Emerging Spectrum of Perforation Peritonitis in Developing World

The Incidence of Acute Peritonitis Secondary to Different Sites of Viscus Perforation

Objective The incidence of peritonitis secondary to viscus perforation will be examined to determine the most common sites of perforation and associated comorbidities. Methods This is a retrospective observational study based on data collected from the King Fahad Hospital of the University (KFUH). This research targeted patients who had viscus organ perforation and the relation of peritonitis secondary to it. The sample was taken from patients under the care of the General Surgery Department from the first of Feb 2016 to the 12th of Sep 2022. The final sample consisted of 450 patients. The method of diagnosis of peritonitis was mainly clinical, and the surgical approach was either through an exploratory laparotomy or a diagnostic laparoscopy. Incidental findings of viscus organ perforation were noted in addition to certain postoperative complications (e.g., adhesions) and hospital stay. Results Analysis of the results showed a significant relation (p<0.001) between viscus organ perforation and peritonitis. The most common comorbidities associated with secondary peritonitis were hypertension (12, 24.5%), diabetes mellitus (10, 20.4%), any abdominal mass (3, 6.1%), and inflammatory bowel disease (1, 2%). However, a chi-square analysis has shown no significant association between peritonitis and the targeted associated comorbidities. Conclusion Perforation of the small intestine carries the biggest association with peritonitis incidence, in addition to comorbidities such as hypertension and diabetes mellitus. Further study to establish the value of these factors might contribute to decreasing the morbidity and mortality of secondary peritonitis.

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.

Clinical profile and management of perforation peritonitis in Bharatpur hospital, Nepal: A prospective study

Introduction

The most common surgical emergency in general surgery is perforation peritonitis. It is a serious condition with a mortality rate of up to 20%, and it is the third most common cause of surgical abdomen after appendicitis and intestinal obstruction. The aim of this study to discuss clinical profile and management of perforation peritonitis in a hospital in central Nepal.

Methods

This prospective study was done for one year at Bharatpur Hospital, Chitwan Nepal. In our study, only patient above 15 years were included and those who were not fit for anesthesia and surgery were excluded. Most of the patient were diagnosed clinically supported by lab investigations and imaging like X-ray and ultrasonography of abdomen. The variables analyzed were the risk factors of the patient like smoking, alcohol, liver disease and previous abdominal surgeries.

Results

The majority of the patients were in the age group 50–59 years in male and 40–49 years in female. Among sixty cases, 31 were female and 29 were male with Female: Male ratio of 1.06:1. The most common cause of perforation found was peptic ulcer compromising 88.3% (53 cases) followed by appendicular perforation accounting 8.3% (5 cases). Similarly, Tubercular perforation was found in 3.3%. Smoking was most common risk factor accounting 88.3%, followed by alcohol consumption (48.33%) while, 15% of patients had positive history of NSAIDs consumption. On imaging, 38.33% patient had air fluid level on X-ray and 78.33% had gas under diaphragm. On blood investigation, leukocytosis was found in 53.33% of patients, hyponatremia in 10% of patients and hypokalemia in 18.33% of patients. While on urine examination, albumin was found in 5% of patients. The repair of perforation along with omentopexy was done in 73.3% of patients while only repair was done in 15% of patients. Only 8.3% opted for appendectomy while a very few patients (3.3%) went for resection with anastomosis. The Postoperative complications found were wound infection (43.3%), paralytic ileus (18.33%), sepsis (15%), followed by electrolyte imbalance (11.6%), postoperative bowel obstruction (6.6%) and burst abdomen (1.6%). While, there were only 3 cases of mortality.

Conclusions

Perforation peritonitis is a frequently encountered surgical emergency. Various factors like age, sex, duration, site of perforation, extent of peritonitis and delay in surgical intervention are associated with morbidity and mortality. A successful management depends upon early surgical intervention, source control and exclusive intraoperative peritoneal lavage.

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Perforation Peritonitis is a serious condition with a mortality rate of up to 20%.

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Age, sex, duration, site of perforation, extent of peritonitis and delay in surgical intervention affect morbidity and mortality.

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Early surgical intervention, source control and exclusive intraoperative peritoneal lavage are solutions.

Intestinal Perforation Secondary to Mucormycosis Associated With Puerperal Sepsis

Mucormycosis is a rare opportunistic infection, usually seen in diabetics, immunocompromised, or those with coronavirus disease 2019 (COVID-19). Gastrointestinal involvement is uncommon but often deadly. We report a case of gastrointestinal mucormycosis causing intestinal perforation in a non-diabetic, COVID-19 negative, immunocompetent woman, associated with puerperal sepsis.

A 22-year-old woman presented to our center on post-natal day five, following delivery with insertion of an intrauterine contraceptive device (IUCD). She had complaints of breathlessness, fatigue, and giddiness. Examination revealed tachycardia, tachypnea, hypotension, and bilateral pedal edema. Following appropriate investigations, she was diagnosed with puerperal sepsis with pre-renal acute kidney injury. Imaging was suggestive of retained products of conception, and she subsequently underwent dilation and evacuation (D&E) on day eight of admission. Following brief symptomatic improvement, on day 10 of admission, she developed vomiting, abdominal distension, and pain, with obstipation. Erect X-ray showed air under the diaphragm, suggestive of perforation. She emergently underwent laparotomy with limited right hemicolectomy, ileostomy with mucous fistula. Intraoperative findings revealed a closed-loop obstruction involving terminal ileum, with two perforations. The biopsy report later revealed colonization of Mucor and hemorrhagic necrosis along the entire length of the resected specimen. She was started on amphotericin B, and after a slow recovery, was discharged.

Gastrointestinal mucormycosis is rare and has a mortality rate of 94%. It is usually seen in those with predisposing factors for mucormycosis. This is the first report of mucormycosis associated with puerperal sepsis. It is typically acquired via ingestion and may cause perforation, where mortality is further increased. Diagnosis can only be confirmed by histopathology demonstrating the characteristic morphology of Mucor. Treatment requires resection of necrotic tissues, intensive treatment with amphotericin B, and correction of predisposing factors. Our case highlights the need for a high degree of suspicion for mucormycosis in patients with intestinal perforation, even if immunocompetent, and its potential association with puerperal sepsis.

COVID-19 as a concomitant diagnosis and the emergencies behind COVID-19 mask – a real challenge that requires a multidisciplinary view of the patient

The etiological cause of Coronavirus infection, which has captured the attention of almost the whole world at the moment, is SARS-CoV2. The clinical picture of coronavirus infection varies from asymptomatic to severe respiratory infection with manifestations of respiratory failure, the development of respiratory distress syndrome and even death. Already in the first months of the coronavirus pandemic in the United States there was a serious decline in the number of patients seeking medical care in the Emergency Department (49.3%) compared to 2019. There is evidence of increased mortality during the pandemic, which causality cannot be directly or associated with coronavirus infection. Even in the context of a global pandemic, we must not forget all other diagnoses and conditions that exist as comorbidity, and emergency care must be provided without delay and delay.