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Original Article

Gastrointestinal perforation peritonitis in India: A study of

442 cases
Laxmi Narayan Meena, Sanchit Jain1, Prahlad Bajiya
Department of General Surgery, SMS Medical College, 1Department of General Surgery, RUHS College of Medical Sciences, Jaipur,
Rajasthan, India

Abstract Introduction: Perforation is defined as an abnormal opening in a hollow organ or viscus. Gastrointestinal
perforation is one of the common surgical emergencies in developing countries. The diagnosis is mainly
clinical and is aided by radiological investigations. The present study was conducted to highlight the spectrum
of hollow viscus perforation peritonitis in terms of etiology, clinical presentations, site of perforation,
surgical treatment, postoperative complications, and mortality encountered at SMS Medical College and
Hospital, Jaipur, India.
Materials and Methods: The study was a hospital‑based prospective observational study conducted from April
2012 to October 2013 in the Department of General Surgery. During the study period, a total of 442 patients
underwent surgery for secondary peritonitis. The patients included in the study were patients (>12 years)
presenting with gastrointestinal perforation and undergoing emergency laparotomy.
Results: Out of 442 patients, 91.2% (403) were males, with male‑to‑female ratio being 10.33:1. The mean
age was 39.13 years. About 79.2% of the patients were below 50 years. Free gas under diaphragm on chest
X‑ray was noted in 86.2% cases. Duodenum was the most common site of perforation in 158 patients.
The most common etiology for perforation was acid peptic disease (41.4%). Simple closure was the most
common surgical procedure being performed in 63.8%. Overall morbidity and mortality recorded in this
study were 42.8% and 14.7%, respectively.
Conclusion: Early diagnosis, resuscitation with fluids, and timely surgical intervention are the most important
factors deciding the fate of the patient with perforation peritonitis.

Keywords: Morbidity, mortality, perforation

Address for correspondence: Dr. Sanchit Jain, 6, Kailash Vihar, Lal Kothi, Tonk Road, Jaipur ‑ 302 015, Rajasthan, India.
E‑mail: sanchit4088@gmail.com

INTRODUCTION viscus. It is derived from the Latin perforatus, meaning “to

bore through.” The spectrum of etiology of perforation is
Generalized peritonitis as a result of gastrointestinal different between developing and developed countries,[4,5]
perforation is a common surgical emergency in India.[1] and there is a paucity of data from India regarding its
In spite of advances in perioperative care, antimicrobial etiology, prognostic indicators, morbidity, and mortality
therapy, and intensive care support, perforation peritonitis patterns. [6] Our study was designed to highlight the
still has high morbidity and mortality.[2‑3] Perforation is spectrum of hollow viscus perforation peritonitis in terms
defined as an abnormal opening in a hollow organ or
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DOI: How to cite this article: Meena LN, Jain S, Bajiya P. Gastrointestinal
10.4103/ssj.ssj_33_17 perforation peritonitis in India: A study of 442 cases. Saudi Surg J
2017;5:116-21.

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Meena, et al.: Gastrointestinal perforation peritonitis in India

of etiology, clinical presentations, site of perforation, had a good appetite; they were accepting orally and had
surgical treatment, postoperative complications, and good ambulation. If a patient had complication, they
mortality encountered by us at SMS Medical College and were managed accordingly. All the patients were called
Hospital, Jaipur. for follow‑up 15 days after surgery and after that as per
requirement.
MATERIALS AND METHODS
All data related to the patient from admission to discharge
The study was a hospital‑based prospective observational was collected in a proforma after taking written consent.
study conducted in the Department of General Surgery, Data were analyzed using IBM SPSS software version 20,
SMS Medical College and Hospital, Jaipur. The study Chi‑square test was used to compare variables, and tests
was done after permission from the Ethical Committee were considered significant when P < 0.05.
and Research Review Board of the institute from April
2012 to October 2013. The cases included in the study RESULTS
were patients (>12 years) presenting with gastrointestinal
perforation and undergoing emergency laparotomy. During the study period, a total of 442 participants
Patients presenting with esophagus, pancreatobiliary tree, or underwent surgery for secondary peritonitis. Among
genitourinary tract perforation or undergoing laparotomy these, 91.2% (403) of them were males and 8.8% (39)
for primary peritonitis, tertiary peritonitis (anastomotic were females, with male‑to‑female ratio being 10.33. In our
leak and fecal fistula), or pancreatitis were excluded from study, the mean age of patients was 39.13 ± 15.29 years.
the study. Three hundred and fifty (79.2%) patients were <50 years,
while only 20.8% (92 patients) were >50 years. The time
All patients admitted to our hospital with acute pain taken by patients between the onset of symptoms and
abdomen or history of blunt trauma abdomen were presentation to the hospital was <48 h in 244 (55.2%)
evaluated with detailed history of their illness with onset and patients and >48 h in 198 (44.8%) patients. Clinical
duration of presenting symptoms. A history of any other presentation of patients varied according to the site
comorbid illness and personal habits was also taken. After a and cause of perforation [Table 1]. Abdominal pain
general and abdominal examination (suggesting perforation was observed in all the patients and distension and
peritonitis), an X‑ray abdomen upright was obtained. constipation in most of the patients. Tachycardia (pulse
A diagnosis of gastrointestinal perforation was made on rate >100/min) was noted in 83.5% of patients, while about
the basis of history, clinical examination, and presence 30% of patients had low urine output. A positive history
of free gas under diaphragm on abdominal X‑ray. In of chronic smoking was noted in 106 patients (24%) and
the rest of the cases, ultrasonography [USG]/computed nonsteroidal anti‑inflammatory drug  (NSAID) abuse in
tomography (CT) abdomen/paracentesis (four‑quadrant
aspiration – 4QA) was done to confirm the diagnosis. As Table 1: Preoperative data
soon as the diagnosis was made, resuscitation was started Variable n (%)

with large volume of crystalloids (blood transfusion if Signs and symptoms

Abdominal pain 442 (100)
necessary), nasogastric suction to empty the stomach, and Abdominal distension 438 (99)
broad spectrum antibiotics were administered. Following Constipation 420 (95)
Fever 152 (34.3)
adequate resuscitation, patients underwent exploratory Vomiting 136 (30.7)
laparotomy by a midline incision, and based on the Diarrhea 14 (3.1)
intraoperative findings, the further management was Tachycardia (pulse>100/min) 369 (83.5)
Hypotension (systolic BP <90 mmHg) 272 (61.5)
decided. The operating surgeon decided the procedure Tachypnea (respiratory rate >20/min) 196 (44.3)
to be performed. Peritoneal cavity was irrigated with Urine output (<0.5 mL/kg/h) 136 (30.8)
warm normal saline (3-5 litres). Intra‑abdominal drains Preexisting comorbid conditions
COPD 27 (6.1)
were placed depending on peritoneal contamination and Hypertension 17 (3.8)
abdomen was closed after achieving complete hemostasis. Diabetes mellitus 12 (2.7)
Postoperatively, intravenous antibiotics were given for Tuberculosis 11 (2.4)
Investigations
5–10 days after the operation. The drug regimen was not Pneumoperitoneum 381 (86.2)
uniform and was based on the cause of perforation and Air fluid levels 103 (23.3)
Hypokalemia (<3 mmol/L) 35 (7.9)
degree of contamination. Standard postoperative care was Hyponatremia (<130 mmol/L) 34 (7.7)
provided to each patient. In case of uneventful recovery, Increased blood urea (>45 mg/dL) or creatinine (>1.5mg/dL) 148 (35)
patients were discharged from the hospital when they BP: Blood pressure, COPD: Chronic obstructive pulmonary disease

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Meena, et al.: Gastrointestinal perforation peritonitis in India

67 (15.2%) patients. Chronic obstructive pulmonary disease 107 (24.2%) patients followed by wound infection in
was the most common preexisting comorbidity seen in 89 (20.1%) patients [Table 4]. In our study, the overall
6.1% patients. In our study, according to radiological morbidity rate was 42.8% (189 patients) and the mortality
investigation, Chest X-ray or X-ray flat plate abdomen rate was 14.7% (65 patients). The mean hospital stay
showed free gas under diaphragm in a majority of was 8.8 days with a standard deviation of 3.74 days. The
perforations (86.2%), but the maximum proportion was maximum duration of stay was 29 days.
found in acid peptic ulcer diseases (100%), followed by
enteric (96.6%) and tubercular (95.5%), and the least was DISCUSSION
found in appendicular (28.6%) type. Multiple air fluid levels
Perforation peritonitis is one of the most common surgical
in X‑ray abdomen erect view suggesting the presence of
emergencies in developing nations like India.[1] In our
obstruction in association with perforation were noticed
in 23.3% patients.
Table 2: Spectrum of perforation peritonitis as per site and
etiology
In our study, according to site [Table 2], gastroduodenal
Etiology n (%)
[205 (46.4%)] was the most common site, followed Gastroduodenal (n=205; 46.4%) Total Gastric Duodenal
by small bowel (jejunum and ileum) [181 (41%)], Acid peptic disease 183 (89) 38 (20.8) 145 (79.2)
appendix [36 (8.1%)], and large bowel [20 (4.5%)]. Trauma 16 (8) 3 (18.8) 13 (81.3)
Overall duodenum was the most common site of Malignancy 6 (3) 6 (100) 0
Small bowel (n=181; 41%) Total Ileum Jejunum
perforation (158 patients). Among the gastroduodenal
Typhoid 85 (47) 82 (96.5) 3 (3.5)
types, acid peptic disease was the most common etiology, Tuberculosis 23 (13) 21 (91.3) 2 (8.7)
with the site of perforation being more commonly Traumatic 49 (27) 21 (42.9) 28 (57.1)
the duodenum in >79% of peptic perforation cases. Malignancy 3 (2) 3 (100) 0
Strangulation of bowel 13 (7) 7 (53.8) 6 (46.2)
Traumatic perforations were also seen more commonly Other 8 (4) 7 (87.5) 1 (12.5)
in duodenum, while all the six patients with malignant Appendix (n=36; 8.1%) Total
perforation had gastric perforation. Jejunal and ileal Appendicitis 35 (97.2)
perforations were seen in 41% patients, with typhoid Malignancy 1 (2.8)
being the most common etiology (85 patients) followed Large bowel (n=20; 4.5%) Total Colon Rectum

by trauma (49 patients). Other categories [Table 2] Trauma 13 (65) 9 (62.9) 4 (30.8)

Malignancy 1 (5) 1 (100) 0
include jejunal diverticulum, ascaris infestation in the Strangulation 4 (20) 4 (100) 0
ileum, and Meckel’s diverticulum. A total of 36 patients Other 2 (10) 2 (100) 0
had perforation in the appendix, of which 97.2%
presented with appendicitis while only one case had Table 3: Operative procedures performed
malignancy. In the large intestine, the most common Operative procedure n (%)
etiology was trauma which was the cause of perforation Simple closure* 282 (63.8)
in 65% population. In our study according to the Stoma formation** 77 (17.4)
Appendectomy 35 (7.9)
peritoneal fluid (exudate), clear fluid (52%) was found in Resection anastomosis 32 (7.2)
maximum proportion, especially in peptic and traumatic Definitive procedure*** 16 (3.6)
perforation. Purulent fluid  (33.5%) was observed in Total 442 (100.0)

peptic, enteric, and appendicular perforations, while *Simple closure: Simple closure with or without omental patch/FJ/GJ,
**Stoma formation: Simple closure/resection anastomosis with diversion
fecal type (12.7%) in enteric and traumatic perforations, ileostomy/colostomy/resection with end stoma with distal mucous fistula/
and hemoperitoneum (1.8%) in traumatic perforations. exteriorization of perforation as stoma, ***Definitive procedure:
Billroth type I/II, right/left hemicolectomy, pancreaticoduodenectomy
with GJ/FJ/HJ/PJ. FJ: Feeding jejunostomy, GJ: Gastrojejunostomy,
In the study, a variety of operative procedures were HJ: Hepaticojejunostomy, PJ: Pancraticojejunostomy
performed depending on the patients’ general condition,
peritoneal contamination, site of perforation, gut viability, Table 4: Postoperative complications
and surgeons’ decision [Table 3]. The most commonly Complication n (%)
executed operative procedure was the simple closure of Lung infection 107 (24.2)
perforation either in a single or in a double layer in 63.8% Wound infection 89 (20.1)
Abdominal collection 45 (10.2)
cases. Stoma surgery had to be performed in 77 patients. Wound dehiscence 40 (9.0)
Leak 27 (6.1)
In the study population, the most commonly observed Dyselectrolytemia 44 (9.9)
Mortality 65 (14.7)
postoperative complication was lung infection in
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Meena, et al.: Gastrointestinal perforation peritonitis in India

study among 442 patients, 91.2% (403) of them were road traffic accidents and assaults. All these findings were
males and 8.8% (39) of them were females. All types of found significant.
perforation occurred more frequently in male patients.
All studies related to perforation peritonitis show a male In our study, generalized peritonitis (98.2%) was observed
preponderance, although the male‑to‑female ratio varies significantly more as compared to localized peritonitis (1.8%).
from 1.34:1 to 7:1.[2,5,7‑10] A possible reason for this finding Localized peritonitis was observed only in appendicular (20%)
may be smoking and alcohol intake, which is more frequent type and malignant (11.1%) type of perforation. Similar
among men, thus increasing the risk of perforation. observations were noted in other studies, although the
percentage of generalized peritonitis varies from 83% to
I n our study, th e mean ag e o f patients was 96%.[5,10,15]
39.13 ± 15.29 years. The overall patients reported in the
younger age group <50 years (350, 79.2%) was more in In our study, according to radiological investigation, on
comparison to the older age group >50 years (92, 20.8%). chest X-ray or X-ray flat plate abdomen free gas under
In all types of perforations, patients were reported more diaphragm was observed in 86.2% patients, but the
in the <50 years’ age group except in the malignant type maximum proportion was found in acid peptic ulcer
of perforation where it was more in >50 years’ age group. diseases (100%), followed by enteric (96.4%) perforation,
Similar observations were found by Jhobta et al.,[5] Gupta and the least was found in appendicular (28.6%) type.
et al.,[9] and Ramakrishnaiah et al.[10] This finding is in contrast USG was required to diagnose 61 (13.8%) patients with
to studies in the Western countries where perforation mostly appendicular and traumatic type of perforation,
primarily occurs in the elderly.[11] This is related due to the while 4QA and contrast‑enhanced CT had a role in the
difference in the etiology. The Western literature suggests diagnoses of traumatic perforation. Bansal et al.[16] reported
that foreign body, ischemia, radiotherapy, diverticula, an overall positivity rate of plain radiography in detecting
Crohn’s disease, etc. are the main causes of perforation, pneumoperitoneum at 89.20%, which was highest for
which are more commonly seen in elderly patients. In stomach and duodenal perforation (94.19%) and the
contrast to this, infection is the most common cause for least for appendicular perforation (7.69%) with highly
perforations in developing countries. This includes acid significant difference (P < 0.001). In contrast, Jhobta et al.[5]
peptic ulcer disease related to Helicobacter pylori infection, found pneumoperitoneum in 67% patients, but none of
typhoid fever, and tuberculosis, which are quite common the patients with appendicular perforation showed such
in young.[7,12‑14] finding. Furthermore, only 70% of patients had an evidence
of pneumoperitoneum in the study by Afridi et al.[15]
Abdominal pain was noted in all patients presenting
with perforation followed by distension in 99% and In our study according to the site, gastroduodenal
constipation in 95%. Vomiting was significantly more type [205 (46.4%)] was the most common site, followed
common in appendicular and strangulation type. Diarrhea by small bowel [181 (41%)], appendix [36 (8.1%)], and
was significantly more common in appendicular type, large bowel [20 (4.5%)] [Table 2]. Similar observations
while fever was significantly more commonly observed were noted by Jhobta et al.[5] in their study on 504 patients.
in appendicular and enteric perforations. Pain abdomen In contrast, in developed Western countries, lower
was the universal presenting symptom in other studies gastrointestinal tract perforation peritonitis has been
on perforation.[9,10] Jhobta et  al.[5] found abdominal pain reported to be more common.[17‑19]
in 98%, while Afridi et al.[15] reported a similar history in
78% patients. Clinical presentation of the patients varied In our study, clear fluid (52%) was the most common
according to the site and cause of perforation. peritoneal exudate. Similar observation was made by Haque
et al.[20] who found clear fluid in 57.3%. In contrast, Jhobta
According to personal history, in our study, NSAID usage et  al.[5] found purulent (71%) to be the most common
was observed more in strangulation type, acid peptic ulcer peritoneal fluid.
disease, and enteric perforation patients. Higher NSAID
intake in peptic ulcer diseases is for treatment of some In our study, a variety of operative procedures were
other pain, while in enteric fever, it was for management of adopted depending on the patients’ general condition,
fever. The proportion of the patients who had a history of peritoneal contamination, site of perforation, gut viability,
chronic smoking was more in peptic perforation followed and surgeon’s decision. The most commonly executed
by strangulation. Alcohol users were more exposed for operative procedure was simple closure in 63.8% cases of
traumatic type of perforation because of higher risk for the perforation, resection anastomosis in 7.2%, stoma in
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Meena, et al.: Gastrointestinal perforation peritonitis in India

17.4%, appendicectomy in 7.9%, and definitive procedure CONCLUSION

in 3.6%. All gastroduodenal perforations were managed
with simple closure with omental patch (majority), simple In developing countries like India, the etiology and site
closure with omental patch and feeding jejunostomy, of perforation continues to be different from developed
Billroth I/II, pancreatoduodenectomy with FJ, and simple countries where lower gastrointestinal tract perforations
closure with triple‑tube decompression. In small‑bowel predominate. The important factors clearly deciding the
perforation, simple closure, resection anastomosis with or fate of the patient with perforation peritonitis are early
without proximal diversion stoma, and loop ileostomy were diagnosis, resuscitation with fluids and electrolyte balance,
done. In the appendix, appendectomy and peritoneal lavage timely surgical intervention, appropriate use of antibiotics,
with drain placement and in colorectal perforation, right/left and eliminating the source of infection. Since the most
hemicolectomy, simple closure with or without stoma, and important factor associated with perforation in developing
Hartmann’s procedure were done. Similar observations were countries is infection, early diagnosis and treatment can
noted by Jhobta et al.,[5] with simple closure being the most reduce the incidence further.
commonly executed operative procedure in 60% patients.
Financial support and sponsorship
Lung infection was the most commonly observed Nil.
postoperative complication followed by wound infection.
Conflicts of interest
Lung infection was significantly higher in proportion in
There are no conflicts of interest.
malignant, tubercular, and peptic perforations. Similar
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