Aetiological Pattern of Gastrointestinal Perforations: A Prospective Observational Study

Abstract

Introduction: Peritonitis secondary to gastrointestinal perforation is one of the commonest surgical emergencies encountered all over the world. This study was done to highlight the spectrum of perforation peritonitis encountered in surgery unit of Dhaka Medical College Hospital. Method: It was observational prospective of 100 cases of perforation peritonitis treated in our hospital. All cases of perforative peritonitis whether spontaneous, infective or neoplastic pathology were included in this study. Results: The maximum numbers of patients were in age group between 31 to 40 years (39 %) with mean age 35 years. Male female ratio was 9:1. The most common aetiology of perforation peritonitis was peptic ulcer disease (73%) followed by enteric fever (12%), appendicitis (10%), tuberculosis (3%) and malignancy (2%). The most common sites of perforation were in descending order of frequency first part of the duodenum (65%), terminal ileum (12%), appendix (10%), gastric antrum (9%), jejunum (3%) and rectum (1%). Abdominal pain (100%) and vomiting (81%) were the most common symptoms while tachycardia (96%), muscle guard and rigidity (100%) were the common signs. Approximately 15-20% presented late with features of shock. Mortality rate was 2% and was significantly high in patients coming hospital late. Conclusion: Gastrointestinal perforations are one of the most common surgical emergencies. Duodenal perforations are most common. Ileal perforations secondary to enteric fever have highest morbidity. Early recognition and timely appropriate intervention is very important in reducing morbidity and mortality. DOI: https://doi.org/10.3329/jdmc.v29i2.51183 J Dhaka Med Coll. 2020; 29(2) : 106109 Introduction Gastrointestinal perforation is a complete penetration of the wall of the stomach, small intestine or large bowel resulting in flowing of contents into the abdominal cavity causing peritonitis. The spectrum of aetiology of perforation peritonitis is different in different countries. In our country, presentation to hospital varies depending on access availability, awareness and economy. Late cases present with generalized peritonitis with purulent or fecal contamination and varying degree of septicaemia. It is important to know all the pattern in which a perforation peritonitis could present and the different aetiologies that lead to perforation peritonitis and the most common among them so that the decision for appropriate management of such a case can be taken at the earliest and the associated morbidity and mortality can be decreased. Our objective was to study the aetiology and pattern of presentation of different gastrointestinal perforations based on clinical findings, radiological report, operative findings and histopathology report. Methods This was a prospective study conducted in the department of surgery Dhaka Medical College Hospital. A total number of 100 cases were studied. Inclusion criteria • All cases presenting with signs and symptoms of perforation peritonitis • All cases with spontaneous, infective and neoplastic pathology were included. Exclusion criteria • Iatrogenic perforations • Perforations treated conservatively • Primary peritonitis In all selected cases, demographic profile, detailed history including time lag between onset of symptoms and presentation to hospital, and clinical examination findings and investigation reports were recorded. After adequate resuscitation, all patients underwent exploratory laparotomy in emergency setting. The pathology was sought for and treated with closure, resection with anastomosis or stoma formation. All operative findings were recorded. Post operatively patient was monitored either in ward or intensive care unit depending patients condition. Results Preoperative data Gastrointestinal perforations were common in the age group of 21 to 50 years; with more than 91% being less than 50 years of age. 88% were male. Comorbidities were mainly in the form of respiratory distress 12%, hypertension 5% and diabetes mellitus 8%. Table 1 Pre-operative data of patients Age (years) No of cases (n= 100) (%) < 50 years 91(91%) >50 years 09(09%) Sex Male 88 Female 12 Abdominal pain (100%) and vomiting (76%) were the most common symptoms. Other symptoms were abdominal distension (62%) and fever (22%). Among physical signs, abdominal tenderness was present in all cases along with muscle guard and rigidity (100%). Obliteration of liver dullness was present in (82%) cases. 15-20% of patients presented with features of sock (Table II). Table-II Signs and symptoms on presentation Symptoms and signs (%)