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ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 2  |  Page : 51-54

The spectrum of nontraumatic perforation peritonitis in Al Noor Specialist Hospital, Makkah


1 Department of Surgery, Faculty of Medicine, Umm al-Qura University, Makkah, Saudi Arabia
2 Department of Surgery, Al Noor Specialist Hospital, Makkah, Saudi Arabia

Date of Web Publication29-May-2018

Correspondence Address:
Dr. Suleiman Jastaniah
Department of Surgery, Faculty of Medicine, Umm al-Qura University, Makkah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_68_17

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  Abstract 

Introduction: Nontraumatic perforation peritonitis is the most common emergency in Saudi Arabia. The spectrum of etiology of perforation in Saudi Arabia continues to be different from the western countries. The objective of this study is to highlight the spectrum of etiology of nontraumatic perforation peritonitis and the predictor factors for increasing mortality in those patients.
Patients and Methods: This is a prospective study (case series); all patients admitted with nontraumatic perforation peritonitis were included in the study from January 2005 to December 2010 and followed up in the outpatient department for 6 months up to 2 years. One hundred and thirty patients of nontraumatic perforation peritonitis were included in the study and their clinical presentation, operative findings, and postoperative course were recorded in Al Noor Specialist Hospital in Makkah (Holy city), Saudi Arabia.
Results: The most common cause of perforation in our series was perforated duodenal ulcer (56 cases), followed by appendicitis (44 cases), perforated gastric ulcer (11 cases), typhoid fever (8 cases), and perforated gastrointestinal cancers (8 cases). Twenty-eight cases (22%) developed complication and three patients died (2.3%).
Conclusion: This study shows that the upper gastrointestinal tract perforation due to nontrauma causes constitutes the majority of cases in Holy city, Makkah, in contrast to the western countries where lower gastrointestinal tract perforation is more common. Our study also highlights the outcome of nontraumatic perforation peritonitis.

Keywords: Anastomosis, Makkah, nontraumatic, perforation peritonitis, primary repair, resection


How to cite this article:
Jastaniah S, Alsharif M, Mimani O, Filmban R, Taggaldin M, Alsarfendi S, Al Najjar H. The spectrum of nontraumatic perforation peritonitis in Al Noor Specialist Hospital, Makkah. Saudi Surg J 2018;6:51-4

How to cite this URL:
Jastaniah S, Alsharif M, Mimani O, Filmban R, Taggaldin M, Alsarfendi S, Al Najjar H. The spectrum of nontraumatic perforation peritonitis in Al Noor Specialist Hospital, Makkah. Saudi Surg J [serial online] 2018 [cited 2018 Dec 11];6:51-4. Available from: http://www.saudisurgj.org/text.asp?2018/6/2/51/233493


  Introduction Top


Perforation peritonitis is one of the most surgical emergencies seen by general surgeons, and it is either traumatic or nontraumatic perforation peritonitis. Nontraumatic perforation peritonitis is more common surgical emergencies than the traumatic, and the spectrum of the etiology differs from the western countries.[1]

This prospective study conducted at Al Noor Specialist Hospital, Makkah, was designed to highlight the spectrum of nontraumatic perforation peritonitis in terms of etiology, clinical presentation, and site of perforation, surgical treatment, postoperative complications, and the predictor factors for increasing mortality.


  Patients and Methods Top


This is a prospective study (case series) conducted by the Department of Surgery in Al Noor Specialist Hospital from January 2005 up to December 2010 and followed up in the outpatient department for 6 months up to 2 years. One hundred and thirty cases of nontraumatic perforation peritonitis admitted to the surgical department were included in the study. All cases with either traumatic perforation peritonitis, primary peritonitis, or that due to anastomotic dehiscence were excluded from the study.

All cases were reviewed in terms of clinical presentation, radiological findings, operative findings, and postoperative course. Data were collected from the patient records during admission and outpatient follow-up of cases.


  Results Top


A total of 130 patients were studied. Mean age was 42.1 (range from 13 to 85 years) with majority of patients being males (70.8%). Nearly 61.5% were in the age group <50 years while 38.5% in the age group >50 years, and 6.7% of patients had comorbid disease. Forty-eight patients were Saudi and 82 patients were non-Saudi [Table 1].
Table 1: Total number of patients, 130

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The clinical presentation of the patients varied according to the site of the perforation. All patients had abdominal pain and only one-third of the patients (33.8%) had associated fever. Only two patients (1.5%) admitted with clinical presentation of septic shock [Table 2].
Table 2: Clinical presentation

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Patients of gastric and duodenal ulcer perforation usually had severe epigastric pain for short period along with generalized tenderness and guarding. Abdominal distension was found in 33% and is common in patients with small or large bowel perforations, along with vomiting in 43%, diarrhea in 7.7%, and constipation in 6.9%. Only 47% had evidence of air under diaphragm on the upright chest X-ray.

Patients with perforated appendix had typical lower abdominal pain and tenderness along with fever (57%), rebound tenderness in the right iliac fossa (65%), and vomiting (59%). None of the patients showed evidence of gas under diaphragm on the upright chest X-ray.

Acid peptic disease was the most common cause of gastric and duodenal perforation (51.5%) whereas cancer was the most common cause of large bowel perforation (8 patients), followed by diverticular disease (4 patients), and typhoid fever was the most common cause of small bowel perforation (3%), followed by tuberculosis (2 patients) [Table 3] and [Table 4].
Table 3: Site of perforation

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Table 4: The etiology

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The contamination during the surgical procedure was either fecal or purulent (85%), and the surgical procedures performed are illustrated in [Table 5].
Table 5: The surgical procedures

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Thirty-one(24%) of 130 cases showed postoperative complications [Table 6]. The morbidity rate was significantly higher in the patients with appendicular perforation (57%) than those with gastroduodenal perforation. There were three patients died from sepsis and multiorgan failure. The factors contributing to mortality were late perforation presentation (>24 h), advanced age, and respiratory complications.
Table 6: Postoperative complications

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  Discussion Top


Nontraumatic perforation peritonitis is a common surgical emergency in Saudi Arabia, most commonly affecting young male patients as compared to the western countries.[1],[2],[3] This is the first paper comes from Holy city, Makkah, presenting the pattern of nontraumatic perforation peritonitis and the risk factors for mortality. The majority of cases were <50 years and most of the cases presented late with generalized or localized peritonitis and some degree of septicemia. The clinical presentation is typical and it is possible to make a clinical diagnosis of peritonitis in all patients.[1]

Small bowel perforations are more common than large bowel perforations as has been noted in studies from India [2] and are in contrast to the studies from other countries such as the United States,[3] Greece,[4] and Japan,[5] which showed that large bowel perforations were more common. Appendicular perforation is the second common cause of nontraumatic perforations as reported by Jhobta et al.[1]

There is a wide variation in the etiological factors between the tropical countries and western countries.[6],[7] Nabi et al. studied 1908 consecutive cases of perforation peritonitis and found that perforated duodenal ulcer due to acid peptic disease and small bowel perforation due to typhoid were the most common causes of perforation peritonitis followed by small bowel tubercular perforations.[8]

Afridi et al. studied 300 consecutive cases in Pakistan and found acid peptic disease (45%), followed by small bowel tuberculosis (21%) and typhoid (17%), and he found large bowel perforation due to tuberculosis (5%), malignancy (2.6%), volvulus (0.3%), and appendicular perforation (5%).[9] Wears in our study acid peptic disease (51.5%), followed by appendicular perforation (33.8%). Tubercular and typhoid perforations were the least common in our setup. Yadav and Garg reviewed that 77 cases of perforation peritonitis found the highest number of perforations in the upper part of the gastrointestinal tract in contrast to the western countries where the perforations seen mostly in the distal part.[10] Nontraumatic perforation peritonitis has a high mortality rate.[10] The overall mortality ranges between 6% and 27%.[7],[11] High mortality is due to late presentation, cause, and the site of perforation.[12] The mortality rate in our study is comparatively low (2.3%). Factors causing the mortality and postoperative complications are advanced age, late presentation, septicemia, and associated comorbidity.[10] The same factors contributed to the mortality and postoperative complications in our study. Respiratory complications are the known risk factors for high mortality.[13],[14] Reoperation was required for patients who have abdominal collection, anosmatic leak, and burst abdomen.


  Conclusion Top


Nontraumatic perforation peritonitis in Holy city, Makkah, continues to differ from the western and eastern countries. Perforation peritonitis is commonly seen in the duodenum and stomach followed by perforated appendix. The least common cause of nontraumatic perforation in this study is due to tuberculosis. Malignancy is still not common as nonmalignant perforation peritonitis. Aggressive resuscitation and early surgical intervention will reduce the morbidity and mortality. Major complications seen in this study are wound infections, abdominal collection, and reperforations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Jhobta RS, Attri AK, Kaushik R, Sharma R, Jhobta A. Spectrum of perforation peritonitis in India--review of 504 consecutive cases. World J Emerg Surg 2006;1:26.  Back to cited text no. 1
[PUBMED]    
2.
Dorairajan LN, Gupta S, Deo SV, Chumber S, Sharma LK. Peritonitis in India--a decade's experience. Trop Gastroenterol 1995;16:33-8.  Back to cited text no. 2
[PUBMED]    
3.
Sharma L, Gupta S, Soin AS, Sikora S, Kapoor V. Generalized peritonitis in India-the tropical spectrum. Jpn J Surg 1991;21:272-7.  Back to cited text no. 3
    
4.
Nomikos IN, Katsouyanni K, Papaioannou AN. Washing with or without chloramphenicol in the treatment of peritonitis: A prospective, clinical trial. Surgery 1986;99:20-5.  Back to cited text no. 4
    
5.
Shinagawa N, Muramoto M, Sakurai S, Fukui T, Hori K, Taniguchi M, et al. A bacteriological study of perforated duodenal ulcers. Jpn J Surg 1991;21:1-7.  Back to cited text no. 5
    
6.
Malangoni MA, Inui T. Peritonitis-the western experience. World J Emerg Surg 2006;1:25.  Back to cited text no. 6
    
7.
Gupta S, Kaushik R. Peritonitis-the eastern experience. World J Emerg Surg 2006;1:13.  Back to cited text no. 7
    
8.
Nabi I, Munjewar C, Ranjan G, Gupta S, Ahirwar N, Chudary P, et al. Spectrum of perforation peritonitis at a tertiary health care centre: A prospective cohort study of 1908 cases. Hellenic J Surg 2016;88:181-5.  Back to cited text no. 8
    
9.
Afridi SP, Malik F, Ur-Rahman S, Shamim S, Samo KA. Spectrum of perforation peritonitis in Pakistan: 300 cases eastern experience. World J Emerg Surg 2008;3:31.  Back to cited text no. 9
    
10.
Yadav D, Garg PK. Spectrum of perforation peritonitis in Delhi: 77 cases experience. Indian J Surg 2013;75:133-7.  Back to cited text no. 10
    
11.
Oheneh-Yeboah M. Postoperative complications after surgery for typhoid Ileal perforation in adults in Kumasi. West Afr J Med 2007;26:32-6.  Back to cited text no. 11
    
12.
Veliyev NA, Merrell RC. Differentiated approach to surgical treatment of patients with perforated duodenal ulcer. Chirurgia (Bucur) 2004;99:119-23.  Back to cited text no. 12
    
13.
Uccheddu A, Floris G, Altana ML, Pisanu A, Cois A, Farci SL, et al. Surgery for perforated peptic ulcer in the elderly. Evaluation of factors influencing prognosis. Hepatogastroenterology 2003;50:1956-8.  Back to cited text no. 13
    
14.
Subramanyam SG, Sunder N, Saleem KM, Kilpadi AB. Peritonitis in patients over the age of 50 years: 98 cases managed surgically. Trop Doct 2005;35:247-50.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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Abstract
Introduction
Patients and Methods
Results
Discussion
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