Perforation peritonitis: A case report

A. Mahalakshmi

Physician Assistant, Kauvery Hospital, Cantonment, Trichy

Abstract

Background

Perforation peritonitis, resulting from gastrointestinal perforation, is a common surgical emergency in India. This study aims to comprehend the spectrum of perforation peritonitis concerning etiology, clinical presentation, site of perforation, surgical treatment, postoperative complications, and mortality encountered at the hospital. The most common cause of perforation peritonitis is acid peptic disease, followed by appendicular, enteric, traumatic, and tubular perforation. Upper gastrointestinal perforation remains the leading cause, contrasting with the Western world where lower gastrointestinal perforations are more prevalent. Additionally, a significant number of traumatic perforations are attributed to the increase in high-speed motor vehicle accident cases in the last few decades. This report details a case of perforation peritonitis in a 22-year-old male successfully managed surgically with no postoperative complications.

Definition

Perforation peritonitis stands as one of the most common surgical emergencies in India, despite advancements in surgical techniques, postoperative care, antibiotic and antimicrobial therapy, and intensive care support. Perforation, defined as an abnormal opening in a hollow organ or viscus, originates from the Latin perforatus, meaning to bore through. The signs and symptoms of almost all cases of perforation peritonitis are typical, and clinical diagnosis can be confirmed in all patients through chest and abdomen X-rays, whole abdomen ultrasound, and CT scans. Peritonitis typically presents as an acute abdomen, with local findings including generalized abdominal tenderness, rigidity, abdominal distension, and decreased bowel sounds. Systemic findings encompass fever with chills or rigor, restlessness, tachycardia, tachypnea, dehydration, oliguria, disorientation, and shock.Prognostic factors include age, vitals, metabolic acidosis, and malnutrition, personal habits such as smoking, alcoholism, and drug abuse. Left untreated, perforation can lead to rapid spread of peritonitis into the blood and other organs, resulting in multiple organ failure.

Case Presentation

A 22-year-old male patient presented with a sudden onset of abdominal pain, initially located in the periumbilical region and later becoming diffuse and continuous. The patient also reported one episode of vomiting, with no history of fever or loose stools, and no constipation.

Past History: No significant past medical or surgical history.

 

Personal history

Diet – Soft diet

Sleep – Normal

Bowel/Bladder – Normal

On Examination

Conscious, oriented and Afebrile

Cardiovascular System (CVS) – S1 S2 +

Respiratory System (R/S) – Bilateral air entry Equal

Abdomen (P/A) – Soft

Diffuse abdominal tenderness and rigidity, absent bowel sounds

Central Nervous System (CNS) – Neurologically intact, no focal neurological deficits.

Lab Investigations

Hb – 13.7 g/dl

PCV – 39.7 g/dl

TC – 9900 cells/mm3

Platelet – 248000 cells/mm3

Microbiology

  • Peritoneal fluid: Few pus cells and no bacteria.

USG Abdomen and Pelvis

  • Minimal free fluid abdomen with pneumoperitonium.
  • Small midline prostatic cyst.

Chest X-ray

USG-Abdom-1
USG-Abdom-2
  1. Normal Abdominal erect X-ray: Perforation in pylorus of the stomach abdomen and pelvis.
  2. Ultrasound: Minimal free fluid in the abdomen with suspected pneumoperitoneum and hollow viscus perforation.

Management

Planned emergency laparotomy and Cellan-Jones repair (omental patch). The patient underwent the procedure under general anesthesia and epidural anesthesia, with an upper midline incision. Omental patch repair was performed using 3.0 PDS, and saline wash was administered. The repair was checked for air leaks, hemostasis was achieved, and the abdominal closure included loop Ethicon for rectum closure and skin clips. The patient received antibiotics and anti-inflammatory drugs for one week postoperatively. Satisfactory healing occurred without any complications.

Discussion

  1. Perforation peritonitis stands out as one of the most common surgical emergencies, frequently observed in the younger age group, particularly in tropical countries.
  2. Site of Perforation: Duodenal pre-pyloric (gastric), small bowel Appendicular Colon.
  3. Etiology of Perforation: Acid peptic disease, Appendicular, Enteric, Traumatic, Tubercular Strangulation.

Complications

Wound infection, Respiratory complications, Dyselectrolytemia, Abdominal collection Leak.

Conclusion

Perforated peritonitis primarily affects young and middle-aged adults, with a higher incidence in males than females. Predisposing factors, such as trauma, tobacco chewing, smoking, alcohol consumption, and the use of analgesics, contribute to the development of perforated peritonitis. The inability of patients to receive proper and comprehensive treatment is a significant factor responsible for perforation. This discussion reflects a successful surgical intervention in a young male patient with perforated peritonitis.

Mahalakshmi-jr

A. Mahalakshmi

Physician Assistant

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