|Year : 2016 | Volume
| Issue : 3 | Page : 99-103
Use of Acute Physiology and Chronic Health Evaluation II score to grade the severity and outcome in patients of typhoid ileal perforation peritonitis
Javid Iqbal1, Rajesh Kumar Meena2, Mahander Pall2, NS Shakhawat2
1 Department of Surgery, Government Medical College, Jammu, Jammu and Kashmir, India
2 Department of Surgery, SMS Medical College, Jaipur, Rajasthan, India
|Date of Web Publication||14-Nov-2016|
Department of Surgery, Government Medical College, Jammu - 180 005, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: Typhoid ileal perforation peritonitis is a potentially life-threatening surgical emergency in developing nations. The severity assessment of a disease condition is useful to prioritize treatment and to reduce morbidity and mortality. Aims: The aim of this study was to use Acute Physiology and Chronic Health Evaluation (APACHE) II score to grade the severity and outcome in patients of typhoid ileal perforation peritonitis. Materials and Methods: A prospective analysis of data was done, which was collected over a period of 3 years for 100 cases of secondary peritonitis following typhoid ileal perforations, irrespective of age, sex, and duration of illness. APACHE II score was used to grade the severity and outcome in these patients. Results: Out of 100 patients included in this study, 87 were male and 13 were females. Age ranges between 14 and 65 years, maximum number of patients were in 2 nd and 3 rd decade of life. History of fever, abdominal pain, and abdominal distention were present in all cases. After onset of fever perforation occurred in 65% patients in 1 st week, there was an increase in mortality with increase in APACHE II score, age >50 years was associated with more mortality. The mean Intensive Care Unit stay in this study was 4.33 days, 5.81 days for survivors, and 3.47 days for nonsurvivors. Mortality in our study was 22%. Conclusion: APACHE II score is an easy and objective tool to grade severity of acute peritonitis and can be used for assessment of outcome. According to this study, patients with higher APACHE II score had highest rate of mortality and vice versa.
Keywords: Ileal perforation, peritonitis, typhoid fever, Widal test
|How to cite this article:|
Iqbal J, Meena RK, Pall M, Shakhawat N S. Use of Acute Physiology and Chronic Health Evaluation II score to grade the severity and outcome in patients of typhoid ileal perforation peritonitis. Saudi Surg J 2016;4:99-103
|How to cite this URL:|
Iqbal J, Meena RK, Pall M, Shakhawat N S. Use of Acute Physiology and Chronic Health Evaluation II score to grade the severity and outcome in patients of typhoid ileal perforation peritonitis. Saudi Surg J [serial online] 2016 [cited 2019 Jul 21];4:99-103. Available from: http://www.saudisurgj.org/text.asp?2016/4/3/99/193982
| Introduction|| |
Typhoid ileal perforation peritonitis is a potentially life-threatening surgical emergency in developing nations.  Although intestinal hemorrhage is the most common complication of typhoid fever, intestinal perforation continues to be the most frequent reason behind high morbidity and mortality.  Generally, hemorrhage and perforation occur in the terminal ileum secondary to necrosis of Peyer's patches at 2-3 weeks after the onset of the disease. , Frequency of perforation varies between 0.8% and 18%. , Early surgical procedures are regarded as definitive treatment along with preoperative resuscitation and postoperative intensive care, the type of procedures that should be used in these patients are still contentious.
Aim of the study
The aim of the study was to use Acute Physiology and Chronic Health Evaluation (APACHE) II score to grade the severity of peritonitis and outcome in patients of typhoid ileal perforation in Jaipur, India.
| Materials and Methods|| |
A prospective analysis of data was done, which was collected over a period of 3 years (September 2011-September 2014) for 100 cases of secondary peritonitis following typhoid ileal perforations in Department of Surgery, SMS Medical College, Jaipur, India. Patients of all age groups and both sex, irrespective of duration of illness, admitted in SMS Hospital with primary diagnosis of enteric peritonitis were included in this study. Patients with generalized peritonitis due to other causes such as perforated appendix, peptic ulcer perforation, traumatic perforation, tubercular perforation, and those already operated for enteric perforation peritonitis were excluded from this study.
Clinical evaluation as well as hematological, biochemical, and radiological investigations were carried out to confirm the diagnosis. Preoperative resuscitation included intravenous fluids, analgesics, oxygenation if necessary, commencement of intravenous antibiotics, and correction of electrolytes imbalance if any. Adequate urine output and normal serum urea level were considered as indicators of adequate resuscitation. Exploratory laparotomy was performed as soon as possible. A midline skin incision was given, operative findings were noted, and the amount of pus and fecal material drained was estimated. Primary repair of distal ileal perforation or any other appropriate operative procedure was performed depending on intraoperative findings. The peritoneal cavity was irrigated with copious amount of warm normal saline and peritoneal drains were inserted to drain the cavity. The midline incision was then closed by synthetic nonabsorbable sutures. Attention was paid to the major complications such as wound infection, wound dehiscence, residual intraabdominal abscess, fecal fistula, and death. The duration and course of morbid conditions were closely observed. Duration of hospital stay, outcome, and all variables to calculate APACHE II score were collected and patients were followed in surgery OPD after they were discharged from the hospital. The data of each patient were then entered into a pro forma prepared for this study.
| Results|| |
Out of 100 patients included in this study, 87 were male and 13 were female. Age ranges between 14 and 65 years, maximum number of patients were in 2 nd and 3 rd decade of life. Enteric perforation peritonitis cases were admitted in the hospital throughout the year, but incidence was more in months of June-September, coinciding with rainy season. History of fever, abdominal pain, and abdominal distention was present in all cases, constipation in 89%, vomiting in 84%, and diarrhea in 7% of cases. On clinical examination, abdominal distension, tenderness, guarding, and rigidity were present in all cases, shifting dullness was present in 98% cases, and absent bowel sounds in 95% cases. 54% of patients presented with 1-2 days old perforation, 38% with 3-4 days old perforation, 7% with 5-6 days old perforation, and 1% with 7 day old perforation. After onset of fever, perforation occurred in 65% patients during 1 st week, in 29% during 2 nd week, in 5% during 3 rd week, and in 1% during 4 th week. Pneumoperitoneum on X-rays was present in 79% of cases. Four quadrant aspirates were positive in 96% of cases. Widal test was done in 76 patients and it was positive in 64.4% of cases. About half of patients had total leukocyte count (TLC) within normal limits, 27% had leukocytosis, and 28% had leukopenia.
On laparotomy, feco-purulent fluid was found in all cases which varied in amount from 200 ml to 03 L. In 71% of cases, single perforation was found; in 21% of cases, two perforations were found; and in 8% cases, there were multiple perforations. Perforations were found within 30 cm of distal ileum in 85% of cases. In 45% of cases, gut was unhealthy that means edema, multiple flakes, and impending perforations were present. [Table 1] shows percentage of patients underwent different surgical procedures as per intraoperative findings.
Most frequent complication was wound infection (51%), followed by respiratory complications (40%), skin excoriation (18%), wound dehiscence (12%), bleeding/disseminated intravascular coagulation (8%), fecal fistula (5%), stoma retraction (5%), decubitus ulcer (4%), and residual intra-abdominal abscess in (4%). [Table 2] shows association between APACHE II score and percentage mortality.
|Table 2: Association between Acute Physiology and Chronic Health Evaluation II score and percentage mortality |
Click here to view
In this study, there was an increase in mortality with an increase in APACHE II score.
Association of increasing age and mortality was assessed and it was observed that there was 23% mortality among patients aged between 11 and 20 years, 16.6% of patients aged between 21 and 30 years, 14.2% of patients aged between 31 and 40 years, 28.5% of patients aged between 41 and 50 years, 66.6% of patients aged between 51 and 60 years, and 100% of patients aged between 61 and 70 years. It showed that age >50 years was associated with high mortality. The mean Intensive Care Unit (ICU) stay in this study was 4.33 days, 5.81 days for survivors, and 3.47 days for nonsurvivors. Patients who had less than mean ICU stay (4.33) suffer 71.4% mortality while those having ICU stay more than mean had 44.4% mortality. Mortality in our study was 22%.
| Discussion|| |
Acute generalized peritonitis from typhoid ileal perforation is a potentially life-threatening condition.  The severity assessment of a disease condition is useful to prioritize treatment as it reduces morbidity and mortality. Many scoring systems have been designed and used successfully to grade the severity of acute peritonitis and intra-abdominal sepsis. ,, The most widely used index, APACHE II, was developed from a mixed group of medical and surgical patients.  High severity scores are usually associated with high morbidity and mortality; therefore, these patients may require more intensive treatment than those with low severity score. Typhoid ileal perforation peritonitis is one of the major cause of perforation in India. , In this study out of 100, 78 patients survived till discharge from the hospital. The overall mean APACHE II score of patients was 8.39 but mean APACHE II score for survivors was 5.51. The mean APACHE II score for nonsurvivors was 16.09. The mean age of patients in our study was 26.47 years. The mean age of survivors was 22.62 years and 29.81 years for nonsurvivors.
In our study, enteric perforation was more common in males (87%), with a male:female ratio of 6.6:1. Higher incidence of ileal perforation in males was also noticed in other studies. ,, Highest incidence of enteric perforation was reported during rainy season, i.e., between June to September. Age ranges from 14 to 65 years in this study and 3/4 th of total cases were in 2 nd and 3 rd decade. Pediatric population was not included in our study as we have separate pediatric hospital. The symptoms and signs were not different from the usual symptoms and signs of acute generalized peritonitis. Fifty-four percent of patients presented within 48 h of occurrence of perforation, 38% presented with 3-4 days old perforation, and 8% admitted with older perforation. This late presentation was due to the fact that patients were treated conservatively at peripheral centers because of improper diagnosis and referred to higher centers on later stage. Mortality was 18.4% of patients presented within 48 h of perforation, 23% of patients presented with 3-4 days old perforation, and 50% of patients having 5-6 days old perforation. Enteric perforation occurs at variable times after onset of fever. Olurin et al.  and Purohit.  observed that majority of perforation occurred in 1 st week of fever. While Eggleston et al.  reported that majority of perforation occurred in 2 nd week of fever. In our study, perforation occurred during 1 st week of fever in 65% of cases and in 35% cases during 2 nd week of fever. This variability in time of occurrence of perforation may be due to difference in bacterial virulence of different geographical areas.
Diagnosis was mainly based on history and clinical findings and was further confirmed by the presence of gas under diaphragm on X-ray, Widal test, blood culture, and operative findings. In our study, Widal test was done in 76 patients and it was positive in 64.4% of cases. Leukopenia (TLC <4000/cumm) is common in enteric fever and it was found in about 28% of the cases in our study while leukocytosis was present in 27% of the cases. In countries such as India, where disease is endemic, the diagnosis is mainly by history and clinical examination. Before 2-3 decades, most surgeons favor conservative management for typhoid perforation but due to high morbidity and mortality, now surgical intervention is the treatment of choice. Numerous operative procedures had been tried in past for enteric perforation and better outcome was reported by different authors by different type of repairs. ,,,, In our study, all patients were treated surgically, primary repair of perforation and loop ileostomy were the main procedures done in 37% and 29% of total patients, respectively. Other procedures done were repair of perforation and proximal loop ileostomy (27%), end ileostomy with distal end closure (2%), and end ileostomy with distal mucous fistula (4%).
Rashid et al.  worked on modified APACHE II score to grade the severity of acute generalized peritonitis from typhoid ileal perforation and found that APACHE II score for survivors was 7.6 and for nonsurvivors was 9.4. There was no death among the patients who scored 0-4, whereas mortality was 13% in those who scored 5-9, 41.2% in those who scored 10-14 and 50% in patients who scored 15-19 APACHE II score. The modified APACHE II score significantly influenced mortality but did not influence other postoperative complications. Our study found that mean APACHE II score in case of enteric perforation peritonitis for survivors was 5.51 and for nonsurvivors was 16.09. Our result for survivors was comparable to it,  but higher for nonsurvivors. Mortality in our study was lower than reported by Mulier et al.  The ICU stay in our study is much lower than reported by Bosscha et al.  both for survivors and nonsurvivors. In our study, survivors spent a mean of 5.8 days in the ICU and nonsurvivors spent a mean of 3.47 days whereas it was 12 days and 17 days, respectively, in study by Bosscha et al.  and 12 days for survivors and 22.7 days for nonsurvivors in study by Barie et al.  In our study, the patients who had less than mean (4.33 days) ICU stay, 71.9% died and 28.5% lived. In patients exceeding mean stay, 44.4% died and 55.5% lived. Our study has poor correlation with hospital stay and mortality. The median age of nonsurvivors was higher than those of survivors  and mortality was more in patients older than 50 years of age.  In our study, patients <50-year-old have 19.79% whereas those over 50 years had 75% mortality. Our study has 22% mortality in case of enteric perforation peritonitis, which was higher as reported by Rashid et al. 
| Conclusion|| |
The treatment of typhoid ileal perforation consists of appropriate early surgical intervention, effective resuscitation in the preoperative period, postoperative care, and use of proper antibiotics. APACHE II Score is an easy and objective tool to grade severity of acute peritonitis and can be used for assessment of outcome. According to this study, patients with a higher score had the highest rate of mortality whereas patients with the lower score had the lowest rate of mortality.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Adesunkanmi AR, Ajao OG. The prognostic factors in typhoid ileal perforation: A prospective study of 50 patients. J R Coll Surg Edinb 1997;42:395-9.
Saxe JM, Cropsey R. Is operative management effective in treatment of perforated typhoid? Am J Surg 2005;189:342-4.
Hosoglu S, Aldemir M, Akalin S, Geyik MF, Tacyildiz IH, Loeb M. Risk factors for enteric perforation in patients with typhoid fever. Am J Epidemiol 2004;160:46-50.
Dutta TK, Beeresha, Ghotekar LH. Atypical manifestations of typhoid fever. J Postgrad Med 2001;47:248-51.
Kotan C, Kosem M, Tuncer I, Kisli E, Sonmez R, Çýkman O, et al
. Typhoid intestinal perforation: Review of 11 cases. Turk J Colorectal Dis 2000;11:6-10.
Atamanalp SS, Aydinli B, Ozturk G, Oren D, Basoglu M, Yildirgan MI. Typhoid intestinal perforations: Twenty-six year experience. World J Surg 2007;31:1883-8.
Greenspan L, McLellan BA, Greig H. Abbreviated injury scale and injury severity score: A scoring chart. J Trauma 1985;25:60-4.
Copeland GP, Jones D, Walters M. POSSUM: A scoring system for surgical audit. Br J Surg 1991;78:355-60.
Adesunkanmi AR, Oseni SA, Adejuyigbe O, Agbakwuru EA. Acute generalized peritonitis in African children: Assessment of severity of illness using modified APACHE II score. ANZ J Surg 2003;73:275-9.
Bion J. Outcomes in intensive care. BMJ 1993;307:953-4.
Bali RS, Verma S, Agarwal PN, Singh R, Talwar N. Perforation peritonitis and the developing world. ISRN Surg 2014;2014:105492.
Sumer A, Kemik O, Dülger AC, Olmez A, Hasirci I, Kiºli E, et al
. Spectrum of perforation peritonitis in Delhi: 77 cases experience. Indian J Surg 2013;75:133-7.
Bayrak V, Bulut G, Kotan Ç. Outcome of surgical treatment of intestinal perforation in typhoid fever. World J Gastroenterol 2010;16:4164-8.
Olurin EO, Ajay OO, Bohrer SP. Typhoid perforation. J R Coll Surg Edinb 1972;12:253-6.
Purohit PG. Surgical treatment of typhoid perforation. Indian J Surg 1978;40:227-38.
Eggleston FC, Santoshi B, Singh CM. Typhoid perforation of the bowel. Experiences in 78 cases. Ann Surg 1979;190:31-5.
Shah AA, Wani KA, Wazir BS. The ideal treatment of the typhoid enteric perforation - Resection anastomosis. Int Surg 1999;84:35-8.
Beniwal US, Jindal P, Sharma J, Jain S, Shyam G. Comparative study of postoperative procedures in typhoid perforation. Indian J Surg 2003;65:172-7.
Shukla VK, Sahoo SP, Chauhan VS, Pandey M, Gautam A. Enteric perforation - Single-layer closure. Dig Dis Sci 2004;49:161-4.
Rashid A. Generalized peritonitis secondary to typhoid ileal perforation assessment of severity using modified APACHE II score. Indian J Surg 2005;67:29-32.
Mulier S, Penninckx F, Verwaest C, Filez L, Aerts R, Fieuws S, et al.
Factors affecting mortality in generalized postoperative peritonitis: Multivariate analysis in 96 patients. World J Surg 2003;27:379-84.
Bosscha K, Reijnders K, Hulstaert PF, Algra A, van der Werken C. Prognostic scoring systems to predict outcome in peritonitis and intra-abdominal sepsis. Br J Surg 1997;84:1532-4.
Barie PS, Hydo LJ, Fischer E. Development of multiple organ dysfunction syndrome in critically ill patients with perforated viscus. Predictive value of APACHE severity scoring. Arch Surg 1996;131:37-43.
Ponting GA, Sim AJ, Dudley HA. Comparison of the local and systemic effects of sepsis in predicting survival. Br J Surg 1987;74:750-2.
Bohnen JM, Mustard RA, Oxholm SE, Schouten BD. APACHE II score and abdominal sepsis. A prospective study. Arch Surg 1988;123:225-9.
[Table 1], [Table 2]