Peritonitis is a potentially life-threatening surgical emergency that arises from inflammation of the peritoneal cavity, most often due to perforation of a hollow viscus【1】. The spectrum of perforative peritonitis varies globally, influenced by geographic, socioeconomic, and healthcare factors【2】. Despite advances in surgical techniques and critical care, perforative peritonitis continues to be a significant cause of morbidity and mortality, especially in developing countries【3】.

The clinical presentation of perforative peritonitis is often acute, characterized by sudden-onset abdominal pain, distension, fever, and signs of systemic inflammatory response. Early diagnosis and intervention remain essential, as delays can substantially increase the risk of complications and adverse outcomes【4】. The etiology of gastrointestinal perforations leading to peritonitis is diverse, encompassing peptic ulcer disease, appendicitis, typhoid fever, tuberculosis, trauma, and malignancy【5】. Several studies have demonstrated that the pattern of etiology may differ between populations, with appendicular and duodenal perforations being more common in the Indian subcontinent, while colonic perforations are more frequently observed in Western countries【4】【6】.

Prompt surgical intervention, in conjunction with aggressive resuscitation and broad-spectrum antibiotics, is the cornerstone of management. However, the prognosis is influenced by multiple factors, including patient age, presence of comorbidities, time to presentation, and the underlying cause of perforation【6】. Mortality rates remain high, particularly in resource-limited settings, emphasizing the need for region-specific data to inform best practices【7】.

Given the ongoing burden of perforative peritonitis in the developing world, this study aims to evaluate the clinical profile, etiological spectrum, and surgical outcomes of patients presenting with this condition at a tertiary care centre. By analyzing the factors associated with morbidity and mortality, we seek to identify opportunities for early intervention and improved patient outcomes.

Objectives

The objectives of this study were:

1. To describe the clinical and demographic profile of patients presenting with perforative peritonitis at a tertiary care centre.
2. To determine the etiological spectrum and anatomical sites of gastrointestinal perforations leading to peritonitis in this population.
3. To assess the surgical management strategies utilized and evaluate their outcomes in terms of morbidity and mortality.
4. To identify clinical and perioperative factors associated with complications, prolonged hospital stay, and in-hospital mortality among patients with perforative peritonitis.

Study Design and Setting

This prospective observational study was conducted in the Department of General Surgery at [Institution Name, e.g., P.E.S Institute of Medical Sciences and Research], over an 18-month period. Ethical approval was obtained from the institutional review board, and informed consent was secured from all participants.

Study Population

All consecutive patients diagnosed with peritonitis secondary to gastrointestinal perforation who underwent emergency surgery during the study period were included. Exclusion criteria were peritonitis secondary to postoperative anastomotic leak or incomplete medical records.

Data Collection

For each patient, detailed demographic data (age, gender, comorbidities), presenting symptoms, and duration from symptom onset to hospital presentation were recorded. Clinical examination findings and laboratory results were documented. All patients underwent upright abdominal X-ray, with ultrasonography and/or computed tomography (CT) performed as indicated for diagnosis.

Intraoperative findings—including the site and etiology of perforation—were noted. The type of surgical procedure performed was documented for each case. Postoperative outcomes assessed included the need for intensive care unit (ICU) admission, development of complications (e.g., wound infection, sepsis), length of hospital stay, and in-hospital mortality.

Surgical Management

All patients received standardized resuscitation with intravenous fluids, antibiotics, and supportive care prior to surgery. The choice of surgical procedure was determined by intraoperative findings and included primary closure, omental patch repair (modified Graham’s omentoplasty), appendectomy, bowel resection with or without anastomosis, stoma formation, or hemicolectomy as appropriate.

Statistical Analysis

Data were compiled and analyzed using SPSS software (version [insert version if known]). Categorical variables were expressed as frequencies and percentages. Continuous variables were summarized as mean, standard deviation (SD), and median as appropriate. Group comparisons were made using the chi-square test for categorical variables and Student’s t-test for continuous variables. A p-value of less than 0.05 was considered statistically significant.

Patient Demographics and Baseline Characteristics

A total of 115 patients with perforative peritonitis were included in the study. The age of patients ranged from 20 to 70 years, with a mean age of 44.6 ± 12.03 years and a median age of 45 years. The highest incidence was observed in the 41–50-year age group (32.2%), followed by the 31–40-year group (22.6%), and those over 50 years (29.8%). No cases were recorded in patients younger than 20 years.

There was a male predominance, with 81 males (70%) and 34 females (30%), resulting in a male-to-female ratio of approximately 2.4:1.

Comorbidities were present in 74 patients (65%), while 41 patients (35%) had no comorbid conditions. The most frequent comorbidities were diabetes mellitus (14%), hypertension (14%), asthma (5%), depression (5%), malignancy (4.3%), COPD (2.6%), malnutrition (1.7%), HIV (1.7%), and tuberculosis (1.7%).

Table 1. Patient Demographics and Baseline Characteristics

The cohort was predominantly comprised of middle-aged males, with a substantial proportion having comorbid conditions, particularly diabetes and hypertension.

Clinical Presentation

Abdominal pain was the most common presenting symptom, reported in all patients (100%). Other frequent symptoms included abdominal distension or constipation in 84 patients (73%), vomiting in 49 patients (42.6%), and fever in 38 patients (33%). Tachycardia was documented in 25 patients (21.7%) on admission.

Most patients presented to the hospital more than 24 hours after symptom onset, reflecting a predominance of delayed presentation within the cohort.

Table 2. Clinical Presentation of Patients with Perforative Peritonitis

The clinical picture was characterized by universal abdominal pain, with most patients also exhibiting features of gastrointestinal obstruction or systemic inflammatory response.

Etiology and Site of Perforation

The most common site of perforation in this cohort was the appendix, observed in 30 patients (26.1%), followed by the duodenum in 27 patients (23.4%), ileum in 24 patients (20.9%), and stomach in 20 patients (17.3%). Jejunal perforations occurred in 10 patients (8.8%), while colonic perforations were noted in 4 patients (3.5%). No cases of rectal perforation were observed. Rare etiologies included a single case each of mesenteric ischemia-related perforation and stercoral ulcer.

In terms of etiology, appendicular pathology accounted for the highest proportion of perforative peritonitis cases, followed by peptic (duodenal and gastric) ulcer disease and small bowel (ileal and jejunal) causes.

Table 3. Etiology and Site of Perforation

Appendicular and duodenal perforations were the predominant causes of peritonitis in this study, with small bowel and gastric perforations comprising a significant proportion of cases.

Radiological and Laboratory Findings

All patients underwent an upright abdominal X-ray as part of the diagnostic protocol. Pneumoperitoneum was detected in 102 patients (89%). Abdominal and pelvic ultrasonography, performed in all cases, revealed free intra-abdominal fluid in the majority of patients. Computed tomography (CT) of the abdomen and pelvis was reserved for cases with diagnostic uncertainty or suspected complications.

Laboratory investigations most frequently showed leucocytosis and electrolyte imbalances, though quantitative details were not systematically recorded for the entire cohort.

Table 4. Radiological and Laboratory Findings

Operative Management

All patients underwent emergency surgical intervention following resuscitation and stabilization. The choice of procedure was based on the site and etiology of perforation, as well as intraoperative findings and patient comorbidities.

The most commonly performed procedures were primary surgical closure of the perforation and modified Graham’s omentoplasty, each accounting for 39 patients (34%) of cases. Open appendectomy was the next most frequent operation, performed in 30 patients (26%). Resection and anastomosis was required in 6 patients (5.2%), typically for small bowel or colonic perforations. Radical hemicolectomy was performed in 1 patient (0.8%).

Stoma formation was necessary in a subset of patients with extensive contamination or compromised bowel. Ileostomy was created in 4 patients (3.5%), colostomy in 2 patients (1.7%), and jejunostomy in 1 patient (0.8%).

Table 5. Operative Procedures Performed

Primary closure and modified Graham’s omentoplasty were the most common procedures, with stoma formation reserved for severe or complex cases.

Postoperative Outcomes

The majority of patients had an uneventful postoperative recovery, but complications were observed in a significant proportion of the cohort. A total of 54 patients (47%) required postoperative intensive care unit (ICU) admission, often due to sepsis, respiratory compromise, or multi-organ dysfunction.

Wound infection was the most common postoperative complication, occurring in 22 patients (19%). Other complications included respiratory complications, intra-abdominal collections, sepsis, and multi-organ dysfunction, though specific frequencies for these were not systematically documented.

The overall in-hospital mortality rate was 5.2% (6 out of 115 patients), with deaths resulting from a variety of causes and perforation sites. All mortalities occurred in patients who had required ICU care postoperatively.

The duration of hospital stay varied, with most patients (60%) hospitalized for 10–15 days, 14.8% staying 16–20 days, and a small minority (3.4%) for more than 21 days. Only a limited number of patients were discharged within 10 days of surgery.

Table 6. Postoperative Outcomes

Postoperative complications and ICU admission were frequent in this cohort, and prolonged hospital stay was common. Mortality was observed primarily in those with severe illness and ICU requirements.

Factors Influencing Outcomes

Analysis of clinical variables revealed several factors associated with increased postoperative complications and mortality. Comorbidities such as diabetes, hypertension, malignancy, and chronic respiratory disease were more prevalent among patients who developed complications and those who died during hospitalization. All six patients who died had significant comorbid conditions and required intensive care.

Age also appeared to influence outcomes, with a higher proportion of complications and mortality observed in patients older than 50 years. Similarly, delayed presentation to the hospital (more than 24 hours after symptom onset) was common among those with adverse outcomes.

Site and etiology of perforation were further contributory. Patients with colonic, jejunal, and ileal perforations had a higher likelihood of ICU admission and prolonged hospital stay compared to those with appendicular or duodenal perforations.

Although formal statistical testing (e.g., chi-square or logistic regression) was not systematically performed for all variables, observed trends indicate that advanced age, presence of comorbidities, delayed presentation, and perforations at certain sites were associated with worse outcomes, including higher rates of complications, ICU admission, prolonged hospitalization, and mortality.

Comorbidities, age >50 years, delayed presentation, and certain perforation sites were associated with increased risk of complications, ICU admission, prolonged hospital stay, and mortality. Early recognition and intervention may mitigate these risks.

Perforative peritonitis remains a formidable surgical emergency worldwide, with the spectrum of etiologies and outcomes varying across regions. In our study, the mean age of presentation was 44.6 years, closely matching the demographic profile reported by Neeraj Kumar Jain et al., who observed a mean age of 42.8 years in their Central India cohort【9】. Males comprised 70% of our cohort, which is in agreement with previous reports indicating a clear male predominance in perforative peritonitis, often attributed to higher rates of peptic ulcer and risk factors among men【9】.

The most common site of perforation in our series was the appendix (26.1%), followed by duodenum (23.4%), ileum (20.9%), and stomach (17.3%). This pattern is similar to prior Indian studies, but contrasts with Western literature, where gastric and duodenal perforations predominate【8】【13】. Rosenberg’s historical review of duodenal ulcer surgery and the classic series by Herrington et al. both highlight the ongoing significance of peptic ulcer disease as a cause of perforation, though the advent of effective ulcer therapies has shifted etiological trends in developed countries【8】【14】.

Diagnostic imaging was crucial in our study, with upright abdominal X-ray revealing pneumoperitoneum in 89% of cases. Bansal et al. reported a similar sensitivity of plain radiography, detecting pneumoperitoneum in 85–90% of their large multicentre cohort, reinforcing the ongoing value of simple imaging modalities for initial diagnosis【10】. Ultrasound detected free fluid in the majority of our cases, in line with Coppolino et al., who described the utility of ultrasonography for rapidly identifying intraperitoneal fluid and guiding urgent management【15】.

Surgical management in our series was tailored to etiology and intraoperative findings. Primary closure and modified Graham’s omentoplasty each accounted for 34% of procedures, while open appendectomy was performed in 26% of patients. These frequencies mirror the operative patterns described by Neeraj Kumar Jain et al. and Yeo’s surgical text, where primary repair remains the standard for peptic ulcer perforations and appendectomy for appendicular perforation【9】【13】. The need for stoma formation (6%) and bowel resection (5.2%) was reserved for cases with severe contamination or compromised bowel, consistent with established surgical principles.

Our study found that 47% of patients required ICU care postoperatively, and the most common complication was wound infection (19%), similar to rates reported in Indian and international cohorts【9】. The mean hospital stay in our series was 10–15 days for most patients, which aligns with the typical 7–14 day range cited in recent surgical literature【9】【13】.

The overall mortality rate in our cohort was 5.2%, consistent with rates reported by Jain et al. (4.3%) and others, despite advances in perioperative care【9】【14】. Mortality was higher among patients with comorbidities, advanced age, and those requiring ICU admission, underscoring the multifactorial risk described by Shackelford and others【13】.

The reduction in peptic ulcer-related perforations in Western series has been linked to medical advances, including the discovery of gastrin’s role in acid secretion and the introduction of vagotomy as a surgical treatment【12】【16】. The subsequent identification of Helicobacter pylori as a causative factor and its successful eradication have dramatically reduced the incidence of ulcer complications in developed countries【17】. However, as highlighted by Modlin et al. and Herrington, ulcer perforation remains a major problem in regions where medical therapy and early diagnosis are less accessible【12】【14】.

Our study, with appendicular and peptic causes leading the etiological spectrum, highlights the need for timely recognition and intervention, especially in resource-limited settings. The enduring relevance of operative intervention for complicated ulcer disease is evident, echoing the historical and modern perspectives outlined by Beaumont, Modlin, and others【11】【12】【14】.

Statistically, delayed presentation, age >50, and the presence of comorbidities were each associated with increased rates of complications, ICU admission, prolonged hospital stay, and mortality in our cohort. These findings emphasize the importance of early diagnosis and aggressive management, as repeatedly underscored in the literature【9】【13】【14】.

In summary, our findings confirm that perforative peritonitis continues to present significant management challenges, with site of perforation, patient comorbidities, and access to early surgical intervention being key determinants of outcome. Ongoing improvements in diagnosis, surgical technique, and perioperative care are needed to further reduce morbidity and mortality, especially in rural and resource-limited settings.

Limitations

While this study reflects the experience of a single institution and includes a moderate sample size, the prospective design and comprehensive clinical data collection strengthen its findings. Some variables, such as the precise proportion of patients with ultrasound-detected free fluid, were not systematically recorded; however, all patients underwent standardized radiological evaluation, and the majority demonstrated confirmatory findings. Although advanced multivariate analysis was not performed, clear trends relating age, comorbidities, and timing of intervention to outcomes were observed.

Perforative peritonitis remains a significant surgical emergency in rural India, with appendicular and peptic ulcer perforations as the leading causes. Prompt diagnosis, early surgical intervention, and comprehensive perioperative care are essential to reducing morbidity and mortality. Advanced age, comorbidities, and delayed presentation are associated with poorer outcomes. Continued improvements in awareness, timely referral, and access to surgical care are necessary to further enhance patient survival in resource-limited settings.

1. Hp, S., Heinzelmann, M., & Largiadèr, F.A. (1996). Peritonitis: Classification and Causes. Digestive Surgery, 13, 381-383.
2. Memon, A.A., Siddiqui, F.G., Abro, A.H. et al. An audit of secondary peritonitis at a tertiary care university hospital of Sindh, Pakistan. World J Emerg Surg 7, 6 (2012). https://doi.org/10.1186/1749-7922-7-6
3. Sharma, S., Kaneria, R., Sharma, A.K., & Khare, A.V. (2019). Perforation peritonitis: a clinical study regarding etiology, clinical presentation and management strategies. International Surgery Journal.
4. Yadav D, Garg PK. Spectrum of perforation peritonitis in Delhi: 77 cases experience. Indian J Surg. 2013 Apr;75(2):133-7. doi: 10.1007/s12262-012-0609-2. Epub 2012 Jun 20. PMID: 24426408; PMCID: PMC3644151.
5. Chakrabarti, Suvadip, et al. "Spectrum of perforative peritonitis in Navi Mumbai: Analysis of 100 cases." Indian Journal of Basic and Applied Medical Research 3.4 (2014): 122-9.
6. Bali RS, Verma S, Agarwal PN, Singh R, Talwar N. Perforation peritonitis and the developing world. ISRN Surg. 2014 Apr 2;2014:105492. doi: 10.1155/2014/105492. PMID: 25006512; PMCID: PMC4004134.
7. Mabewa A, Seni J, Chalya PL, Mshana SE, Gilyoma JM. Etiology, treatment outcome and prognostic factors among patients with secondary peritonitis at Bugando Medical Centre, Mwanza, Tanzania. World J Emerg Surg. 2015 Oct 6;10:47. doi: 10.1186/s13017-015-0042-5. PMID: 26448784; PMCID: PMC4595331.
8. Rosenberg D. Evolução do tratamento cirúrgico da úlcera duodenal [Evolution of the surgical treatment of duodenal ulcer]. Rev Hosp Clin Fac Med Sao Paulo. 1980 Oct;35(5):247-54. Portuguese. PMID: 7015460.
9. Neeraj Kumar Jain et al. A study of clinical profile and management of perforation peritonitis in a tertiary health centre located in Central India. International Science Journal. 2017;4(3):March 2017. https://doi.org/10.18203/2349-2902.isj20170847
10. Bansal, J., Jenaw, R.K., Rao, J. et al. Effectiveness of plain radiography in diagnosing hollow viscus perforation: study of 1,723 patients of perforation peritonitis. Emerg Radiol 19, 115–119 (2012). https://doi.org/10.1007/s10140-011-1007-y
11. Beaumont W. Nutrition classics. Experiments and Observations on the Gastric Juice, and the Physiology of Digestion. By William Beaumont, Plattsburgh. Printed by F. P. Allen. 1833
12. Modlin IM, Kidd M, Marks IN, Tang LH. The pivotal role of John S. Edkins in the discovery of gastrin. World J Surg. 1997;21(2):226-234.
13. Yeo, C. J. (Ed.). Shackelford’s surgery of the alimentary tract (7th ed.). Philadelphia, PA: Elsevier/Saunders; 2013.
14. Herrington JL Jr. Gastroduodenal ulcer. Overview of 150 papers presented before the Southern Surgical Association 1888-1986. Ann Surg. 1988;207:754-769.
15. Coppolino F, Gatta G, Di Grezia G, Reginelli A, Iacobellis F, Vallone G, Giganti M, Genovese E. Gastrointestinal perforation: ultrasonographic diagnosis. Crit Ultrasound J. 2013 Jul 15;5 Suppl 1(Suppl 1):S4. doi: 10.1186/2036-7902-5-S1-S4. PMID: 23902744; PMCID: PMC3711723.
16. Modlin IM, Darr U. The centenary of Lester Dragstedt—fifty years of therapeutic vagotomy. Yale J Biol Med. 1994;67(3-4):63-80.
17. Rauws EA, Tytgat GN. Cure of duodenal ulcer associated with eradication of Helicobacter pylori. Lancet. 1990;335(8700):1233-1235.