Spectrum of perforation peritonitis in delhi: 77 cases experience

Chicken bone-induced ileal perforation peritonitis mimicking duodenal perforation peritonitis: a case report

Introduction

Foreign body ingestion can lead to bowel perforation and peritonitis. We present a case of a 54-year-old male who ingested a chicken bone, resulting in ileal perforation that mimicked duodenal perforation peritonitis.

Case Presentation

The patient has a history of peptic ulcer disease and regularly used non-steroidal anti-inflammatory drugs over the counter, adding more evidence to the provisional diagnosis of duodenal perforation. Exploratory laparotomy revealed the ileal perforation and the chicken bone was successfully removed. Wedge resection of the perforated segment and ileo-ileal anastomosis were performed.

Discussion

Although history, examination, and investigation were more in favor of duodenal ulcer, our patient had ileal perforation due to chicken bone. Prompt identification and early surgical intervention are crucial to prevent complications and reduce mortality rates. The patient had an uneventful recovery.

Conclusion

Timely referral to a tertiary care center is essential for early surgical intervention and successful management of bowel perforation caused by a foreign body.

A comparative analytical study on outcome of secondary peritonitis using Mannheim's peritonitis index in geographically diverse Indian patients

Objectives

Secondary peritonitis is caused by infection of the peritoneal cavity due to perforation of the alimentary tract. Mannheim's peritonitis ındex (MPI) is a prognostic scoring system that predicts outcomes in peritonitis. Increasing MPI scores correlate with poor outcomes and mortality. The objective of this study is to evaluate the effectiveness of MPI-based prognosis and its impact on Indian patients with secondary peritonitis.

Material and Methods

For understanding the effectiveness of the MPI scoring system, a cross-sectional data analysis of published studies on secondary peritonitis from 10 geographical locations in India was performed. The 10-site study results were compared with unpublished in-house study data for individual MPI parameters to analyze any variations of MPI score-based predictions across a diverse Indian population. Patients were divided into risk groups on the basis of MPI scores: <21 mild, MPI= 21-29 moderate, MPI> 29 severe risk.

Results

We observed a significant correlation between mortality with age and gender as reported worldwide. Site of perforations were prevalent in the upper alimentary tract with the majority being gastro-duodenal for the Indian population as opposed to distal parts in the western population. Higher lethality in India is often associated with evolution time, organ failure, and sepsis due to delayed presentation and poor management.

Conclusion

MPI scoring is effective in predicting risk across geographically diverse Indian populations. The sensitivity and specificity of MPI scores are more reliable and a score >29 specifically recommends aggressive resuscitation & monitoring of patients, initiation of broad-spectrum antibiotics, and intensive care support to reduce mortality and morbidity.

The Role of the Mannheim Peritonitis Index for Predicting Outcomes in Patients With Perforation Peritonitis in a Rural Hospital in India

Introduction Acute secondary peritonitis due to hollow viscus perforation is a life-threatening surgical condition with significant morbidity and mortality, depending on the severity with outcomes that differ in the Western and developing world. Various scoring systems have been developed to assess the severity and its relation to morbidity and mortality. We conducted this study to evaluate the role of the Mannheim peritonitis index (MPI) in predicting outcomes in perforation peritonitis patients in a rural hospital in India. Materials and methods A prospective study of 50 patients with hollow viscus perforation with secondary peritonitis presented to the emergency department, Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha, from 2016 to 2020. Each operated patient was scored according to the MPI to predict mortality. Results The majority of the patients were discharged uneventfully and about 16% (8/50) of the patients expired. The patients with an MPI score of more than 29 had maximum mortality of 62.5%. Mortality was seen in 37.5% of the patients with MPI scores between 21 and 29, whereas no mortality was recorded in patients with an MPI score of 21. Higher mortality was associated with age greater than 50 years (p=0.007), the presence of malignancy (p=0.013), colonic perforation (p=0.014), and fecal contamination (p=0.004). There was no significant correlation with gender (p=0.81), the presence of organ failure (p=1.6), delayed presentation, i.e., preoperative duration >24 hours (p=0.17), and the presence of diffuse peritonitis (p=0.25). Conclusion MPI is a specific, easily reproducible, and less cumbersome scoring method for predicting mortality in patients with hollow viscus perforation (secondary) peritonitis with minimal laboratory investigations. Higher scores correlate with a poorer prognosis and need intensive management, making use of MPI in clinical practice relevant and beneficial, especially in resource-poor settings.

Pre-operative Intraperitoneal Drainage Under Local Anesthesia: A Promising Resuscitation Tool in Peritonitis Secondary to Hollow Viscus Perforation During the Corona Pandemic

Introduction To study the role of intraperitoneal drainage in the resuscitation of patients with perforation peritonitis during the corona pandemic. Materials and methods This retrospective study was conducted in the general surgery department of Nishtar Medical University/Hospital Multan from April 2020 to September 2020. Patients of peritonitis who presented with bilateral pulmonary crepitations, SpO2 less than 92%, PaO2 less than 60 mmHg on arterial blood gas (ABG), and chest x-ray (CXR) finding of bilateral infiltrates are included. Due to high suspicion of associated coronavirus infection such patients needed polymerase chain reaction (PCR) for virus detection and special measures were required for resuscitation before any definitive treatment. A delay of six to eight hours is usually encountered while ensuring proper safety measures and dedicated operation theaters. Initial resuscitation started with intravenous fluids and broad-spectrum antibiotics were given to all patients. Twenty-seven patients were resuscitated with preoperative intraperitoneal drainage while waiting for PCR and 13 patients were resuscitated without drainage. Data analysis was carried out using the statistical package for the social sciences (SPSS) version 19 software. The mean was calculated for age while frequency and percentages were calculated for gender, comorbidities, and causes of delay. The mortality was compared using the chi-square test. Results The mean age of patients was 43.73 ± 16.04 years. The common cause of peritonitis were perforations due to duodenal ulcer, typhoid, tuberculous (TB), and biliary origin. The variables that led to suspicion of coronavirus were SpO2 < 92%, PaO2 <60mmHg and bilateral infiltrates on chest x-ray. PCR for coronavirus was positive in nine patients. Mortality was 29.6% in those resuscitated with intraperitoneal drainage before the definitive procedure and 54% in those not resuscitated with intraperitoneal drainage. Conclusions The surge of coronavirus infection has put the healthcare staff at great risk. This has led to strict protocols and precautionary measures in the management of patients with perforation peritonitis with suspected corona infection. The local guidelines for the management of patients with acute abdomen should include aggressive measures right from the start during the corona pandemic. Intraperitoneal drainage, early in the management of perforation peritonitis decreases morbidity and mortality in suspected corona infected patients.

Treating Surgical Infections in Low- and Middle-Income Countries: Source Control, Then What?

Surgical infections present a significant burden of disease globally. Management focuses on source control and appropriate antibiotic therapy. This remains a challenge in low- and middle-income settings, where access to surgical care and antibiotics is limited. This paper discusses the complex challenges facing the management of surgical infections in low- and middle-income countries.

Outcomes of Emergency Laparotomy (EL) Care Protocol at Tertiary Care Center from Low-Middle-Income Country (LMIC)

BACKGROUND

Emergency laparotomy mortality ranges between 10 and 20% in best of Western healthcare systems and is currently a major focus for quality improvement programs. In contrast, emergency surgery scenario in LMIC is largely undefined, often neglected and complex (large burden of diseases but only limited capacity for adequate treatment). We evaluated the efficacy of 'EL care protocol' aimed at cost-effective optimal utilization of best available local expertise and infrastructure.

METHODS

One hundred and two consecutive adult patients (≥16 years) who underwent EL from December 2012-December 2015 at a private tertiary hospital were retrospectively analyzed. The patients who underwent emergency laparoscopic procedures were excluded from the analysis. The EL care protocol included. (1) Admission to surgical intensive care unit for pre- and postoperative optimization. (2) Preferred radiologic investigation: abdominal computed tomography (CT) scan. (3) Surgery and critical care by senior surgical gastroenterologists and internists/anesthesiologists, respectively. Outcome measures were procedure-related complications (Clavien-Dindo classification), readmissions and costs.

RESULTS

Of the 102 patients, there were 62 males and 40 females with median age of 60 (range 16-93) years. There were no complications in 22 (21.6%) patients, while Clavien-Dindo complications grade I or II occurred in 48 (47%) patients. Grade V Clavien-Dindo complications and the 30-day mortality were similar of 19 (18.6%). The readmission rate was 8 (7.8%). The expected mortality for the study group by P-POSSUM score was 31.2 (30.6%). The ratio (O/E) of observed to expected mortality was 0.61. The all inclusive median cost of treatment was INR 379,255 ($5590).

CONCLUSIONS

LMIC centers should develop their own center-specific EL care protocols to improve outcomes of EL.

Amoebic Colonic Perforation Presenting as Peritonitis in Emergency, Incidence and Outcome: Our Experience

OBJECTIVES

Amoebiasisis a common parasitic infection and fulminant amoebic colitis remains a very rare complication of this disease. The objective of the present study was to find the incidence and outcome of perforation peritonitis due to amoebic colitis in MMIMSR, Mullana, Ambala, India.

MATERIAL AND METHODS

200 patients with perforation peritonitis were studied retrospectively, out of which 22 cases had colonic perforation, were selected over a period of five years, between 2012 to 2017, at MMIMSR Mullana. All patients had undergone emergency laparotomy and cases with amoebic colonic perforation established on histopathology were studied in terms of incidence, clinical presentation and outcomes.

RESULTS

Out of 200 emergency exploratory laparotomies carried out during 2012-2017 at MMIMSR, Mullana, 22 (11%) patients had amoebic colonic perforation. The disease was more common among men as compared to women (21:1). The mean age of patients was 60±10 years. Symptom duration ranged from 1 to 8 days. 15 (68%) patients had historyof chronic alcohol intake and 2 (9%) had a recent episode of loose stools. Chest X-ray showed free gas under the diaphragm in 45% (10/22) of patients. Ultrasonography whole abdomen showing associated liver abscess was seen in 8/22 (36%) patients. Intraoperatively caecal perforation was seen in 20 cases, out of which 16 had concomitant ascending colon perforation and 2 sigmoid colon perforation. Bowel resection was performed depending upon the site and extent of the colon involved- right hemicolectomy (16), limited ileocolic resection (4) and sigmoidectomy (2). Proximal diversion stoma was made in all cases. Postoperative complications encountered were wound infection in 20 (91%) cases, followed by burst abdomen in 8 (36%) cases, stoma related complication in 6 (27%) cases. The overall mortality rate due to sepsis was 54% (12/22).

CONCLUSION

Although amoebiasis is a common parasitic infection, fulminant amoebic colitis remains a very rare complication with a reported incidence of 1%. Even with aggressive management of this entity, patients have got a poor prognosis. Resection with exteriorization of bowel is the current gold standard treatment in such cases.

A 14-year-old girl presenting with tuberculous intestinal perforation while in a temporary shelter after the 2015 earthquake in Nepal

A 14-year-old Nepalese girl presented with fever, abdominal pain and vomiting. She was living with her family in a temporary settlement camp following the earthquake in Nepal in 2015. She had had abdominal pain for 2 months and fever for 1 month. Abdominal examination suggested acute peritonitis. At laparotomy, three ileal perforations were detected and histopathology demonstrated caseous granulomas. Her father had sputum-positive pulmonary tuberculosis. She was diagnosed with abdominal tuberculosis and responded well to anti-tuberculosis chemotherapy. Intestinal perforation is a rare complication of tuberculosis in children.

Tuberculosis terminal ileitis: A forgotten entity mimicking Crohn’s disease

Intestinal tuberculosis (TB) is an uncommon lesion for which differential diagnosis can be difficult. We present a case of a 53-year-old male and a systematic review of the literature, from clinical symptoms to differential diagnosis, unusual complications and therapy. The patient was admitted to the hospital with signs of acute abdomen as a result of a perforated terminal ileitis. Based on the skip lesions of the terminal ileum and cecum, Crohn’s disease (CD) was clinically suspected. An emergency laparotomy and right colectomy with terminal ileum resection was performed and systematic antibiotherapy was prescribed. The patient’s status deteriorated and he died 4 d after the surgical intervention. At the autopsy, TB ileotyphlitis was discovered. The clinical criteria of the differential diagnosis between intestinal TB and CD are not very well established. Despite the large amount of published articles on this subject, only 50 papers present new data regarding intestinal TB. Based on these studies and our experience, we present an update focused on the differential diagnosis and therapy of intestinal TB. We highlight the importance of considering intestinal TB as a differential diagnosis for inflammatory bowel disease. Despite the modern techniques of diagnosis and therapy, the fulminant evolution of TB can still lead to a patient’s death.