Open Access Original

Article DOI: 10.7759/cureus.15301

Causes of Acute Peritonitis and Its Complication

Danesh Kumar 1 , Ishan Garg 2 , Atif Hussain Sarwar 3 , Love Kumar 1 , Vikash Kumar 4 , Sonam Ramrakhia 5, 6
, Sidra Naz 7 , Amna Jamil 8 , Zoya Qamar Iqbal 4 , Besham Kumar 9

1. Internal Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, PAK 2. Clinical Medicine, Ross
University School of Medicine, Bridgetown, BRB 3. Internal Medicine, Ghulam Muhammad Mahar Medical College,
Sukkur, PAK 4. Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK 5. Medicine, Liaquat University of
Medical and Health Sciences, Jamshoro, PAK 6. Medicine, Mustafai Trust Central Hospital, Sukkur, PAK 7. Internal
Medicine, University of Health Sciences, Lahore, PAK 8. Obstetrics and Gynecology, Jinnah Postgraduate Medical
Centre, Karachi, PAK 9. Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK

Corresponding author: Amna Jamil, amnajamil.aj10@yahoo.com

Abstract
Introduction
Peritonitis is a significant cause of morbidity and mortality in surgical settings. Coexisting premorbid illness
and postoperative complications were found to be associated with death. This study aimed to analyze
various etiologies that cause peritonitis and shed light on the factors responsible for unsatisfactory results.

Method
This longitudinal study included 309 patients above 12 years of age, of either gender, with confirmed
diagnosis of peritonitis. Exploratory laparotomy was done to identify the cause of peritonitis. Patients were
monitored postoperatively till their discharge or death for the development of complications.

Results
Our results showed that the most common cause of acute peritonitis was duodenal perforation (26.2%),
followed by typhoid ileal perforation (24.2%) and ruptured appendix (16.8%). At least one complication was
observed in 31% of the participants. The most common complication was dehydration (18.8%), followed by
septicemia (11.3%) and paralytic ileus (6.4%). Ten (3.2%) patients died in the hospital.

Conclusions
Acute peritonitis is a serious surgical emergency caused by a number of diseases. Early surgical treatment
along with antibiotics, followed by aggressive resuscitation can yield improved outcomes in patients with
peritonitis.

Categories: Gastroenterology
Review began 05/16/2021
Keywords: peritonitis, etiology, complications, typhoid ileal perforation, ruptured appendix
Review ended 05/23/2021
Published 05/28/2021

© Copyright 2021 Introduction

Kumar et al. This is an open access article
Peritonitis, an inflammation of the peritoneum, is a life-threatening acute surgical emergency. It presents
distributed under the terms of the
Creative Commons Attribution License with severe abdominal pain and is a significant cause of morbidity and mortality ranging from 10%-60% in
CC-BY 4.0., which permits unrestricted surgical settings [1]. Existing literature shows that etiologies of peritonitis vary by geographic locations and
use, distribution, and reproduction in any local environmental factors with genetic predisposition. Appendicitis and typhoid ileal perforation are the
medium, provided the original author and
common causes of peritonitis with an estimated prevalence of about 43.1% and 35.1%, respectively [2-3].
source are credited.
Other causes of peritonitis include gastroduodenal perforations, intestinal volvulus, ruptured abscesses,
traumatic bowel perforation, perforated peptic ulcers, primary/idiopathic peritonitis, tubo-ovarian
abscesses, and amoebic colonic perforations. Knowledge of several distinct causes and presentation of
peritonitis in a particular setting will lead to improved local care and better overall understanding of the
disease process, as cause is directly related to prognosis [2-3].

Aggressive fluid resuscitation and early surgical intervention are the mainstay of therapy of peritonitis.
Enterocutaneous fistulas, surgical site infection, sepsis, and multiorgan failure are the commonest
complications seen in surgical settings. Others include abdominal compartment syndrome, wound
dehiscence, and respiratory insufficiency. Complications are influenced by advanced age and comorbidities.
Coexisting premorbid illness and postoperative complications were found to be associated with death [4,5].
Despite the rapid advancement in surgical techniques, modified antimicrobial therapies, and intensive care
support, the management of peritonitis continues to be more demanding, challenging, and complex than
ever [4].

Severely ill patients usually present in the late stage of the disease. Consequently, there is less time for

How to cite this article

Kumar D, Garg I, Sarwar A, et al. (May 28, 2021) Causes of Acute Peritonitis and Its Complication. Cureus 13(5): e15301. DOI
10.7759/cureus.15301
 diagnostic approaches and proper decision-making for a strong treatment method. Lack of awareness, late
presentation, and its correlation with morbidity and mortality demonstrate that there is room for
betterment in medical treatment by a thorough examination of the etiologies, presentation, and results.
Prior studies primarily focused on single etiologies; therefore, they have not focused on interconnected
etiologies. The present study aimed to analyze various etiologies of peritonitis and shed light on the factors
responsible for unsatisfactory results.

Materials And Methods

This longitudinal study was conducted in the emergency unit of a tertiary care hospital in Pakistan from
January 2019 to March 2021. Patients with a confirmed diagnosis of peritonitis above 12 years of age and of
either gender, which included 309 patients, were included in the study. Patient were enrolled via
consecutive convenient non-probability technique. Their informed consent was taken. Ethical review board
approval was taken before start of patient enrollment. Diagnosis of peritonitis was made based on clinical
and radiological findings. Clinical findings included abdominal pain, vomiting, constipation, generalized
abdominal tenderness, and absent bowel sounds. Peritonitis was indicated by X-ray showed air under the
diaphragm.

Exploratory laparotomy was done to identify the cause of peritonitis. Operative findings like duodenal
perforation, ileal perforation, ileal stricture with perforation, and ruptured appendix were noted in a self-
structured questionnaire. Surgical intervention was done when required and the cause of perforation was
treated. Patients were monitored postoperatively for the development of complications. Complications such
as organ failure, septicemia, peritoneal abscess, paralytic ileus, burst abdomen, and surgical site infection
were recorded. Complications due to ileostomy or any other surgical intervention were not taken into
consideration in this study. Statistical Package of Social Sciences (SPSS) for Windows, version 22.0 (IBM
Corp., Armonk, NY) was used to analyze data. Frequencies and percentages were calculated for categorical
variables.

Results
Acute peritonitis was more common in males (65.0%) and in the age group from 21 to 40 years (Table 1).

Demographics Frequency (percentage)

Gender

Male 201 (65.0%)

Female 108 (35.0%)

Age group in years

12–20 77 (24.9%)

21–40 97 (31.3%)

41–60 79 (25.5%)

60+ 56 (18.1%)

TABLE 1: Demographics of the participants enrolled.

The most common cause of acute peritonitis was duodenal perforation (26.2%), followed by typhoid ileal
perforation (24.2%) and ruptured appendix (16.8%) (Table 2).

2021 Kumar et al. Cureus 13(5): e15301. DOI 10.7759/cureus.15301 2 of 5

 Causes Frequency (percentage)

Duodenal perforation 81 (26.2%)

Typhoid ileal perforation 75 (24.2%)

Ruptured appendix 52 (16.8%)

Tuberculosis perforation 31 (10.0%)

Tumor perforation 21 (6.7%)

Liver cirrhosis 19 (6.1%)

Gangrenous gut 15 (4.8%)

Acute pancreatitis 06 (1.9)%

Acute diverticulitis 05 (1.6%)

Pelvic inflammatory disease 04 (1.2%)

TABLE 2: Causes of acute peritonitis.

At least one complication was observed in 97 (31.3%) participants. The most common complication was
dehydration (18.8%), followed by septicemia (11.3%), and paralytic ileus (6.4%). Ten (3.2%) patients died in
the hospital (Table 3).

Complications Frequency (percentages)

No complications 212 (68.6%)

Dehydration 57 (18.4%)

Septicemia & organ failure 35 (11.3%)

Paralytic ileus 20 (6.4%)

Burst abdomen 19 (6.14%)

Surgical site infection 15 (4.8%)

Enterocutaneous fistulas 11 (3.5%)

Hepatorenal syndrome 01 (0.3%)

Hepatic encephalopathy 01 (0.3%)

TABLE 3: Complications of acute peritonitis.

Discussion
The present study demonstrated peritonitis was significantly more prevalent in males, with a peak age group
of 21-40 years. Among the factors causing peritonitis, duodenal perforation was the most common, followed
by typhoid ileal perforation and ruptured appendix. Postoperative morbidity rate was 31.3% with
dehydration being the most common complication, followed by septicemia and paralytic ileus. The mortality
rate was 10%.

The findings of the present study are also supported by a study conducted by Choua et al. [6], who found that
males were at a higher risk of developing peritonitis, and the average age of the participants was 25.8 years.
The most common cause according to their study was visceral perforation, followed by diffuse appendiceal
peritonitis. Participants in the present study also had duodenal perforations and affected appendix as the
primary cause [6]. However, the morbidity and mortality rates in their study were lower than those of the
present study. Another study carried out by Hagos et al. also showed similar results [7]. Males were seen to
develop peritonitis more frequently. Acute appendicitis and perforated peptic ulcer disease were among the
common causes; problems with appendix and visceral perforations were also observed in the present study.

2021 Kumar et al. Cureus 13(5): e15301. DOI 10.7759/cureus.15301 3 of 5

 The morbidity rate was 30.8% in their study, with wound infections and sepsis being common complications,
which was also observed in the present study. However, the mortality rate in the present study was 10%.
Mortality rates in some other studies were 11.8% [8] and 12.63% [9]. The possible explanation for this
variation in mortality rate is early diagnosis and presentation accompanied with effective surgical
treatment.

Helicobacter pylori is the main causative agent of acute peritonitis secondary to duodenal perforation [10]. It
is more common in developing countries where people do not have access to mineral water. However,
boiling tap water would prevent peritonitis, and physicians are advised to diagnose and treat H. pylori
infections with triple therapy including proton pump inhibitors (PPIs) at an early stage to avoid secondary
complications [11]. Another leading cause is typhoid ileal perforation; typhoid fever is progressively being
eradicated in most parts of the world but it is still endemic in India. Typhoid frequently leads to intestinal
hemorrhage causing increased mortality and morbidity [12]. Moreover, the third leading cause was ruptured
appendix as shown in other studies by Schietroma et al. [13] and Lin et al. [14]. However, most of these
causes are due to unsanitary conditions and the use of contaminated water. The adaptation of a healthy
lifestyle accompanied by early diagnosis and aggressive resuscitation, in addition to prompt surgical
intervention can help avoid complications of acute peritonitis [15].

Conclusions
Acute peritonitis, a serious surgical emergency, is caused by a number of diseases. According to the present
study, H. pylori infections leading to duodenal perforation, typhoid ileal perforation, and ruptured appendix
are the most common causes. These can be avoided by leading a hygienic lifestyle. In the case of H. pylori
infection, PPI maintenance therapy can help avoid reinfection. Moreover, early surgical treatment along
with antibiotics followed by aggressive resuscitation can yield improved outcomes for peritonitis.

Additional Information
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Jinnah Sindh Medical
University issued approval JSMU/IRB/2019/32. Animal subjects: All authors have confirmed that this study
did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform
disclosure form, all authors declare the following: Payment/services info: All authors have declared that no
financial support was received from any organization for the submitted work. Financial relationships: All
authors have declared that they have no financial relationships at present or within the previous three years
with any organizations that might have an interest in the submitted work. Other relationships: All authors
have declared that there are no other relationships or activities that could appear to have influenced the
submitted work.

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