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Aljehaiman F, Almalki FJ, Alhusain A, Alsalamah F, Alzahrani K, Alharbi A, Alkhulaiwi H. Prevalence, Pattern, Mortality, and Morbidity of Traumatic Small Bowel Perforation at King Abdulaziz Medical City: A Retrospective Cohort Study. Cureus 2024; 16:e52313. [PMID: 38357047 PMCID: PMC10866392 DOI: 10.7759/cureus.52313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
Introduction Bowel perforation, whether from trauma or other causes, presents with diverse clinical scenarios. Small bowel perforation (SBP), a potentially fatal condition often linked to blunt trauma like motor vehicle accidents, necessitates prompt detection and intervention, crucial for improved outcomes. This study investigated the prevalence, predictors, presentation, diagnostic findings, morbidity, and mortality of traumatic SBP for comprehensive insights. Methodology This was a retrospective cohort study conducted at King Abdulaziz Medical City, Riyadh. A review of 838 cases, which represent all abdominal trauma patients from January 2017 to March 2023, was done. Forty patients who developed SBP and have complete data were included in this study. One case was excluded due to incomplete medical records. Data were collected with the non-probability convenience sampling technique via the BestCare system using a data collection sheet. Data were analyzed with IBM SPSS 29 (IBM Corp., Armonk, NY). Results Out of all abdominal trauma cases (n=838), 40 patients developed SBP (n=40, 4.77%). Males constituted 87.5%, and the most common mechanism was motor vehicle accidents (57.5%). Complications included cardiac arrest, disseminated intravascular coagulation (DIC), and leak (7.5% each). In motor vehicle accidents, SBP primarily affected patients who were in the driver's position (78.3%). Clinical signs at presentation revealed abdominal tenderness (52.5%), abdominal distension (22.5%), and abnormal systolic blood pressure (mean 115.3 mmHg). Linear regression showed gender and age positively associated with morbidity (p=0.474, p=0.543) while BMI exhibited a negative relationship (p=0.314). Logistic regression revealed non-significant predictors of mortality, except for mean initial hematocrit (HCT) (p=0.721, aOR=0.098). Conclusion Our study provides crucial findings on the incidence, patterns, mortality, and morbidity of traumatic bowel perforation, contributing to the existing body of research. The identified prevalence of 4.77% and mortality at 17.5% from the studied population underline the serious impact of this condition, and the 37.5% complication rate observed demonstrates the potential risks involved. The average hospital stay is found to be 14 days, adding further to the disease burden. These findings underscore the importance of specific preventative measures, particularly related to motor vehicle accidents (MVAs), and highlight potential markers for predicting outcomes, such as age, gender, and mean initial HCT. This substantiates the need for further research involving larger cohorts and prospective designs to gain comprehensive insights and establish more robust preventative and treatment strategies.
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Affiliation(s)
- Fahad Aljehaiman
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Research, King Abdullah International Medical Research Center, Riyadh, SAU
| | - Faisal J Almalki
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Abdulah Alhusain
- Plastic and Reconstructive Surgery, King Abdulaziz Medical City, Riyadh, SAU
| | - Faris Alsalamah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | | | | | - Hani Alkhulaiwi
- Trauma and Acute Care Surgery, King Abdulaziz Medical City, Riyadh, SAU
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Muacevic A, Adler JR, Singh H, Josan A. An Isolated Perforation of the Fourth Part of the Duodenum Following Blunt Abdominal Trauma: A Case Report. Cureus 2023; 15:e33571. [PMID: 36788890 PMCID: PMC9910818 DOI: 10.7759/cureus.33571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 01/12/2023] Open
Abstract
An isolated perforation of the duodenum is rare in cases of blunt abdominal trauma, and diagnosis is often delayed due to subtle clinical signs. We present the case of a 13-year-old male patient who presented to the hospital with an alleged history of being run over in the abdomen by a vehicle and a complaint of severe abdominal pain. Radiography of the abdomen in the standing position showed air under the diaphragm, and ultrasonography revealed free fluid in the pelvic and peritoneal cavities, clinching the diagnosis of hollow viscus perforation. The patient was resuscitated and underwent an exploratory laparotomy under general anesthesia. On exploration, no perforation was found in the intraperitoneal organs. The retroperitoneum was opened, and the Cattell-Braasch maneuver was used to approach the duodenum. A single perforation was discovered in the fourth part, and a modified graham patch repair was done. As soon as the patient's bowel sounds returned, a low-fat diet was started through a nasojejunal tube placed distal to the perforation site. The patient was discharged in good condition and is doing well with regular follow-ups. This case emphasizes the need for a high index of suspicion for gut perforation of both intra- and retroperitoneal organs after blunt trauma. This will help in early diagnosis and timely management to reduce perforation-associated mortality. Damage control surgery, with primary closure of the perforation, is well-suited and preferred in an emergency and resource-limited setting.
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Gaye AM, Thiam I, Deguenonvo GNC, Guèye M, Sarr ISS, Dial CMM. Lithopedion as a factor in post‐traumatic intestinal perforation. J Forensic Sci 2022; 67:2097-2100. [DOI: 10.1111/1556-4029.15070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/19/2022] [Accepted: 05/19/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Abdou Magib Gaye
- Anatomy and Pathological Cytology Laboratory of the Aristide Le Dantec Hospital Dakar Senegal
| | - Ibou Thiam
- Anatomy and Pathological Cytology Laboratory of the Aristide Le Dantec Hospital Dakar Senegal
| | | | - Mamour Guèye
- Department of Gynecology and Obstetrics of the Aristide Le Dantec Hospital Dakar Senegal
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Singh S, Chand P, Kundal S, Singh G, Kundal D. Incidental Finding of Ascaris in Peritoneal Cavity During Laparotomy for Blunt Trauma Abdomen: A Rare Case. Cureus 2022; 14:e24970. [PMID: 35706732 PMCID: PMC9187280 DOI: 10.7759/cureus.24970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2022] [Indexed: 11/17/2022] Open
Abstract
Ascaris migration from the intestine into the peritoneal cavity is rarely seen and the usual presentation is the acute abdomen. Our case report is of a young male who got admitted after a roadside accident with polytrauma including blunt trauma abdomen. When the patient was taken up for exploratory laparotomy, a freely lying tubular structure was noticed in the pelvis and small intestinal perforation. On inspection, it turned out to be an Ascaris worm. This is a case report of a rare presentation of Ascaris lumbricoides with jejunal perforation following blunt trauma. This blunt trauma could have been the cause of an intestinal perforation resulting from a concealed presence of an impending Ascaris perforation.
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5
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Singh AK, Bais PS, Chand K, Dey S. Mesenteric Injury in Blunt Abdominal Trauma in Children: Is Early Surgical Intervention Need of the Hour? J Indian Assoc Pediatr Surg 2022; 27:381-386. [PMID: 36238336 PMCID: PMC9552660 DOI: 10.4103/jiaps.jiaps_40_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 09/23/2021] [Accepted: 05/14/2022] [Indexed: 11/12/2022] Open
Abstract
Objective There is an increasing trend of observational, nonsurgical management of abdominal injuries in children. We analyzed the feasibility and outcome of our management protocol in managing cases of the mesenteric injuries in blunt trauma abdomen in pediatric age group. Methods Single-center retrospective analysis of pediatric trauma case records from July 2018 to March 2020 was performed. Results Thirty-four cases of blunt abdominal trauma of whom 13 had mesenteric injuries were reviewed. The male-to-female ratio was 2.2:1, and the mean age was 9.11 ± 4.90 years. Mesentery of the small bowel was the most commonly injured segment and treatment consisted of repair of mesenteric tear, resection, and anastomosis with or without stoma formation. Conclusions Isolated mesenteric injury of all grades should be managed either with diagnostic laparoscopy or laparotomy irrespective of hemodynamic status.
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Affiliation(s)
- Amit Kumar Singh
- Speciality of Trauma Surgery, Apex Trauma Centre, Sanjay Gandhi Post Graduate Institute of Medical Sciences, New Delhi, India,Address for correspondence: Dr. Amit Kumar Singh, Department of Trauma Surgery, Apex Trauma Centre, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh, India. E-mail:
| | - Prateek Singh Bais
- Department of Anaesthesiology, Apex Trauam Centre, Sanjay Gandhi Post Graduate Institute of Medical Sciences, New Delhi, India
| | - Karunesh Chand
- Department of Pediatric Surgery, Command Hospital, New Delhi, India
| | - Santosh Dey
- Department of Pediatric Surgery, Command Hospital, Lucknow, Uttar Pradesh, India
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Fonseca EKUN, Yamauchi FI, Steinman M, Mussi TC, Tachibana A, Baroni RH. Isolated middle colic artery injury after blunt abdominal trauma. EINSTEIN-SAO PAULO 2018; 16:eAI438. [PMID: 30427478 PMCID: PMC6223945 DOI: 10.31744/einstein_journal/2018ai4384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 06/01/2018] [Indexed: 11/08/2022] Open
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Mahmood I, Mustafa F, Younis B, Ahmed K, El-Menyar A, Asim M, Al-Hassani A, Peralta R, Al-Thani H. Postoperative complications of intestinal anastomosis after blunt abdominal trauma. Eur J Trauma Emerg Surg 2018; 46:599-606. [PMID: 30251153 DOI: 10.1007/s00068-018-1013-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/19/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Intestinal disruption following blunt abdominal trauma (BAT) continues to be associated with significant morbidity and mortality despite the advances in resuscitation and management. We aim to analyze the management and postoperative outcomes of intestinal injuries secondary to blunt abdominal trauma. METHOD We retrospectively reviewed all adult patients with intestinal injuries who underwent laparotomy for BAT between December 2008 and September 2015 at Level I trauma center. Data included demographics, mechanism of injury, site (small and large intestine), type of repair, (enterorrhaphy and resection with anastomosis), type of anastomosis (hand-sewn or stapled anastomoses), need for damage control laparotomy, postoperative complications, and mortality. Data were analyzed and compared for postoperative complications. RESULTS A total of 160 patients with bowel injuries were included with mean age of 33 years, and 95.6% were males. Injuries involving small bowel, colon, and combined small and large bowel were found in 57.5%, 33.1%, and 9.4%, respectively, with only two duodenal and one rectal injury cases. There were 46.3% patients underwent debridement and primary closure, while 53.8% required resection with anastomosis. Anastomoses were side-to-side stapled in 79.1%, hand-sewn in 14.0%, and combination in 7.0% of patients. The overall postoperative complications (17.5%) in terms of wound infection (n = 16), intra-abdominal abscess (n = 13), and anastomotic leak (n = 13). There were two deaths occurred because of bowel injury complications. Need for blood transfusion, high serum lactate, number of re-laparotomies, and mortality were significantly associated with postoperative complications. On multivariate regression analysis, serum lactate (OR 1.27; 95% CI 1.01-1.60; p = 0.04) was found to be the independent predictor of postoperative complications. CONCLUSION Repair of traumatic blunt bowel injury remains a surgical challenge.
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Affiliation(s)
- Ismail Mahmood
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Fuad Mustafa
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Basil Younis
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Khalid Ahmed
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Ayman El-Menyar
- Clinical research, Trauma and Vascular Surgery Section, Hamad General Hospital, PO Box 3050, Doha, Qatar. .,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Mohammad Asim
- Clinical research, Trauma and Vascular Surgery Section, Hamad General Hospital, PO Box 3050, Doha, Qatar
| | - Ammar Al-Hassani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
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Arslan S, Okur MH, Arslan MS, Aydogdu B, Zeytun H, Basuguy E, Icer M, Goya C. Management of gastrointestinal perforation from blunt and penetrating abdominal trauma in children: analysis of 96 patients. Pediatr Surg Int 2016; 32:1067-1073. [PMID: 27666540 DOI: 10.1007/s00383-016-3963-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2016] [Indexed: 11/26/2022]
Abstract
AIM The objective of the present study was to evaluate the diagnostic methods, concomitant organ injuries, factors affecting mortality and morbidity, treatment methods, and outcomes of patients treated for traumatic gastrointestinal (GI) perforation. MATERIALS AND METHODS We conducted a retrospective review of the medical records of 96 patients who had been treated for GI perforation between January 2000 and October 2015. Data were collected and organised according to the following categories: general patient information, age, gender, hospitalisation period, trauma mechanisms, concomitant injuries, radiological assessment, diagnosis and treatment methods, treatment forms, and complications. The cases were divided into two groups, blunt and penetrating traumas, and the patients within each group were compared. Colorectal trauma cases were not included in this study. Patients suspected of a GI perforation were assessed by standing plain abdominal radiograph (SPAR) and ultrasound scan (US). Patients who had a normal SPAR, and showed free or viscous fluid in the abdomen on US underwent computed tomography (CT) scanning. Surgery was performed if patients displayed free air in the abdomen on a SPAR or CT scan, showed viscous fluid without any additional injury, provided normal radiological images but displayed signs of peritonitis, or were clinically unstable. The patients were scored according to the Injury Severity Score (ISS) system. RESULTS In total, 96 patients, with an average age of 10.3 ± 4 years (1-17 years) and diagnosed with a GI perforation, were reviewed retrospectively. The patients included 88 (91 %) males and 8 (9 %) females. The presence of free air on SPAR was detected in 42 (52 %) patients, whereas no free air was detected in 39 (48 %) patients. Non-specific significant findings were detected in 45 (76 %) out of 59 patients by USS, and in 78 % of patients by CT (viscous fluid, fluid, free air). The most affected organ was the ileum, which was detected in 37 (39 %) patients. Primary repair was performed on 71 (74 %) patients, while resection was performed on 22 (23 %); 3 (3 %) patients underwent an ostomy. Ten (10 %) patients experienced complications and five (5 %) patients died. The ISS scores for blunt and penetrating traumas were 14, 15 and no significant difference was detected between the scores (p > 0.05). CONCLUSIONS Although the complication rate for patients with penetrating trauma was higher than for those with blunt trauma, the rate of mortality increased in patients with blunt trauma. Free air may not be detected by SPAR even if a GI perforation exists. Since diagnostic challenges may increase the rate of mortality and morbidity in GI perforations, we believe that a combination of radiological imaging and rapid abdominal examination is important in cases where SPAR cannot detect free air.
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Affiliation(s)
- Serkan Arslan
- Department of Pediatric Surgery, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey.
- Dicle Üniversitesi Tıp Fakültesi, Çocuk Cerrahi A.D., Diyarbakır, Turkey.
| | - Mehmet Hanifi Okur
- Department of Pediatric Surgery, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey
| | - Mehmet Serif Arslan
- Department of Pediatric Surgery, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey
| | - Bahattin Aydogdu
- Department of Pediatric Surgery, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey
| | - Hikmet Zeytun
- Department of Pediatric Surgery, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey
| | - Erol Basuguy
- Department of Pediatric Surgery, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey
| | - Mustafa Icer
- Department of Emergency Medicine, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey
| | - Cemil Goya
- Department of Radiology, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey
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Isolated complete jejunal transection following abdominal blunt trauma with delayed presentation. Trauma Case Rep 2015; 1:60-63. [PMID: 30101178 PMCID: PMC6082438 DOI: 10.1016/j.tcr.2015.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2015] [Indexed: 11/24/2022] Open
Abstract
In blunt trauma, diagnosis of small bowel injury is infrequent and accounts for less than 1.1% of blunt trauma admissions. Of those, only 0.3% are perforated.1 Isolated transection of the jejunum following blunt abdominal trauma has rarely been reported in literature.2,3 Most cases of small bowel perforations after blunt trauma occur as a result of motor vehicle crashes and falls from heights and are often associated with multiple injuries.4 This is a report of a 26 year-old female that presented 14 h after being involved in a motor vehicle crash and was found to have complete transection of her proximal jejunum with underlying mesenteric injury. Following the crash, the patient extricated herself from the vehicle, went home, and fell asleep with no significant complaints initially reported. She woke up hours later with severe abdominal pain and presented to our emergency department. CT was performed and revealed free fluid in the abdomen. Subsequently, an exploratory laparotomy was performed that revealed complete jejunal transection with underlying mesenteric injury. Isolated complete transection of the proximal jejunum should be considered in the evaluation of patients following blunt abdominal trauma, and presentation may be delayed up to 14 h. To the best of our knowledge, this is the first case report of complete transection of the proximal small bowel following a motor vehicle crash with the longest delay in presentation reported in the literature.
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Mori H, Tsushimi T, Kobara H, Nishiyama N, Fujihara S, Matsunaga T, Ayaki M, Chiyo T, Masaki T. Seatbelt syndrome with gastric mucosal breaks and intra-gastric wall air leakage. Intern Med 2015; 54:2599-601. [PMID: 26466695 DOI: 10.2169/internalmedicine.54.4766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
As numerous reports were published regarding the so-called seatbelt syndrome involved in car crashes, most of them were mentioned about small intestine, duodenum and colon perforations and solid organ bleeding. No reports have been published regarding multiple gastric mucosal tears with intra-gastric wall air leakage with massive bleeding. A 65-year-old woman was admitted after a motor vehicle crash. She vomited massive fresh blood. Gastric mucosal breaks, approximately 5 cm in length, were observed. Computed tomography imaging revealed multiple gastric mucosal breaks. We report a rare case wherein a traffic accident caused a serious condition associated with massive digestive bleeding.
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Affiliation(s)
- Hirohito Mori
- Department of Gastroenterology and Neurology, Kagawa University, Japan
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Chakma SM, Singh RL, Parmekar MV, Singh KHG, Kapa B, Sharatchandra KH, Longkumer AT, Rudrappa S. Spectrum of perforation peritonitis. J Clin Diagn Res 2013; 7:2518-20. [PMID: 24392388 DOI: 10.7860/jcdr/2013/5768.3596] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Accepted: 08/14/2013] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Perforation peritonitis mostly results from the perforation of a diseased viscus. Other causes of perforation include abdominal trauma, ingestion of sharp foreign body and iatrogenic perforation. The diagnosis is mainly based on clinical grounds. Plain abdominal X-rays (erect) may reveal dilated and oedematous intestines with pneumoperitoneum. Ultrasound and CT scan may diagnose up to 72% and 82% of perforation respectively. The present study was carried out to study various etiological factors, modes of clinical presentation, morbidity and mortality patterns of perforation peritonitis presented in the RIMS hospital, Imphal, India. MATERIAL AND METHODS The study was conducted from September 2010 to August 2012 on 490 cases of perforation peritonitis admitted and treated in the Department of Surgery. Initial diagnosis was made on the basis of detailed history, clinical examination and presence of pneumoperitoneum on erect abdominal X-ray. RESULTS A total of 490 patients of perforation peritonitis were included in the study, with mean age of 48.28 years. 54.29% patients were below 50 years and 45.71% patients were above 50 years. There were 54.29% male patients and 45.71% female patients. Only 30% patients presented within 24 hours of onset of symptoms, 31.43% patients presented between 24 to 72 hours and 38.57% patients presented 72 hours after the onset of symptoms. Mean duration of presentation was 54.7 hours. Overall 469 patients were treated surgically and 21 patients were managed conservatively. Overall morbidity and mortality recorded in this study were 52.24% and 10% respectively.
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Affiliation(s)
- Sujit M Chakma
- Final year PGT, Surgery, Regional Institute of Medical Sciences (RIMS) , Imphal, India
| | - Rahul L Singh
- Final year PGT, Surgery, Regional Institute of Medical Sciences (RIMS) , Imphal, India
| | - Mahadev V Parmekar
- Final year PGT, Surgery, Regional Institute of Medical Sciences (RIMS) , Imphal, India
| | - K H Gojen Singh
- Final year PGT, Surgery, Regional Institute of Medical Sciences (RIMS) , Imphal, India
| | - Buru Kapa
- Final year PGT, Surgery, Regional Institute of Medical Sciences (RIMS) , Imphal, India
| | - K H Sharatchandra
- Final year PGT, Surgery, Regional Institute of Medical Sciences (RIMS) , Imphal, India
| | - Amenla T Longkumer
- Final year PGT, Surgery, Regional Institute of Medical Sciences (RIMS) , Imphal, India
| | - Santhosh Rudrappa
- Final year PGT, Surgery, Regional Institute of Medical Sciences (RIMS) , Imphal, India
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