Spectrum of perforation peritonitis in Pakistan: 300 cases Eastern experience

Peritonitis due to perforation of the gastrointestinal tract is the most common surgical emergency all over the world [1]. The spectrum of etiology of perforation differs from its western counter part [2]. Majority of the patients present late, with purulent peritonitis and septicemia [3]. surgical treatment of perforation peritonitis is highly demanding and very complex, combination of improved surgical technique, anti microbial therapy and intensive care support has improved the outcome of such cases [4]. Objective of this study Was to highlight the clinical presentation, causes of perforation, site, surgical treatment, postoperative complications and mortality at (DUHS&CHK) Pakistan, which is a tertiary care hospital.

This was a prospective study include three hundred consecutive patients of perforation peritonitis Conducted in the Department of general surgery Dow University of Health Sciences and civil Hospital Karachi (DUHS&CHK) Pakistan over a period of two and half years from 1st September 2005 – 1st March 2008, over a period of two and half years.

Perforation peritonitis is the most common surgical emergency noticed in the younger age group [5]. as noticed in our study, mean age was 40.5 years. Majority of the patients in our study were male 68.3%, and female 31.7%. Another study also showed more male patient of perforation peritonitis with male female ratio 3:1 [6]. Perforation of the proximal part of the gastrointestinal tract were more common [7], which is in contrast to the studies from western countries where perforations are common in the distal part [8]. Duodenal ulcer Perforation was the most common perforation noticed in our study. Another study conducted by Gupta S and Kaushik R shows the same result [9]. It is noticed in our study that proper hydration, good antibiotic cover and simple closure of the perforation using an omentopexy significantly decrease mortality rate [10]. There are other treatment options for perforated peptic ulcer like Bilroth I, Bilroth II, Truncal vagotomy drainage procedure [11, 12] and Laparoscopic repair of perforated gastroduodenal ulcer by running suture is an option [13]. Gastric ulcer rarely present with perforation peritonitis, gastric perforations are related to the wide spread use of NSAIDS [14]. as seen in our study 15% patients have positive history of NSAIDS. Perforation is a rare complication of gastric carcinoma, accounting for less than 1%. Perforated gastric ulcer have high incidence of malignancy [15], as seen in our study, out of 7 gastric perforations 2 were malignant.

Causes of ileal perforations noticed in our study were tuberculosis and typhoid. Primary intestinal tuberculosis is uncommon in European and North American countries today [16]. Tuberculosis is a disease that can affect any part of the body at any age in Eastern countries, most common site of extra pulmonary tuberculosis is the illeocaecal region and terminal ileum [17]. It can be fatal even in the young and fit [18]. Tubercular Ileal perforations present alone or in combination with Caecum. Ileocaecal tuberculosis presents as a mass in right lower quadrant, or obstruction due to stricture in ulcerative type of tuberculosis with perforation peritonitis [19]. The most common complication of small bowel tuberculosis was obstruction due to the narrowing of the lumen by hyper plastic Ileocaecal tuberculosis or stricture of small intestine and perforation in ulcerative type of tuberculosis, which are commonly multiple [20]. Perforation peritonitis may present during the anti tuberculosis treatment [21] as seen in our study, 11% patients present with perforation during anti tuberculosis treatment. Management of tubercular perforation of ileum depends upon the condition of the gut, general condition of the patient and number of perforation.

Ileocaecal tuberculosis by right hemicolectomy with or without stoma, perforation along with multiple stricture resection anastomosis with a covering stoma or only stoma [22, 23]. Typhoid enteric perforations managed by either primary repair or only stoma depend upon the condition of the gut and general condition of the patient and also managed laproscpically [24]. Primary repair of the typhoid perforation is a safe and effective treatment [25], as seen in our study 15% patients managed by primary repair.

Colorectal perforation is a rare cause of perforation peritonitis seen in 8.3% patients. Malignancy is a rare cause of perforation peritonitis in our setup, peritonitis due to malignancy was seen only in 2.6% of cases as compared to the western counter part [26]. Rectal perforation have high morbidity and mortality and its treatment options are based on the surgeons personal experience, patients general condition, age of the patients and degree of peritonitis. Primary anastomosis and protective ileostomy is a superior treatment to Hartman procedure in acute left sided colon perforation in the absence of fecal peritonitis [27]. Perforation peritonitis have a high mortality, the over all mortality ranges between 6–27% [9, 28] High mortality was depend upon the site and cause of perforation. The death rate from perforated duodenal ulcer was 32.2% and from perforated gastric ulcer was 20.1% [12]. Different studies show the different mortality, gastric perforation 36% [29], enteric perforation 17.7% [30], colorectal perforation 17.5% [31]. Our mortality was comparatively low 10.6%, might be due to the formation of only stoma in emergency in patients with serious illness and omentopexy in all patients present with gastro duodenal perforation due to acid peptic disease. Factors contributing to the high mortality and postoperative complications are advanced age, late presentation, delay in the treatment, septicemia and associated co morbid, Respiratory complications are the known risk factors for the high mortality [32]. Re look laparotomies and abdominal washout had a definite role to play in perforation peritonitis [33], as seen in our study 37.3% patients go through redo surgery. Abdominal washout and tension suturing, factors contributing to redo surgery were persistent septicemia due to abdominal collection, inter loop abscess, anastomosis leakage and burst abdomen.

To conclude Spectrum of perforation peritonitis in Eastern country Pakistan continues to differ from western country. Perforations are seen mostly in the small bowel rather than the large bowel. Majority of perforations noticed in the duodenum due to acid peptic disease followed by small bowel tuberculosis and typhoid. Majority of the perforations in the large bowel are due to tuberculosis and perforated appendix. Malignancy was the least common cause of perforation peritonitis in our set up. Aggressive resuscitation and early minimum surgery required to avoid the high morbidity and mortality. Major complications noticed are the Wound infection and wound dehiscence. Over all mortality was 10.6%.