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  IN THIS Article
 ::  Abstract
 ::  Introduction
 ::  Material and Methods
 ::  Results
 ::  Discussion
 ::  Acknowledgement
 ::  References

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ARTICLE
Year : 1977  |  Volume : 23  |  Issue : 1  |  Page : 28-32

Fatal perforative peritonitis - (study of 38 cases)


Department of Surgery, Seth G. S. Medical College and K. E. M. Hospital, Parel, Bombay-400 012, India

Correspondence Address:
Sulabha V Punekar
Department of Surgery, Seth G. S. Medical College and K. E. M. Hospital, Parel, Bombay-400 012
India
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Source of Support: None, Conflict of Interest: None


PMID: 615256

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 :: Abstract 

The etiology, clinical features and treatment of thirty-eight cases of fatal perforative peritonitis were studied. The commonest cause of fatal peritonitis in this series was found to be ileal perfo­ration. Early diagnosis, intensive post-operative management includ­ing fluid and electrolyte balance, and employment of potent anti­biotics like gentamycin and kanamycin would definitely help in reducing mortality of peritonitis.



How to cite this article:
Punekar SV, Patel C V, Parulkar G B. Fatal perforative peritonitis - (study of 38 cases). J Postgrad Med 1977;23:28-32

How to cite this URL:
Punekar SV, Patel C V, Parulkar G B. Fatal perforative peritonitis - (study of 38 cases). J Postgrad Med [serial online] 1977 [cited 2020 Oct 22];23:28-32. Available from: https://www.jpgmonline.com/text.asp?1977/23/1/28/42789



 :: Introduction Top


The mortality of perforative peritonitis presenting itself as an acute surgical emergency remains about 30% in India. There are several reports published of peritonitis as general or individual perforation. Very few studies have been done on only fatal cases of peritonitis. The intention of the present study was to investigate the aetiology of fatal peritonitis so that a better treatment could be planned.


 :: Material and Methods Top


The total number of surgical admission; into The K.E.M. Hospital, Bombay during 1973-1975 was 22833. Out of these, 297 were admitted as perforative peritonitis Thirty-eight cases of peritonitis who died before or after operation were selected for the present study. Their clinical features results of laboratory investigations, operative findings and autopsy data were cri­tically analysed retrospectively.


 :: Results Top


1. Age: Patients ranged in age group of 10 days to 75 years. Maximum number of patients (17 out of 38) were in the Group of 20-40 years.

2. Sex: Twenty-seven were males and eleven females, the male to female ratio being 2.5: 1.

3. Duration of Symptoms: Varied from 1 day to 6 weeks, but the majority of patients had symptoms for 1-7 days.

4. Symptoms: The commonest symp­toms were as follows:

­(a) Abdominal Pain No.of.Patients -38, Percentage -100

(b)Fever,vomiting abdominal distension No.of Patients -19,Percentage -50

5. Signs:

(a) Abdominal tenderness - 38 -100

(b) Tachycardia:

Pulse 100-120/ mt. - 31 - 90

Pulse 120-140/mt. - 20 - 58

(c) B.P. (Below 80 mm, Hg. Syst.) - 10 - 26

(d) Signs of peritonitis - 19 - 50

6. Investigations:

(a) X-ray of Abdo- No. of Positive men (for Gas Patients in under Dia­phragm) - 38 - 14(36%)

(b) Peritoneal tap - 12 - 9(75%)

(c) The routine blood counts were done in 26 cases but not in all cases because of the emergency nature of the illness. Haemoglobin estimation was done in 26 cases and the range was 6 to 13 Gms.% . Serum electrolyte readings showed hypokalaemia (K-2-3 mEq/L) hyponatraemia (Na-120-130 mEq/L) and hypochloraemia (Cl 80-90 mEq/L) in 30% of cases, most of which were post-operative read­ings.

(d) Pus from peritoneal cavity collect­ed at the time of diagnostic tap, during operation or autopsy was sent for smear and culture. In the majority of cases the organisms detected were E. Cole, sensitive to gentamycin, ampicillin and kana­mycin. In 8 cases Klebsiella and in 2 cases Pseudomonas and Strepto­cocci were grown.

7. Management: Pre-operative sup­portive therapy including I.V. fluids, anti­biotics and blood transfusion was given in all cases. Penicillin, streptomycin, chloramphenicol, tetracyclines were the common antibiotics used alone or in com­bination. The first three drugs in combin­ation were used in 25 patients while Gen­tamycin was used in only four patients.

Further treatment was as follows:

Type of Treatment - No. of Patients

1. Exploratory laparotomy and closure of perforation - 26

2. Drainage of peritoneum under local anaesthesia - 4

3. Patients died before oper­ation could be undertaken - 8

TOTAL 38

8. Duration of Hospitalization: The average survival of patients after admis­sion was 7.5 days (range-3 hours to 33 days).

9. Autopsy Findings: Autopsies were performed in 32 cases. The diagnosis and cause of death were obvious in 6 operat­ed cases and therefore autopsy was not performed in these patients. Various sites of perforations are given in Table below:


 :: Discussion Top


The highest age incidence (44%) in the 2nd and 3rd decade found in this study is more or less similar to that reported in other series. The male: female ratio is somewhat different than in other series [2] but no definite conclusion can be drawn as this series is very small. It is difficult to compare the present series with any one report because it includes only fatal cases of peritonitis. However, individual type of perforation is studied and com­pared wherever possible.

In other series duodenal perforation was the commonest cause of peritonitis [1],[2]­whereas in this series it was the second commonest cause (23%). The previous history of ulcer was not present in 66% of cases in this series as compared to 59.5%, in Budharaja et al, [2] series 60% by Udwadia, et al, [13] and 75% by James and Mark. [9] The treatment of simple closure of perforation and drainage of peritoneal cavity was done in 8 out of 9 duodenal perforations it this series. This treatment is preferred to definitive surgery in bad generalised peritonitis cases in the opinion of James and Mark. [9] Only one patient was not fit for general anaesthesia where peritonea] cavity was drained under local anaes­thesia. Ninety per cent of these patients had come to hospital 6-7 days after the onset of acute symptoms. Seven out of nine patients were about 55 years of age. These two causes account for the deaths in duodenal ulcer perforation in this series.

Ileal perforation was the commonest cause in this series (42%) . In about 62% of these, a history of previous illness was available for 7 to 10 days. The ileal per­foration thereby seems to occur at the end of first or beginning of second week, an observation similar to that by other series. [1],[2],[10],[12] During these first 7-10 days, patients were treated at home and no definite history regarding the names of drugs was available in most of these cases. The use of corticosteroids cannot therefore be ruled out. The Widal Test was positive in only 20% of cases while other authors have re­ported higher percentage. [5],[10] Though the site of perforation was simi­lar to that in other series, [5],[10] the incidence of multiple perforation was much smaller (2.5%) in this study as compared to 5% by Gandhi et al [7] Twelve out of 16 pati­ents were operated under general anaes­thesia. There has been controversy bet­ween the conservative treatment as advo­cated by Huckstep [8] and surgical closure as advised by Franklin. [6] The surgical closure and peritoneal lav­age appears to be more rational because it prevents the continuous leak from the site of perforation. On the other hand, patient with ileal perforation is in severe fluid and electrolyte imbalance and does not usually stand the strain of prolonged anaesthesia for exploratory laparotomy and closure. Probably an elaborate at- tempt to correct electrolytes with local drainage of peritoneum before surgery would improve patient's general condition to enable him to stand the strain of anaes­thesia and operation.

The histopathological studies showed non-specific type of ulcer a little more common (43% ) than typhoid ulcer per­foration as compared to other series (23%). [10] The peritonitis sets in very fast once the perforation occurs in ileum and the diagnosis is usually delayed because of previous illness of patients like diar­rhoea, abdominal distension and fever. This is another factor increasing the mor­tality in ileal perforation.

The incidence of colonic perforation as found on autopsy studies here was 18.5%, as compared to 30.4% by Kean et al, [11] and 10.5% by Clerk. [4] The age group 23 to 75 years was similar to that in other series [3],[12] Amoebic colonic perforation was much commoner cause of perforation yet the clinical picture in these cases ap­peard to be deceptive, as in four out of seven cases accurate diagnosis was delay­ed till autopsy. History of diarrhoea was present in 56%, as compared to 45.7% [13] in other series. The site of colonic perfora­tion was caecum and ascending colon in 66% and rectosigmoid in 33%, similar to those reported by Chen et al . [3] Multiple perforations were found in 2 patients (8%) as compared to 75% reported by Chen et al. [3] The highest mortality in colo­nic perforation may be explained by­ (1) variability of clinical picture, (2) its frequency in older age groups, (3) multi­plicity of perforations, (4) gram negative organisms invading peritoneum. This mortality could be reduced by-(1) Ab­andoning the conservative management at earlier stage in a doubtful case, (2) drainage of peritoneum with colostomy, (3) diversion of faecal matter, (4) use of higher antibiotics along with anti­amoebic drugs.

This series included only one case of amoebic liver abscess rupture. Repeated aspiration, local drainage, drugs like metronidazole and chloroquin have prob­ably caused reduction in mortality in recent years.

Appendicular perforation was less com­mon (3%) in this series as compared to higher figures in other series like Budha­ raja et al [2] and Chen et al. [3]

The culture studies of pus collected from peritoneal cavity showed E. coli growth sensitive of gentamycin, kanamy­cin, and ampicillin, similar to those re­ported by Budharaja et al. [2] The majority of patients were treated with a combina­tion of penicillin, streptomycin and chloramphenicol. Only 4 patients were given gentamycin and ampicillin after initial treatment with 3 antibiotics men­tioned earlier, because the cost of higher antibiotics was prohibitive. The use of these broad spectrum antibiotics like gentamycin and kanamycin at art earlier stage in frank cases of generalised peri­tonitis would have probably helped to reduce mortality. Early diagnosis, inten­sive post-operative management as re­gards fluid electrolyte balance and em­ployment of higher antibiotics would help reduce mortality of perforative peri­tonitis.


 :: Acknowledgement Top


Thanks are due to the Dean, K.E.M. Hospital, Bombay 12, for permission for allowing us to use hospital data and to publish this paper.

 
 :: References Top

1.Bhansali, S. K.: Gastrointestinal Perfora­tions-a clinical setudy of 96 cases. J. Postt rad . Med., 13: 1-12, 1967.  Back to cited text no. 1    
2.Budharaja, S. N., Chidambaram, M., and Perianayagam, W. J.: Peritonitis-(an analysis of 117 cases). Ind. Jour. Surg., 35: 456-464, 1973.  Back to cited text no. 2    
3.Chen, W. J., Chen K. M. and Marie, L.: Colon Perforation in Amoebiasis. Arch. Surg., 103: 676-680, 1971.  Back to cited text no. 3    
4.Clark, H. C.: Distribution and complica­tion of amoebic lesion found in 186 post­mortem examinations. Amer. J. Trop. Med. 5: 125-171, 1925.  Back to cited text no. 4    
5.Dunkerley, G. E.: Perforation of the ileum in enteric fever. Notes on 22 consecutive cases. B.M.J., 2: 454-457, 1946.  Back to cited text no. 5    
6.Franklin, W. P. Li: Surgical treatment of typhoid perforation of the intestine. Brit. J. Surg., 50: 976-979, 1962-63.  Back to cited text no. 6    
7.Gandhi, G. M., Desai, G. B., Shrikantiah. R. and Tanga, M. R.: Typhoid Enteric Per­foration. Quart. Jour. Sc. 11: 137-192. 1975.  Back to cited text no. 7    
8.Huckstep, R. L.: Recent advances in the surgery of typhoid fever. Ann. Roy. Coll. Surg. Eng., 26: 207-230. 1960.  Back to cited text no. 8    
9.James, B.D. and Nark, M.D.: Factors in­fluencing the treatment of perforated duodenal ulcer. Surg., Gynec. & Obst., 129: 325-330, 1969.  Back to cited text no. 9    
10.Karmarkar, S. R., Trivedi, D. R. and Bhalerao, R. A.: Perforation of the ter­minal ileum. Ind. Jour. Surg., 34: 423-426, 1972.  Back to cited text no. 10    
11.Kean, B. H., Gilmore, H. R. Jr. and Van Stone, W. W.: Fatal amoebiasis. Re­port of 148 fatal cases from the Armed Forces Institute of Pathology., Ann. Intern. Med., 44: 831-843, 1956.  Back to cited text no. 11    
12.Patel, R. A., Vaghaiwalla, M. R. Gadkari. N. N., Desai, A. P. and Parulkar, G. B.: Amoebic colonic perforation-a clinico­pathological review of 35 necropsy patients. Ind. Jour. Surg., 36: 47-52, 1974.  Back to cited text no. 12    
13.Udwadia, T. E., Sen, P. K., Mody, A. E. and Parulkar, G. B.: Acute Duodenal per­foration-analysis of clinical findings and evaluation of treatment in 317 cases. Ind. Jour. Med. Scs. 17: 321.332. 1963.  Back to cited text no. 13    




 

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