This study outlines the percentage of acute secondary peritonitis patients, distribution of acute secondary peritonitis by age, sex, etiology, symptoms, outcomes of surgically managed, casual factors and reason of delayed referral of patients at Herat Regional Hospital at 2018–2019.
In our study, the maximum incidence of peritonitis was found to be between the age of 10–19 years accounting for 32.25%, followed by 20–29 years (23.99%), in 30–39 years (12.11%) and the least age was between 70–80 about 2.62%. In a study by Raj Kumar et al in India 23.53% patients were in age group 21–30 years, 13.73% patients in age-group of 31–40 years and 1.96% patients in age group of 71–80 years [11]. In another study by Varun Raju Thirumalagiri, 30% patients were between 20–29 years, 6% patients between 30–39, 14% patients between 40–50 years old [7]. In another study conducted by Raj Kumar et al in a tertiary care hospital 54.25% patients were in age group of 21–50 years old [12]. Our research is equal to Raj Kumar and Thirumalagiri researches in the 2nd, 3th and 7th decades of live. Our research showed that 56.24% of patients are in the 2nd and third decades of life which is the age of working, education and reproduction.
In our study among 496 patients 58% were male and 42% were female. In study of Raj Kumar et al 86.26% of the patients were male and 13.73% were female and male to female ratio was 6.26:1 [11]. In another study by M.R. Shanker et al 76% of patients were male and 24% females and a male to female ratio was 2.84:1 [13]. In another study by Shahida Parveen Afridi et al 68.3% of patients were male and 31.7% were female with the ration of 2.1:1 [14]. Our findings in the term of sex are different from researches by Afridi, Raj and Shanker. This difference is because Herat Regional Hospital is the only tertiary and referral hospital in West Region of Afghanistan which accepts all critical patients. On the other hand, as mentioned before Herat Regional Hospital is accepting all kinds of patients even gynecological patients.
2.8% of emergency operations in our hospital in the department of general surgery were for peritonitis. This finding is not comparable with many other studies. M. R. Shanker et al, in India in 2018 reported an incidence rate of 26% [13]. Arveen et al in a study from 2006–2008 at JIPMER reported an incidence rate of 25% [15]. This big difference might be because Herat Regional Hospital accepts all kinds of patients including routine and trauma, on the other hand we excluded trauma peritonitis from our research so this may have significant impact on the incidence.
In our study we observed that the most common etiology of acute secondary peritonitis was acute appendicitis (64.51%), small bowel perforation (9.7%), peptic ulcer perforation (8.50%), colonic perforation (3.22%). The researches by others are summarized at the following chart:
Table 5
Casual factors
|
Our research
|
Raj kumar et al 12
|
Jonathan Sameul et al 16
|
Atul Kumar Vyas et al 17
|
Shanker et al 18
|
Ohene-Yeboah M 21
|
Acute appendicitis
|
64.51%
|
9.80%
|
22%
|
18%
|
44%
|
43.1%
|
Peptic ulcer perforation
|
8.50%
|
77.13%
|
11%
|
57%
|
36%
|
12%
|
Small bowel perforation
|
9.7%
|
7.84%
|
11%
|
13%
|
--
|
10.50%
|
Colonic perforation
|
3.22%
|
--
|
--
|
--
|
--
|
---
|
According to our findings the most cause of peritonitis is acute appendicitis (64.51%). Our results are consistent with western experience [20], Shanker (44%) and Ohene-Yeboa (43.1%) however some series from India have shown different results Vyas (18%) and Kumar (9.8%). This difference clarifies that the number of peritonitis due to acute appendicitis is still high in Afghanistan. In a study by varun Raju Thirumalagiri et al [7] and Rajender Singh Jhobta [19] colonic perforation stands 4%, while in our research is 3.22%, which is approximately the same as others. As you see the table above in the field of small bowel perforation, our research is the same as others. Peptic ulcer perforation in our research is the same with the researches by Jonathan Sameul et al and Ohene-Yeboah et al but there is still big difference with Raj Kumar and Atul Kumar researches which might be that in Raj Kumar and Atul Kumar the number of studied patients are less, on the other hand perforation of peptic ulcer is one of the most cases of general peritonitis in India [27].
The mortality rate in our study was 3.03% while it was 8% in the study by Thirumalagiri VR [7], 10% in study by Jhobta [19] and 8.82% in study of SK. Doklestic[22]. In fact, our research is almost the same as above researches in the incidence of mortality because we referred our critical patients (6.85% ) to other centers and we don’t know about their results.
Our research regarding the frequency of symptoms are with the following: 97% abdominal pain, 81% nausea and vomiting, 51% constipation and obstipation, 21.50% abdominal distention and 10.50% fever. Other researches regarding the symptoms are as follow:
Table 6
Frequency of symptoms
|
Our research
|
M.R. Shanker et al 18
|
Raj Kumar et al 12
|
Atul Kumar Vyas 17
|
Sivaram et al 23
|
Abdominal pain
|
97%
|
100%
|
100%
|
100%
|
100%
|
Nausea/vomiting
|
81%
|
--
|
--
|
64%
|
55%
|
Constipation
|
51%
|
48%
|
--
|
84%
|
--
|
Abdominal distention
|
21.5%
|
52%
|
86.27%
|
88%
|
44%
|
fever
|
10.5%
|
--
|
33.99%
|
34%
|
25%
|
As seen in above table, abdominal pain, constipation and vomiting are almost the same in our research with other researches. In our research abdominal distention and fever has big difference with researches by Raj Kumar and Atul Kumar. The difference might be due to a long gap between the beginning of symptoms and coming to hospital and we also have some uncommon peritonitis like peritonitis due to uterus, ovarian cyst, spleen, liver tumor and many more
In our research, there was a significant gap from onset of symptoms to the surgery time. From 496 patients 75.21% had a delay of more than 24 hours from the onset of the first complaint to laparotomy. The highest number of patients with 23.18% had delays for 3 days and even some patients has symptoms for 4 to 8 weeks (1.81%). A research by Atul Kumar Vyas et al [17] showed that 64% of patients presented at variable times beyond 24 hours from onset of symptoms. Kotiso et al. noted 25% mortality rate in patients with symptoms over 2 days in compare to 7.6% less than 2 days [24]. In a research by Ranju Singh et al among 84 patients 100% who died had symptoms more than 3 days [26]. Timing of presentation over 24 hours was found to be a significant factor in developing of post-operative mortality and morbidity [25].