Evaluation of cases of hollow viscus perforation

INTRODUCTION: Hollow viscus perforation is defined as the perforation of any hollow viscus in a patient who presents with acute abdomen with the presence of extra luminal air radiologically. The Causes of hollow viscus perforation includes peptic ulcer disease, perforation of a gastrointestinal neoplasm [benign or malignant], acute appendicitis with perforation, and acute colonic or small bowel diverticulitis, including Meckel’s diverticulitis. Some rare causes may include iatrogenic perforations caused by endoscopes or catheters, or spontaneous rupture of the distal esophagus (Boerhaave's syndrome), and foreign body ingestion as well as ischemia leading on to loss of bowel wall integrity. In my study, I have statistically analysed the incidence of hollow viscus perforation at different sites in GIT (excluding appendicular perforation) and to know about the various etiological factors, size of perforation and the other associated pathologies of various causes in Chengalpattu government hospital in the period of October 2010 - October 2012. AIMS OF THE STUDY: To statistically analyse the incidence of the perforation at different sites of Gastrointestinal Tract and their Etiologies. To know the site, size of the perforation and the surrounding in duration and the associated pathology intraoperatively. OBJECTIVES: 1. To study etiological factors of perforation like a. Traumatic (blunt), b. Non-traumatic that is due to Peptic ulcer disease, Infections (typhoid fever, tuberculosis), Neoplasms and other, Rare causes. 2. The relationship of smoking and alcohol with acid peptic disease. 3. To study about the site, size and presentation (acute or chronic) of various hollow viscus perforation. 4. To find out the commonest type of perforation in our set up and etiological factors for the same. 5. To study the various mode of complications. MATERIALS AND METHODS: The patients who are taken up for study are analysed from their case details from the medical registry and the details of the patient and their clinical details are analysed. Among the 166 patients taken up for study, they are prospectively and retrospectively analysed and follow up were done and they are filed up to give the study regarding hollow viscus perforation. I have attached the proforma of the patients. METHODOLOGY: Patients satisfying the inclusion criteria and who gave consent are taken up for the study. A clinical history and appropriate investigations are done as mentioned in the proforma enclosed. Based on the risk factors and clinical manifestations, definite surgery or plan for conservative management will be decided. First all the patients and the details of their age and occupation and the place from they hailed are documented. The patients are asked for the details of the previous admission to the hospital for peptic ulcer or intake of antiulcerogenic drugs from the counter directly. If so details of the ulcer, duration of pain, aggravating and relieving factors are enquired and taken up for study. The history regarding the loss of weight and loss of appetite are asked to work up for tumour cases. Inclusion Criteria: Patients aged between 20 and 70 years admitted with 1. Obliteration of liver dullness. 2. Radiologically by free air under the right dome of diaphragm in x-ray abdomen erect view. Exclusion Criteria: 1. Patients aged below 20 years and above 70 years. 2. Patients with stab injury abdomen.\ud 3. Patients with appendicular perforation (diagnosed USG or intraoperatively). 4. Patients who did not give consent for the study. 5. Patients who on chronic treatment with NSAIDS, antiplatelet drugs and the steroids. CONCLUSION: There are various indices mentioned in literature to predict morbidity and mortality due to sepsis. We in our study conclude that the AGE OF THE PATIENT, GENDER STATUS, SMOKING, ALCOHOL CONSUMPTION and PREVIOUS HISTORY OF ACID PEPTIC DISEASE. are independent predictors of morbidity and mortality in patients with hollow viscus perforation. The mortality and morbidity can be best avoided by monitoring the patients perioperatively and to give high quality of care by anaesthesiologists for risk assessment of the cases and to give goal directed therapy. 1. The most frequent cause of Hollow viscus perforation encountered in my study was peptic ulcer perforations, which was observed in 64% of cases. 2. The highest incidence of bowel perforation (22 %) was observed in the age group 21 to 30 years, followed by 60-69 years (21 %). 3. Males were predominantly affected, with a male to female ratio of 5:1. 4. The mortality rate in my study was around 10 %. 5. The most important factor clearly deciding the fate of the patient is eliminating the source of infection. 6. The omental patch procedure was a simple and very effective method for closure of any size of perforations. Perforation of peptic ulcer was the most commonly encountered perforation (62 %), followed by small bowel perforations. 7. Gastric ulcer perforations carry higher mortality risk than duodenal ulcer patients. Irrespective of the etiologies, all gastric ulcer perforations should be sent for biopsy from the perforation edges. 8. Typhoid fever should be treated with appropriate antibiotics to prevent enteric perforation and if perforation occurs, there should not be any delay in surgical intervention. 9. Perforations due to tuberculosis are solitary or multiple and carry worst prognosis, so these patients should be subjected to resectional procedure of the involved segment. 10. Colonic perforations should be treated surgically by primary closure or two staged procedures depending up on the condition of the patient and fecal contamination of the peritoneal cavity