in the ratio of 5:1 Ethical approval: The study was approved by the
in the present study. Our observation are in line with institutional ethics committee
those of Jhobta et al in whose series the ratio was 7:1, but
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Cite this article as: Mukherjee S, Raza MA, Jindal

R, Ratnakar. A retrospective study of perforation
peritonitis in a tertiary care hospital in Uttar Pradesh,
India. Int Surg J 2016;3:2074-8.

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