A Clinical study of Perforative Peritonitis

INTRODUCTION: Peritonitis is one of the most common surgical emergency encountered in day to day practice. Peritonitis is the inflammation of serous membrane called peritoneum that lines the peritoneal cavity either in response to injury or infection. It may be localized or generalized infection. Peritonitis is organized into three types based upon the source and nature of microbial contamination. Primary peritonitis or spontaneous bacterial peritonitis is an infection or inflammation of the peritoneal cavity without any hollow viscous perforation, usually from extra-peritoneal source due to ascites. Secondary peritonitis follows an intraperitoneal source usually following perforation of a hollow viscous organ in gasro intestinal tract. Tertiary peritonitis develops following inadequate treatment or failure of treatment of secondary peritonitis. Peritonitis due to perforation of hollow viscous (secondary peritonitis) is the most common type of Peritonitis. Despite advances in diagnosis, surgical technique, antimicrobial therapy and intensive care support, secondary peritonitis remains a potentially fatal surgical emergency which requires institution of timely treatment for the best possible outcome, if not it may result in severe bacterial Peritonitis leading to deadly complication ranging from toxaemia to circulatory collapse and death. OBJECTIVES OF OUR STUDY: 1. To study the relative incidence of peritonitis secondary to hollow viscus perforation in relation to Age, Sex, Anatomical location,Symptoms and signs, 2. To analyse various etiology of hollow viscous perforation leading to perforative peritonitis. 3. To analyse various management modalities and its out come in our Hospital. 4. To Review literature on various types of peritonitis. STUDY CRITERIA: INCLUSION CRITERIA: • Patient with past history of peptic ulcer disease with features of peritonitis. • Patient who presented with features of peritonitis either radiologically or clinically. • Patient who presented with features of peritonitis in whom peritoneal fluid culture was positive. • Patient with traumatic ( blunt or penetrating ) injury of the abdomen with the signs of hollow viscous perforation. EXCLUSION CRITERIA: • Patient with post operative peritonitis. • Patients with peritonitis due to entero cutaneous fistula • Patient with iatrogenic perforation during laparotomy or scopy. • Patient with oesophageal perforation, and peritonitis due to pancreatic pathology. • Perforative peritonitis in pediatric age group. CONCLUSION: A clinical study of perforative peritonitis ― it was concluded that • Most common age group affected by perforative peritonitis is 40 years and above. • Duodenal ulcer perforation due to peptic ulcer was the most common cause of perforative peritonitis • The advent of anti secretory drugs (H2 blockers ,proton pump inhibitors ) and effective antibiotics against H.Pylori has virtually eliminated the need for elective surgery for peptic ulcer disease. But still perforation due to peptic ulcer disease remains a major cause for emergency laparotomy which carries significant morbidity and mortality. • Reduction in time elapse between the onset symptoms and signs to presentation to the hospital and prompt resuscitation and early surgical intervention has marked impact on overall prognosis by reducing the morbidity and mortality to the patient. • Diagnosis of perforative peritonitis is purely clinical and minimal investigation is adequate for institution of definitive treatment. • Absence of liver dullness obliteration and pneumo peritoneum on plain radiograph of abdomen and chest does not rule out perforative peritonitis, since both of them were absent in many cases. • Laparotomy with closure of perforation with live omental patch is enough for peptic duodenal ulcer perforation and biopsy is rarely required since most of them are benign. • Peptic gastric ulcer perforation needed biopsy since most of them are malignant and it is treated by simple closure or with omental patch or resection. • Thorough peritoneal lavage is gold standard in management of perforative peritonitis. • Most important observation from our study is the increased incidence of post operative complication in our patient. mainly surgical site infection, which increases the morbidity and mean duration of hospital stay and monetary expense of the patient which needs to be addressed. • Patient education about appropriate medical management of peptic ulcer, enteric fever, tuberculosis, & avoiding the precipitating factors such as alcohol, smoking may reduce the incidence of perforative peritonitis