Small-bowel perforations. A study of 32 cases

Emerging Spectrum of Perforation Peritonitis in Developing World

Background: Gastrointestinal perforations constitute a major cause of patients with acute abdomen pain coming to the surgery emergency room. Incidence, site of perforation, and age is different in the developing world and is showing new trends. The etiological spectrum in the developing world is different from the western world. This study was conducted to find out the latest trends in perforation peritonitis in India. Methods: This study was conducted in a single surgical unit of Darbhanga Medical College and Hospital, India. A total of 350 consecutive patients with perforation peritonitis were studied in terms of age, sex, seasonal variation, biochemical parameters, clinical presentation, radiological and intraoperative findings, surgical intervention, and postoperative outcome. Results: The most common cause of perforation peritonitis in our study was a duodenal ulcer (~50%) followed by typhoid (20%), traumatic (14.5%), appendicular (7.4%), and tubercular (3.1%) cases. Males were three times more commonly affected than females. Peak incidence was noted in the 2^nd and 3^rd decades of life. Peptic ulcer perforations were common in autumn and winter and typhoid perforations were common during the summer and rainy seasons. Conclusion: Spectrum of perforation peritonitis cases in this part of world is different from developed western countries. It is different in respect of younger age at presentation, site of perforation, and etiological factors. Infective pathology makes up to a quarter of total cases in the developing world. The developing world has more perforation peritonitis cases involving the upper gastrointestinal tract, while the western world has a predominance of lower gastrointestinal tract perforations.

A Comparative Study between the Outcome of Primary Repair versus Loop Ileostomy in Ileal Perforation

Introduction. Ileal perforation peritonitis is a common surgical emergency in the Indian subcontinent and in tropical countries. It is reported to constitute the fifth common cause of abdominal emergencies due to high incidence of enteric fever and tuberculosis in these regions. Methods. Sixty proven cases of ileal perforation patients admitted to Surgical Emergency were taken up for emergency surgery. Randomisation was done by senior surgeons by picking up card from both the groups. The surgical management was done as primary repair (group A) and loop ileostomy (group B). Results. An increased rate of postoperative complications was seen in group A when compared with group B with 6 (20%) patients landed up in peritonitis secondary to leakage from primary repair requiring reoperation as compared to 2 (6.67%) in ileostomy closure. A ratio of 1 : 1.51 days was observed between hospital stay of group A to group B. Conclusion. In cases of ileal perforation temporary defunctioning loop ileostomy plays an important role. We recommend that defunctioning ileostomy should be preferred over other surgical options in cases of ileal perforations. It should be recommended that ileostomy in these cases is only temporary and the extra cost and cost of management are not more than the price of life.

Differential diagnosis of Crohn's disease and intestinal tuberculosis in patients with spontaneous small-bowel perforation

BACKGROUND/AIMS

Spontaneous small-bowel perforation caused by Crohn's disease (CD) or intestinal tuberculosis (ITB) is a rare disease entity. We investigated the clinical features and radiologic findings of patients with CD or ITB who presented with a spontaneous small-bowel perforation.

METHODS

Between January 2001 and December 2010, sixty-two patients underwent surgery due to a spontaneous small-bowel perforation, including 21 (33.9%) CD patients and 18 (29.0%) ITB patients. Clinical and radiologic features were compared between CD and ITB patients.

RESULTS

The mean age was significantly lower in CD patients than in ITB patients (p = 0.014). Diarrhea was more common in CD. By contrast, night sweating and a previous history of tuberculosis were more common in ITB. Only 27.8% of patients with ITB had a positive QuantiFERON-TB Gold test. CT findings such as bowel wall thickening of more than 10 mm, omental thickening, and intra-abdominal lymphadenopathy larger than 10 mm were more common among perforations caused by ITB. Mesenteric fat infiltration was a more frequent finding in CD than in ITB.

CONCLUSIONS

Clinical symptoms and radiologic findings may aid in the differential diagnosis between CD and ITB in patients presenting with spontaneous small-bowel perforation.

Perforation peritonitis and the developing world

Background. Perforation peritonitis is the one of the commonest emergency encountered by surgeons. The aim of this paper is to provide an overview of the spectrum of perforation peritonitis managed in a single unit of a tertiary care hospital in Delhi. Methods. A retrospective study was carried out between May 2010 and June 2013 in a single unit of the department of Surgery, Lok Nayak Hospital, Delhi. It included 400 patients of perforation peritonitis (diffuse or localized) who were studied retrospectively in terms of cause, site of perforation, surgical treatment, complications, and mortality. Only those patients who underwent exploratory laparotomy for management of perforation peritonitis were included. Results. The commonest cause of perforation peritonitis included 179 cases of peptic ulcer disease (150 duodenal ulcers and 29 gastric ulcers) followed by appendicitis (74 cases), typhoid fever (48 cases), tuberculosis (40 cases), and trauma (31). The overall mortality was 7%. Conclusions. Perforation peritonitis in India has a different spectrum as compared to the western countries. Peptic ulcer perforation, perforating appendicitis, typhoid, and tubercular perforations are the major causes of gastrointestinal perforations. Early surgical intervention under the cover of broad spectrum antibiotics preceded by adequate aggressive resuscitation and correction of electrolyte imbalances is imperative for good outcomes minimizing morbidity and mortality.

Risk adjustment is crucial in comparing outcomes of various surgical modalities in patients with ileal perforation

Background

Using crude mortality and morbidity rates for comparing outcomes can be misleading. The aim of the present study was to compare the outcome of various surgical modalities without and with risk adjustment using Physiologic and Operative Severity Scoring for the enUmeration of Mortality and morbidity (POSSUM) score in cases of ileal perforations.

Methods

Prospective study on 125 patients of ileal perforations. Resection anastamosis (Group I) was done in 38 patients, primary repair (Group II) in 42 patients and 45 patients had an ileostomy (Group III). The disease severity was assessed in all patients using POSSUM score. The odds of death without and with risk adjustment using POSSUM mortality score were calculated for all groups

Results

Seventeen patients (14%) patients died and 99 (79%) developed postoperative complications. Using crude mortality rates Group I appeared to be the best treatment option with only 2 (5%) deaths followed by Group II with 5 (12%) deaths where as Group III had the worst outcome with 10 deaths (22%). However, Group III (ileostomy) patients had higher mean POSSUM mortality and morbidity score (55.55%, 91.33%) than Group I (28%, 75.26%) and Group II (27%, 73.59%). Taking Group I as the reference (odds ratio, OR1) odds of death were greatest in Group III (OR 5.14, p = 0.043) followed by Group II (OR 2.43, p = 0.306). With risk adjustment using POSSUM mortality score the odds of death decreased in Group III (OR 1.16 p = 0.875). For the whole group, there was a significant association between the POSSUM score and postoperative complications and deaths. Mean POSSUM mortality and morbidity score of those who died (63.40 vs.33.68, p = 0.001) and developed complications (66.32 vs.84.20, p = 0.001) was significantly higher. For every percent increase in severity score the risk of postoperative complications and death increased by 1.10 (p = 0.001) and1.06 (p = 0.001) respectively.

Conclusion

Despite ileostomy patients having highest crude mortality and complication rates, after risk adjustment it was equally safe. Severity of the disease rather than the surgical option had a significant impact on the outcome in patients with ileal perforations.

Spectrum of perforation peritonitis in India--review of 504 consecutive cases

BACKGROUND/OBJECTIVE

Perforation peritonitis is the most common surgical emergency in India. The spectrum of etiology of perforation in Tropical countries continues to be different from its Western counterpart. The objective of the study was to highlight the spectrum of perforation peritonitis as encountered by us at Government Medical College and Hospital (GMCH), Chandigarh.

METHODS

Five hundred and four consecutive cases of perforation peritonitis over a period of five years were reviewed in terms of clinical presentation, operative findings and postoperative course retrospectively at GMCH, Chandigarh.

RESULTS

The most common cause of perforation in our series was perforated duodenal ulcer (289 cases) followed by appendicitis (59 cases), gastrointestinal perforation due to blunt trauma abdomen (45 cases), typhoid fever (41 cases) and tuberculosis (20 cases). Despite delay in seeking medical treatment (53%), the overall mortality (10%) was favourably comparable with other published series though the overall morbidity (50%) was unusually high.

CONCLUSION

In contrast to western literature, where lower gastrointestinal tract perforations predominate, upper gastrointestinal tract perforations constitute the majority of cases in India. The increasing incidence of post-traumatic gastro-enteric injuries may be due to an increase in high speed motor vehicle accidents which warrant early recognition and prompt treatment to avoid serious complications and death.

Peritonitis - the Eastern experience

Peritonitis is a common emergency encountered by surgeons the world over. This paper aims to provide an overview of the spectrum of peritonitis seen in the East. Studies dealing with the overall spectrum of secondary peritonitis in various countries of this region were identified using Pubmed and Google. These were analyzed for the site and cause of perforation and the mortality. It was observed that perforation of duodenal ulcers was the most the commonly encountered perforations. These are followed by small bowel and appendicular perforations. Colonic perforations were uncommon. The overall mortality ranges between 6–27%.

Evaluation of best surgical procedures in typhoid perforation--an experience of 60 cases

The results of treatment of 60 cases of typhoid perforation were reviewed over a period of 4.5 years. Closure of the perforation was the method of treatment in 28 (46.66%) cases and closure of the perforation with side-to-side ileotransverse anastomosis was done in 32 (53.33%) cases. Faecal fistula was the most severe post-operative complication following simple closure of the perforation, causing death in all patients and leading to a 25% mortality in those treated by this technique. No fistula was found following closure of the perforation with side-to-side ileotransverse anastomosis, leading to a much lower mortality of 6.22%. The overall mortality in this series was 15%. Apart from toxaemia, surgical failure was the main contributory factor to such a high mortality. In this series, closure of the perforation with side-to-side ileotransverse anastomosis was the better surgical procedure.

Jejunal perforation caused by blunt abdominal trauma in a patient with Crohn's disease: report of a case

We report herein the case of a 23-year-old man with Crohn's disease who was found to have a perforated small bowel following blunt abdominal trauma sustained in a traffic accident. The general findings of diffuse peritonitis were identified by physical examination, and a plain X-ray film showed free air in the abdominal cavity. An emergency laparotomy was performed which revealed three perforated ulcers in the affected intestine. An abrupt increase in intraluminal pressure due to the striking force of the steering wheel to the abdomen was assumed to have been the cause of these perforations.

Nontraumatic perforation of the small bowel

Small intestinal perforation is an infrequent but often fatal complication of a variety of disorders. Treatment of 76 adults with nontraumatic perforation occurring during a 21 year period was reviewed. The majority of perforations were due to mechanical causes, malignancy, and Crohn's disease. An abdominal mass (53 percent, p less than 0.05) and fever (81 percent, p less than 0.01) were most frequently documented in patients with Crohn's disease, whereas a positive result on fecal occult blood testing (77 percent, p less than 0.025) was common in those with malignant perforations. Otherwise, clinical and laboratory manifestations, including radiographic evidence of free air, were inconstant. The overall mortality rate was 29 percent, with 65 (86 percent) of the patients undergoing operation. Survival was independent of diagnostic delay (p greater than 0.10). In general, despite various causes and delays in diagnosis, resection and primary anastomosis remains an effective treatment for perforation of the small bowel.

Nontraumatic perforations of the small intestine

Nontraumatic perforation of the small intestine is very rarely found as a cause of acute abdominal disease. A series of 15 adult patients admitted to our hospital from 1973 to 1983 is reviewed. Underlying conditions were primary neoplasia (three patients), adhesions (three patients), intraluminal foreign bodies (two patients), metastases (two patients) and diverticulum (one patient). In four patients, the pathogenesis remained unclear (idiopathic perforations). As surgical therapy, resection and anastomosis is preferred in order to make a thorough histologic examination of the perforated bowel possible. A possible role of local drug toxicity in the pathogenesis of perforations has been discussed herein. No anastomotic leakage was observed. Four patients died (27 percent).

Spontaneous free perforation of the small intestine

In western cultures, spontaneous free perforation of the small intestine in adults is rare. The vast majority of published reports are of isolated cases. A review of 19 patients treated at the Lahey Clinic over the past 23 years is presented. All patients presented with an acute onset of peritoneal signs, and free perforation subsequently was documented at operation or at autopsy. Causes of the perforations were malignancy, six; inflammatory small bowel disease, four; combinations of radiotherapy, chemotherapy, or steroids, four; mechanical, three; and iatrogenic, two. Of the 19 patients, 15 had a history of previous abdominal surgery or recent steroid use, chemotherapy, or radiation therapy. Although the underlying disease may be of prime importance in causing perforation, these treatment modalities may be important factors in enhancing predisposition to perforation. Of the 16 patients operated on, ten had intestinal resection with primary anastomosis, and six had primary closure of the perforation. Four major complications included two deaths, and five minor complications occurred. In general, earlier operative intervention decreased mortality. A population of patients who may be at risk for small bowel perforations is identified. A review of the pertinent literature is presented.

Free perforation of the small intestine

Surgeons operating on patients with an obscure peritonitis should be aware of the diverse etiologies of small intestinal perforation and the general principles of management of each. A series of 16 adult patients with free perforation of the small intestine and spreading peritonitis in the absence of bowel obstruction, incarcerated hernia, or trauma is reviewed. Etiologies were as follows: Crohn's disease, four patients; foreign body ingestion, two patients; jejunal diverticulosis, one patient; lymphoma, two patients; cancer chemotherapy, one patient, amyloidosis, one patient; idiopathic, five patients. Although all patient presented with diffuse peritonitis, the findings of fever and leukocytosis were inconstant. Free air was demonstrated on radiographs in only eight of 16 patients, and the correct preoperative diagnosis was not made except in the four patients with Crohn's disease. Resection and primary anastomosis were utilized successfully in ten patients, the remainder of the patients undergoing oversewing the the perforation. Four patients (25%) died.