The term peritonitis stands for “the inflammation of the peritoneum”. Peritonitis can be of 3 types: “primary, secondary, and tertiary peritonitis”. Primary peritonitis is “a diffuse bacterial infection (usually caused by a single organism) without loss of integrity of the gastrointestinal tract.” These patients are usually managed in medicine department [1]. Secondary peritonitis is acute condition due to infection of peritoneum as a result of perforation in the gastrointestinal tract. It is one of the most prevalent forms of peritonitis. Despite development of sophisticated diagnostic and therapeutic methods, it is often linked to high morbidity and mortality [2]. Tertiary peritonitis is termed recurrence of intra-peritoneal infection which occurs after 48 hours of apparently adequate and successful surgery to regulate secondary peritonitis.

The inappropriate or delayed initial management of cases with peritonitis has led to high mortality throughout the world. Even in modern tertiary care emergency center, mortality rate of up to 40 percent were observed in patients who have developed sepsis and septic shock [3].

For betterment of large population, a low-cost and feasible technique to rapidly identify patients needed Intensive care is very important. Scores of warning system based on physiological, simple-to-measure criteria, including degree of awareness, non-invasive blood pressure, rate of respiration, body temperature, rate of pulse, and oxygen saturation, should be evaluated.

Various scoring systems like MPI (“Mannheim Peritonitis Index”) [4], The WSESSSS (“World Society of Emergency Surgery Sepsis Severity Score”) [5], PIRO-IAS (“Predisposition, Infection Response Organ Dysfunction Score for Intra-Abdominal Sepsis”) [6], are used to prognosticate different patients of peritonitis. Most of these instruments are not exclusively pre-operative or bedside, and several need lab values which are difficult to obtain in resource-crunched centers. Thus, they have limited function in early pre-operative risk stratification and Making therapeutic decisions for a patient having peritonitis. Instead, they have been found to have good roles in intensive care units, research, and surgical audits

 A new and easy scoring system known as PIPAS (“Physiologic Indicators for Prognosis in Abdominal Sepsis-score severity score”), was designed by WSES (“The world society of emergency surgery”) in 2019, which is used for early bedside prognostication for peritonitis mortality. This scoring system includes eight variables obtained from a physical evaluation and history. Every variable is assigned a score of zero or one, with highest score of eight; higher the score, poor would be the outcome. Sartelli along with colleagues discovered that score of PIPAS severity accurately predicted mortality from peritonitis in a predominantly European group [7].

The PIPAS Severity Score, taking physiological parameters easily identifiable, immediately allows healthcare personels to evaluate the severity and start aggressive management. This scoring system is particularly useful for individuals doing work in “low- and middle-income” nations since imaging for diagnosis is frequently incapable of accommodating population size and in some cases completely absent in primary care settings [8].

qSOFA is substitute for SOFA and allocates 1 point for all three parameters: “Glasgow coma scale<15, respiratory rate≥22 breaths per min, and systolic blood pressure<100mmHg”.  Based on 3rd international consensus definitions of sepsis as well as septic shock that all may be a secondary peritonitis sequela, SOFA score of ≥ 2 is related to a mortality rate higher than 10%. This has been based to stratify qSOFA, that is utilized in bedside evaluation of the patients having infection and are hazard for unfavourable outcomes outside of the ICU, in two groups: < 2 was low risk & ≥ 2 was high risk [9].

Both qSOFA criteria & PIPAS severity score devices are simple to use, can be performed at the bedside, and primarily use pre-operative parameters, making them potentially valuable for early prognostic estimation of peritonitis due to perforation. However, predictive capacity of these tools as mortality indicators of peritonitis in our situation has to be evaluated and compared yet [10].

This study examined 162 cases of peritonitis patients who sought surgical treatment in emergency of General Surgery department of a Northern Indian tertiary care centre from April 2024 - December 2024.

Inclusion criteria were patients who were above 18 years of age, patients having peritonitis due to perforation of gut, and patients giving informed written consent for operation.

Exclusion criteria were patients who were less than 18 years, peritonitis developed due to causes other than perforation, patients operated outside our centre, patients having previous history of abdominal surgeries, cases of iatrogenic perforations and patient not giving informed operative consents.

The purpose of this study was to ascertain whether PIPAS severity score is more precise compared to qSOFA at predicting unfavourable peritonitis outcomes in patients. Each case was evaluated pre-operatively at the time of admission for PIPAS severity & qSOFA score, and all cases has been monitored intra- and post-operatively until discharge from hospital, or a maximum of thirty days if the patient's stay in hospital was lengthy;

The major result of interest has been mortality associated with peritonitis. Other objectives were to predict requirement of intensive care, hospital stay, and other morbidities.

The following information was recorded: gender and age of each and every patients; existence of co-morbidities which included cardiac diseases, renal disease, existence of any malignancy.

At admission, the following clinical findings were noted: abdominal outcomes (diffuse or localized abdominal pain, and rigidity); core temperature (fever greater than 38.0°C, hypothermia who were having core temperature less than 36.0°C), rate of respiration (breaths/min); brachial blood pressure (mmHg); pulse rate (bpm); and level of consicousness by AVPU (“Alert/Verbal/Painful/Unresponsive”) response scale and by Glasgow Coma Scale(GCS) also. These laboratory investigations were also sent and gathered: Platelet count (cells/ mm3), WBC (cells/mm3), and blood oxygen saturation level percent (SpO2) in air. All patients had chest X-ray and abdominal X-rays done. Arterial Blood Gas analysis was also done.

The term "case of peritonitis" refers to set of clinical signs & symptoms (abdominal guarding, discomfort, and rigidity with imaging findings) suggestive of peritonitis that has been confirmed operatively by the surgeon.

All study participants initially were treated according to our hospital’s initial resuscitation guidelines for gut perforation which were, vital monitoring, input output charting, correction of hydration status and electrolyte deficits by intravenous fluid infusion, ryle’s tube decompression, foley’s catheterization, along with intravenous broad-spectrum antibiotics within one hour of admission. Scores were taken before the initial resuscitation at the time of admission.

All the patients underwent midline exploratory laparotomies under general anesthesia, done by Senior residents of the department of General Surgery assisted by third year junior residents seeking guidance from consultants.

STATISTICAL ANALYSIS

The presentation of the Categorical variables was done in the form of number and percentage (%). On the other hand, the quantitative data were presented as the means ± SD and as median with 25th and 75th percentiles (interquartile range). Receiver operating characteristic curve was used to calculate cut off point, specificity sensitivity, positive predictive value and negative predictive value of total PIPAS score, total qSOFA score for prediction of mortality.

The data was entered in the Microsoft EXCEL spreadsheet and the final analysis was done using the Statistical Package for Social Sciences (SPSS) software, IBM manufacturer, Chicago, USA, ver 25.0.

For statistical significance, p value of less than 0.05 was considered statistically significant

In our study 129(79.63%) patients were males and 33(20.37%) females. The average age of research participants was 39.33 ± 16.2, and the median age (25th-75th percentile) was 35. (27-51.75). [Table-1] [Figure-1]

Table 1:- Demographic characteristics distribution.

Outcomes observed in the study showed that 140(86.42%) cases were discharged, 22(13.58%) cases expired, 14 were males and 8 were females. 43 patients required Intensive Care Unit (ICU).  The average number of days that research participants spent in the hospital was 10.27 ± 3.59, with a median (25th-75th percentile) of 9 days (8-12).[Table-2].

Table 2:- Outcome and Other Important Variables

ROC curves that are above the diagonal line are thought to have a respectable capacity to forecast death. The total PIPAS severity score's discriminatory power (AUC 0.748; 95 percent CI: 0.674 - 0.813) was satisfactory. [Figure-2]. However, the total qSOFA score's discriminating power (AUC 0.612; 95 percent CI: 0.533 to 0.688) was insignificant [Figure-3].

Mean value of total PIPAS severity score, total qSOFA score of study subjects was 2.65 ± 0.9 and1.93 ± 0.95 with median(25th-75th percentile) of 3(2-3)and  2(1-3)[Table-3]

Table 3: -Receiver operating characteristic curve of Total PIPAS severity score, Total qSOFA score for predicting mortality.

Among both the parameters, Total PIPAS severity score was good predictor of mortality at > 3 cut-off point having area under curve of 0.748 for correctly predicting mortality. Total qSOFA score had sensitivity of 77.27%, and total PIPAS severity score had sensitivity of 50.00%

In prediction of mortality, Total PIPAS severity score had lowest sensitivity of 50.00 percent. The specificity of the overall PIPAS severity score was 88.57 percent, whereas the specificity of the entire qSOFA score was 39.29 percent. In prediction of mortality, Total qSOFA score had less specificity at 39.29%.

Highest negative and positive predictive value has been noted in total PIPAS severity score (40.70% and 91.90% respectively). There is mostly a inverse relation between specificity and sensitivity (increase in sensitivity usually have decrease in specificity), so we selected the variable whose combination of specificity and sensitivity provides the greatest predictive value, i.e. the greatest area under the curve, so the total PIPAS severity score was good predictor of mortality.[Table-3]

Table 3: -Receiver operating characteristic curve of Total PIPAS severity score, Total qSOFA score for predicting mortality.

This analysis investigated the prognostic capacity of 2 bedside measures (qSOFA criteria & PIPAS severity score) to detect mortality due to peritonitis caused by perforation of a hollow viscus organ in real-time clinical scenario of tertiary surgical facility in a developing nation. We would like to point out that the effective implementation of these 2 technologies in our research demonstrates that they are both practically applicable and usable even in low-resource environments [10,11].

The mortality rate (13.8%) in current study of patients with perforational peritonitis is within 10 to 20 percent range of peritonitis mortality commonly stated in Indian region but it is still greater compared to that of notified in European and developed countries [12]. This is most likely due to differences in quality of health care system and the early availability of quality health care.

We discovered that PIPAS severity score was considerably good discriminative power for in-hospital peritonitis mortality on comparison with qSOFA score instrument.

This is the 1st time that these methods were compared; although, comparison of trends in discriminative ability of instruments for gut perforation mortality were noted in few non-comparative investigations. The AUC of PIPAS severity score device for predicting death in large cohort of peritonitis patients was 0.85, according to the findings of Sartelli and colleagues. Our research showed similar results with discriminatory power of total PIPAS severity score (AUC 0.748; 95 percent CI: 0.674 - 0.813) was acceptable.

Other studies evaluating the prediction ability of numerous scoring systems for peritonitis mortality showed that “qSOFA has fair discriminative ability” (AUC 0.723), and obtained that total qSOFA score has discriminatory power (AUC 0.612; 95 percent  CI: 0.533 to 0.688). 

The advantage of PIPAS score instrument over qSOFA in regard to discriminative ability and specificity in predicting peritonitis-related mortality makes previous instrument the preferable early prognostic screening instrument for peritonitis.

LIMITATIONS

The research had few drawbacks. It was once a unicentric observational study. The examined individuals may be sicker and have poorer results as a result of delays caused by multiple referral levels. Therefore, the result may / may not apply to basic levels of surgical emergency centers. Second, we utilized the PIPAS Severity score & qSOFA score, which had been generated pre-operatively for a single time, to predict mortality in analysis. Serial evaluations, particularly during postoperative period, will have provided additional information, such as mortality attributed to post-operative problems.

In our study, the mortality rate of patients of perforation peritonitis was more. PIPAS severity score tool demonstrated greater ability to predict in-patient mortality on comparison to qSOFA score tool. The PIPAS score of two or more cut-off values was having greater specificity compared to qSOFA criteria while latter has high sensitivity.

We advise using PIPAS severity score tool, either by itself or in conjunction to qSOFA criteria, as earlier prognostic tool in peritonitis cases to forecast death in the emergency.

1. Sartelli, M., Catena, F., Abu-Zidan, F.M. et al. Management of intra-abdominal infections: recommendations by the WSES 2016 consensus conference. World J Emerg Surg 12, 22 (2017). https://doi.org/10.1186/s13017-017-0132-7
2. Sartelli, M., Catena, F., Di Saverio, S. et al. Current concept of abdominal sepsis: WSES position paper. World J Emerg Surg 9, 22 (2014). https://doi.org/10.1186/1749-7922-9-22
3. Martin-Loeches I, Timsit JF, Leone M. et al Clinical controversies in abdominal sepsis. Insights for critical care settings. J Crit Care. 2019 Oct;53:53-58. doi: 10.1016/j.jcrc.2019.05.023. Epub 2019 Jun 3. PMID: 31195156.
4. Linder MM, Wacha H, Feldmann U, et al Der Mannheimer Peritonitis-Index. Ein Instrument zur intraoperative Prognose der Peritonitis [The Mannheim peritonitis index. An instrument for the intraoperative prognosis of peritonitis]. Chirurg. 1987 Feb;58(2):84-92. German. PMID: 3568820.
5. Sartelli M, Abu-Zidan FM, Catena F, et al. Global validation of the WSES Sepsis Severity Score for patients with complicated intra-abdominal infections: a prospective multicentre study (WISS Study). World J Emerg Surg. 2015;10:61. https://doi.org/10.1186/s13017-015-0055-0 Epub 2015/12/18.
6. Posadas-Calleja JG, Stelfox HT, Ferland A, et al. Derivation of a PIRO Score for Prediction of Mortality in Surgical Patients With Intra-Abdominal Sepsis. Am J CritCare.2018;27(4):28794. https://doi.org/10.4037/ajcc2018576 Epub 2018/07/03.
7. Sartelli M, Abu-Zidan FM, Labricciosa FM, et al. Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) Study: a WSES observational study. World J Emerg Surg. 2019;14:34. https://doi.org/10.1186/s13017-019-0253-2 Epub 2019/07/26.
8. Moons KG, Harrell FE, Steyerberg EW. Should scoring rules be based on odds ratios or regression coefficients? J Clin Epidemiol. 2002;55:1054–5
9. Koch, C., Edinger, F., Fischer, T. et al. Comparison of qSOFA score, SOFA score, and SIRS criteria for the prediction of infection and mortality among surgical intermediate and intensive care patients. World J Emerg Surg 15, 63 (2020). https://doi.org/10.1186/s13017-020-00343-y
10. Goulden R, Hoyle MC, Monis J, et al. qSOFA, SIRS and NEWS for predicting in hospital mortality and ICU admission in emergency admissions treated as sepsis. Emerg Med J. 2018;35(6):345–9. https://doi.org/10.1136/emermed-2017-207120 Epub 2018/02/23.
11. Jiang J, Yang J, Mei J, Jin Y. Head-to-head comparison of qSOFA and SIRS criteria in predicting the mortality of infected patients in the emergency department: a meta-analysis. Scand J Trauma Resusc Emerg Med. 2018;26(1):56. https://doi.org/10.1186/s13049-018-0527-9 Epub 2018/07/13.
12. Sartelli, M., Catena, F., Ansaloni, L. et al. Complicated intra-abdominal infections in Europe: a comprehensive review of the CIAO study. World J Emerg Surg 7, 36 (2012). https://doi.org/10.1186/1749-7922-7-36