Acute generalized peritonitis from gastrointestinal hollow viscus perforation is a potentially life-threatening condition. It is a common surgical emergency in many general surgical units in the developing countries and it is often associated with high morbidity and mortality.^1,2 Despite the surgical treatment, sophisticated intensive care units, last generation antibiotics and a better understanding of pathophysiology, the mortality rate of perforation peritonitis is still high. Early prognostic evaluation of peritonitis is desirable to select high risk patients for more aggressive therapeutic procedure such as radical debridement, lavage, open management and planned laparotomy. Scoring systems have been advocated as prognostic predictors, they reduce all the clinical problems including lots of variables to a simple number.³

Most studies have shown that among scoring system based on physiological parameters, the most reliable system is APACHE II (Acute Physiological and Chronic Health Evaluation) score.^4-5 APACHE - II introduced in 1985 was a simplified modification of original APACHE. The APACHE - II scores consisted of three parts – 12 acute physiological variables (0-60) points, Age (0-6) points, Chronic health status (0-5) points. The probability of death can be calculated from the individual APACHE - II total scores (0-71) points.^6-7

Keeping in view the above-mentioned facts, the present study was conducted to evaluate the prognostic value of APACHE II scoring system in cases of perforation peritonitis and to examine its usefulness in stratifying the patients according to their surgical risk.

The study was conducted in the Department of General Surgery, Pt. B.D. Sharma PGIMS, Rohtak.  The study population included 100 of cases of perforation peritonitis who underwent surgery after fulfilling the inclusion criteria over a period of one year. All patients of perforation peritonitis above 18 years and below 80 years were included in the study who underwent exploratory laparotomy.

Methodology

All patients presented to the hospital with clinical signs and symptoms like Abdominal distension with absent bowel sounds, generalized tenderness, rebound tenderness, guarding and board like rigidity were admitted. All patients after clinical examination were examined for various investigations viz. hematocrit, Leucocyte count (Total & Differential), Blood urea/serum creatinine, Serum electrolytes (Na+/K+), Arterial blood gas analysis, X ray chest PA view and Erect X ray abdomen.

After all investigations diagnosis of perforation peritonitis was made and patients were planned for exploratory laparotomy. APACHE II score was calculated for every patient before surgery. Post operative outcome like duration of hospital stay, duration of need for nasogastric tube aspiration, chest infection, wound infection, wound dehiscence, and mortality were noted and correlated with APACHE II scoring. Predicted risk of mortality was calculated according to APACHE II death equation. Observed death rate was compared with predicted death rate for the study group.

Statistical analysis

At the end of the study, the data was collected and analysed statistically. A p value of <0.05 was considered as significant.

Table 1: Age Distribution

Among 100 cases studied there were 85 males and 15 of the patients were females. Age ranged from 18 years to 80 years with mean age of 37.04. In this study majority of the patients were in age group from 18 to 50 years (81%)

Table 2: Cause of Perforation Peritonitis

On basis of preoperative workup, operative findings and pathological findings patients were distributed according to their cause of perforation as per Table 2. Among 100 cases of perforation peritonitis 38.0% patients had enteric perforation, 30.0% patients had peptic perforation, 22.0% patients had tubercular perforation, 5.0% patients had perforation due to gangrenous bowel, 3.0% patients had appendicular perforation and 2.0% patients had colonic perforation.

Table 3: APACHE II Score

Patients were distributed into three subgroups depending upon their APACHE II score which was calculated for every patient at time of admission. Among 100 cases of perforation peritonitis 62.0% patients had APACHE II score between 0 to 6, 30.0% patients had APACHE II score between 7 to 12, 8.0% patients had APACHE II score between 13 to 18 and mean of APACHE II score was 6.40.

Table 4: APACHE II and any Complication

Complications after surgery in three subgroups of APACHE II score observed in Table 4.  In study 27.4% of the patients in the group APACHE II score 0 to 6  had complications, 86.7% patients in the group APACHE II score 7 to 12 had  complications and 100.0% of the patients in the group APACHE II score 13 to 18 had complication.

Table 5: APACHE II Score and ICU Admission

Patients in group APACHE II score 0 to 6 did not require ICU admission, 16.7% of the patients in  group APACHE II score 7 to 12 had ICU Admission, 87.5% of the patients in  group APACHE II score 13 to 18 had ICU Admission. Patients in the group APACHE II score 13 to 18 had the largest proportion of ICU Admission. 

Table 6: APACHE II Score and outcome

Outcome in 3 groups of patients is shown in table 6. All patients in the group of APACHE II score 0 to 6 were discharged, 93.3% of the patients in the group of APACHE II score 7-12 were discharged while 6.7% of the patients were expired. All of the patients in the group of APACHE II score 13 to 18 expired.

Perforation peritonitis was more common in the age group of 18-30 years (52%). It was more common in males (85%). Byalpudi  et al and Singh S et al in their studies also reported male preponderance  of 78% and 77% in cases with perforation peritonitis  respectively.^7,8 The leading cause of perforation peritonitis was enteric perforation (38%), followed by peptic perforation (30%) and tubercular perforation Study conducted by Agarwal A et al showed that peptic perforation (39%) was most common cause of perforation in their study followed by tubercular perforation (24%).⁹ Maximum number of patients (62%) were in low risk group (APACHE II score of 0- 6), 30% patients were in the medium risk group (APACHE score 7-12) and 8% patients were in high risk group (APACHE score 13- 18) mean APACHE II score in our study was 6.4.  Similar findings were noted by Singh et al in their study. Mean APACHE II score in their study was 8.7 and 71% patients were in low APACHE II score.¹⁰

APACHE II score correlated well with the outcome in current study, 62 patients in low risk group were discharged in satisfactory condition and out of 30 patients in medium risk group 28 were discharged and 2 patients expired and out of 8 patients in high risk group all 8 patients  expired. In study conducted by Agarwal et al, 100% patients in low risk group and 95.8% patients in medium risk group were discharged in satisfactory manner and 100% patients expired in high risk group which is similar to our study.9 There are other studies also in which mortality rate was 100% in patients having APACHE II score more than 20.^11-13

Out of 100 patients admitted during the study period there were 90 (90%) survivors and 10(10%) were non survivors. Mean APACHE II score in survivors was 5.5 while in non survivors mean APACHE II score was 14.4. Systemic complications were found in 12% in survivors while in non survivors it was in 100% patients. In study conducted by Srikanth et al, the mean APACHE II score in survivors was 9.88 whereas in non survivors 19.25.¹⁴ This concludes that mortality is directly related to high APACHE II Score.

Present study concluded that the APACHE II score can be used to predict the outcome of patients who presents with hollow viscus perforation. Patients with an APACHE II score of more than 14 have very high risk of mortality postoperatively and those who have a score of less than 10 are at risk of developing systemic complications. In addition, the APACHE II score can also correlate with the hospital and ICU stay. We recommend further studies with a large sample size to be conducted to report results with much higher clarity.

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