Peritonitis – Epidemiology and Management at A Rural Hospital in Zambia
Roan Antelope General Hospital
Correspondence to: Dr. Sergiy Karachentsev, P.O. Box 90297, Luanshya, Zambia. Phone: +260212515010. Fax: +260212671151. Email: firstname.lastname@example.org.
Background: Peritonitis is a common surgical emergency encountered the world over with varying etiologies. It is associated with significant morbidity and mortality despite intensive research and advances in management.
Objectives: To describe epidemiology of peritonitis in rural population of Zambia. To assess the role of a low-volume surgical hospital in the treatment of peritonitis.
Methods: The records of 119 patients operated on for peritonitis at a rural surgical hospital in Zambia over a 10-year period were retrospectively reviewed. The contributions of various causes of peritonitis to morbidity and mortality were analyzed.
Results: There were 73 males (61.4%) and 46 females (38.6%). The common sources of peritonitis were perforated peptic ulcer, acute appendicitis, pelvic inflammatory disease, and perforation of terminal ileum. Post-operative period became complicated in 42 patients (32.3%). Fourteen patients (11.8%) died post-operatively. The highest level of mortality was in patients with perforated peptic ulcer (26%). Organ failure was found in 29 patients (24.4%) and was associated with increased risk of death.
Conclusions: Individual approach with identification of signs of organ failure is essential to determine the patient’s prognosis and decide on the level of care. Patients without organ dysfunction could be successfully managed in rural surgical hospital.
Keywords: Peritonitis, epidemiology, morbidity, mortality, rural hospital, Zambia
Ann Afr Surg. ****; **(*):***
Conflicts of Interest: None
© 2020 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.
Peritonitis continues to generate debate in surgical community worldwide, as morbidity and mortality are still unacceptably high (1). This is especially true in a developing world setting with a huge burden of community-acquired urgent surgical conditions and a limited access to modern diagnostic and therapeutic facilities (2). Despite the importance, the problem of peritonitis remains far from resolved and some areas of the management have not been covered yet. First, the spectrum of the disease in developing nations is different from that found in the western world and could vary from country to country (3). There is a paucity of research on complicated intra-abdominal infection done in central and southern Africa. Second, studies originating from the developing countries produce data predominantly from the tertiary referral hospitals of metropolitan areas (4, 5). As a result, the rural population, which dominates in the developing countries, becomes under-represented in research with only isolated articles published (6, 7, 8). Third, and with connection to the above, the role of a rural surgeon in the management of peritonitis still remains unclear, even after publication of the Lancet Commission recommendations ‘Global Surgery 2030’ (9).
This study, therefore, aimed to evaluate etiology of peritonitis among the rural population of Zambia and to assess risk factors leading to lethal outcome. Findings obtained could be of some value for rural surgeons facing the dilemma of operating patients immediately or referring them to the tertiary center for further management. The author believes that both epidemiological and risk-related components of the study will help in decision-making and show the ways of reducing morbidity and mortality which was actually the ultimate goal of this work.
Materials and Methods
All patients with peritonitis admitted to Roan Antelope General Hospital, Zambia from 16th March 2009 to 24th of September 2019 were retrospectively identified from patient records. This is the second level referral hospital having a capacity of 350 beds and operating as the main medical center in the area with the population of around 200 000 people. Permission to conduct the study and to publish results was sought from the Hospital Ethical Committee and all data were kept confidential.
Out of total 128 patients, six patients who were referred out to continue treatment elsewhere and three patients with suspected peritonitis who died before the surgery started were excluded from the study. At the same time, three patients who were operated in other institutions and transferred to our hospital were included in the research.
Demographic data, length of the history, physiological parameters, laboratory values, diagnostic investigations, and outcomes were compiled from medical records. Positive abdominal findings included abdominal pain, rigidity of abdominal wall muscles and positive rebound sign. A patient was considered to have organ dysfunction presented with signs of altered mental status (agitation, somnolence, disorientation), systolic blood pressure < 100 mmHg, respiratory rate > 22/min, urine output < 20 ml/hr and laboratory findings of creatinine ≥177 μmol/L and urea ≥16.7 mmol/L. X-ray and ultrasonography (US) of the abdomen were done to aid in diagnosis as per requirement. Free gas in peritoneal cavity found on X-ray characteristically suggested perforated hollow viscus. Presence of distended bowel loops was an additional sign of secondary paralytic ileus. Positive findings on US-abdomen included free intraperitoneal fluid, absence of bowel activity, and dilation of bowel. Intravenous (IV) fluid resuscitation, administration of broad-spectrum antibiotics and nasogastric decompression started early on admission. Outcome data included morbidity and mortality related to the surgery within one month of the procedure.
The data were presented in frequency tables and percentages as well as graphical representation. Outcome related to different etiologies was compared. Continuous variables were expressed as mean ± standard deviation (SD) and median including ranges; categorical data were expressed as absolute figures and percentages. Statistical evaluation of data was performed by Student’s t test, Fisher’s exact test and one-way ANOVA test where appropriate. A p value of < .05 was considered as significant.
Out of 119 patients, 73 were men (61.4%) and 46 were women (38.6 %). Age ranged from 8 to 72 years, with the peak age incidence being in the 21-30 years age group. Age distribution with respect to gender and source of peritonitis is presented in figure 1 and table 1.
The main etiological factors of peritonitis and associated morbidity and mortality were perforated peptic ulcer and acute appendicitis (27 and 26 patients respectively) followed by pelvic inflammatory disease (22 patients), perforation of small bowel (16 cases), and abdominal trauma (9 patients) (table 1). Mean age differed across the groups, with youngest cohort appeared to be of abdominal trauma, while the oldest group was of perforated peptic ulcer. The difference in mean age between the groups was determined by one-way ANOVA test and found to be statistically significant (F5,113 = 5.95, p < .0005). Among nine patients with abdominal trauma, seven sustained blunt injury, while two victims were operated for penetrated stab wounds. Injuries to the small bowel were found in six patients, the stomach – in two, colon – in one, uterus – in one and the gallbladder in one patient. Two patients had combined traumas: stomach + small bowel and stomach + colon. Among other sources of peritonitis were as follows: intestinal obstruction (N = 6), acute pancreatitis (N = 3), spleen abscess (N = 2), acute perforated cholecystitis (N = 1), strangulated inguinal hernia (N = 1), acute mesenteric ischemia with necrosis of ileum (N = 1), perforated carcinoma of sigmoid colon (N = 1), inguinal lymphadenitis and pararectal abscess with formation of pelvic abscesses (N = 2). In two patients, laparotomy revealed primary peritonitis due to widespread abdominal tuberculosis and advanced tumor of ovarium. Risk factors for lethal outcome were determined using Mannheim peritonitis index (MPI) which was calculated for each patient (table 2).
Procedures were performed after pre-operative optimization of patients’ condition which started shortly after the primary survey in the Emergency Department. In cases of hemodynamic instability, patients were offered intensive IV resuscitation with repeated boluses of fluids and hourly control of urinary output.
All perforated peptic ulcers were located in the anterior wall of proximal duodenum or pre-pyloric area of the stomach (type III according to modified Johnson classification). The common operation was primary closure (N = 15). In 11 patients, omental pedicle flap was employed to secure the suture line. In one patient excision of peptic ulcer with pyloroplasty Heineke-Mikulitz was performed. Patients with perforated appendicitis were operated by the open procedure with lower midline laparotomy. Five appendectomies were also done as a part of other procedures. Patients with generalized peritonitis caused by pelvic inflammatory disease (PID) were managed by eliminating the source of the infection (resection of ovarium, oophorectomy, tubectomy) and copious wash-out with normal saline solution. Spontaneous perforations of small bowel were characteristically located within 90 cm of the terminal ileum. In 13 patients a single perforation was found, 2 patients presented with 2 and 3 perforations respectively. Simple suturing was the most frequently used treatment modality applied in spontaneous perforation as well as traumatic rupture of the small bowel. In cases of necrosis or dubious viability of the intestinal wall resection of the affected segment was performed. The list of the procedures is presented in table 3.
The three patients who underwent enterostomy as a first stage of the treatment, were subsequently operated two to six months thereafter to restore the continuity of the gastro- intestinal tract with ileocecal (N = 1) and colorectal anastomoses (N = 2). Post-operative period became complicated in 42 patients (32.3%). The most common complication was surgical wound infection (N = 22, 16.9%), followed by progressive peritonitis (N = 6, 4.7%). Among others, less frequent complications of respiratory infection (N = 2), entero-cutaneous fistula (N = 1), early post-operative intestinal obstruction (N = 1), and HIV-induced encephalopathy (N = 1) were recorded. Fourteen patients (11.8%) died.
This retrospective observational study characterized 119 episodes of community-acquired peritonitis in rural area in Zambia. The data obtained describe the main etiological factors for development of peritonitis and risk factors for post-operative death.
Peritonitis is commonly seen surgical emergency in African continent as well as in other countries (1, 2, 4). In this study, the principal etiological factors leading to the development of peritonitis were perforation of peptic ulcer (22.7%), acute appendicitis (21.9%), PID (18.5%) and spontaneous perforation of the small bowel (13.5%). These data reflect the results of literature review provided by Sanjay Gupta et al. (2006) with exception of PID (3).
PID is a common condition in developing countries. For example, in Zambia, 10% of outpatient attendance at health institutions is due to sexually transmitted infections (10). In case of ineffective treatment in local clinic, pelvic inflammation could rapidly lead to development of intra-abdominal sepsis with corresponding morbidity and mortality. By including this cohort in the study, the author aimed to demonstrate the real epidemiology of peritonitis among the rural population which comprises the majority of people living in this country. Most patients presented late to the hospital exhibiting signs of well-established peritonitis. Delayed presentation of acute surgical conditions is a well-known fact for surgeons working in the developing countries, and Zambia is not an exception to this rule (11). Delays in treatment of peritonitis is associated with increased morbidity and mortality in most of the research papers (12, 13). The length of the history of symptoms was different in cohorts of the patients, with the shortest being in abdominal trauma and the longest in perforated peptic ulcer. Factors associated with seeking care late investigated by Munyaneza M. et al. (2020) in a recent research performed in Rwanda (14). They included socio-demographic characteristics, cost of care and travel time. Another well-recognized factor of delayed presentation is late referral from the local clinic and district hospitals. In this study, only nine of the patients (7.6%) were admitted during the first 24 hours of the illness, and all of them survived. All the deceased patients were admitted with duration of the symptoms above 24 hours. This fact demonstrates the importance of timely admission and high predictive value of the medical history length for mortality.
Different scoring systems to assess severity and prognosis of peritonitis could be found in the literature (15, 16). Developed in 1987, MPI remains highly recommended (17). Because of its simplicity and high predictive value, it was used in the current study. The MPI ranged from 10 to 32 points with a mean of 22.1±5.2. The patients were divided in three groups: those with a MPI of < 21, those with MPI ranging from 21 to 27 and those with MPI > 27. MPI calculated for the patients who were successfully treated appeared to be significantly lower than the index defined for the patients who died (21.2±4.5, 95% CI 20.3–22.1and 29.9±2.4, 95% CI 28.6–31.2 respectively, p < .00001). All 62 patients with MPI of below 21 survived, while those with that of above 27 appeared to have a serious risk of mortality (nine patients died and six survived). In the cohort of 21 to 27 index chances of favorable outcome are quite high (37 patients were cured and 5 died). It is noteworthy that all deceased patients had MPI of 27 and above and thus this value could be considered as an important cut-off in assessment of individual prognosis for patients.
Organ dysfunction appears to be an important prognostic factor in peritonitis (12, 13). In this study, signs of organ failure were positive in 29 patients (24.4%) and these patients bore statistically significant increased risk of death when comparing with the patients without organ dysfunction. By contrast, other components of MPI like age over 50 years old, malignancy and the degree of spreading of the inflammatory process in the peritoneal cavity, were not statistically significant for the lethal outcome although demonstrated increased relative risk. These findings contradict data published by Sanjeev S. et al (2016), who have shown statistically significant relation of mortality with female gender, duration of the symptoms above 24 hours, and presence of feculent exudate (13). Here we should consider the following. Firstly, statistical power of the current study seems to be reduced by small size of the groups and presence of disproportionate pairs inside the groups. Secondly, among 16 patients aged 50 or more years, only 3 had co-existing medical conditions, namely arterial hypertension which was under medications control (American Society of Anesthesiologists grade II). Thus, absence of systemic medical co-morbidities plays a protective role here diminishing a value of increased age per se. Next, all nine patients who were admitted within the first 24 hours of disease survived. Therefore, short history has a clear clinical significance in reducing risk of death here. One should also recognize that with increasing duration of peritonitis the risk of organ dysfunction increases which was shown by one prospective study on enteric perforation peritonitis from India (2011) (15). The signs of impending or developed organ failure could be of especially high significance in low-resource rural environment in terms of defining the level of care. Those patients with suspicion on organ dysfunction should have a very low threshold of referring to the tertiary hospital for intensive care and operative treatment. On the other hand, patients with negative criteria for organ failure and MPI of no more than 27 could be safely stayed in the low-volume hospital for definitive surgical management. This practice could prevent development of life-threatening complications during the transfer, would relieve tertiary hospitals of their heavy surgical load, and will definitely contribute to maintenance of surgical expertise in surgeons working at rural hospitals. In this respect the current study advocate recommendations outlined by the Lancet commissions for Global surgery for the year 2030 in targets for access to timely essential surgery and surgical volume (9).
Surgery to control the intra-abdominal sepsis was performed early after intensive IV resuscitation. The length of pre-operative management ranged from 2 to 24 hours and was not statistically different between the cohorts of the patients. It depended on the clinical condition of the patient, uncertainty in diagnosis, and immediate availability of medical staff. If system-based delays threatened the patients’ condition, they were urgently referred to the tertiary hospital. This group was not large and was excluded from the study. Individual approach to the patients with a special attention to pre-operative optimization allowed the majority of patients (94.9%) to undergo surgery without intra-operative and immediate post-operative complications.
Pelvic inflammatory disease is a common infection in women of reproductive age both in industrialized nations and the developing countries (18), and this is actually a spectrum of diseases ranging from cervicitis to pyosalpinx and tubo-ovarian abscess. Although most patients with PID could be successfully managed with antibacterial treatment, there are situations when inflammatory process spreads to the whole peritoneal cavity (19). In these cases, surgery became necessary aiming at the source control of abdominal sepsis, which was performed in 22 patients in this study. In surgical treatment of small bowel perforations of both spontaneous and traumatic etiology, the author considers primary suturing and direct anastomosis to be safe even in the presence of diffuse peritonitis, as there were no incidences of leakage. We could not histologically and hematologically confirm all the causes of spontaneous ileal perforation not related to intestinal obstruction, but clinically they looked like typhoid perforation.
Wound infection is the most common post-operative complication in patients with peritonitis (20) and it ranges from superficial collection of pus to severe necrotizing infection. Rates for wound sepsis varies significantly from country to country from 8 to 71.4 per cent (4, 21). In this study, post-operative wound sepsis developed in 16.9% of patients (22/130). In 19 patients, a collection of pus beneath the suture line was found. Two patients experienced deep wound sepsis, in one case a necrotizing infection of the abdominal wall (Meleney’s gangrene) was developed. These patients required appropriate antibiotic cover and serial debridements under general anesthesia. All three patients were successfully discharged, the last one on post-operative day 43.
In seven cases of ongoing post-operative peritonitis, five developed due to recollection of inflammatory exudates and formation of intra-abdominal abscesses during the hospital stay (N = 6) or after discharge (N = 1). In two patients with perforated peptic ulcer, post-operative period complicated by leakage at the suture line. These patients were re-explored, one of them twice. The author utilized on-demand relaparotomy strategy that lies in line with current clinical practice and international literature (22) and recommended as a viable option by World Society of Emergency Surgery (2017) (1). One more relaparotomy was done for early post-operative intestinal obstruction. Two out of seven re-operated patients died.
There is significant difference in reported mortality in peritonitis worldwide varying from 6.4% to 25% (3, 23). The rate of mortality in this work was 11.8%. Differential analysis indicated that the highest contributor to death toll was perforation of peptic ulcer (7 out of total 14 deaths). The mortality rate for this source of peritonitis in the study was 26% (7/27), which lies within ranges found in the literature (from 5.8% in Turkey (2015) (24) to 37% at tertiary hospital in Zambia (2011) (11)).
This study had several limitations. This is an observational retrospective study with rather small size of patients’ cohorts performed in a low-volume hospital. It was assumed that patients entered in the study received reasonably standard care in accordance to the recent evidence-based recommendations. However, system-related problems associated with lack of resources and facilities may have led to inadequate management, thus contributing negatively to outcomes. On the other hand, some of the patients pre-operatively and seven of operated patients were excluded from the study as they were transferred to the tertiary institution in complicated state with development of multi-organ failure for further management. Loss of these patients for statistical analysis could overestimate treatment effect and reduce the validity of the study.
The main sources of peritonitis among the rural population of Zambia, according to the current study, were perforated peptic ulcer, acute appendicitis and PID, followed by small bowel perforation. Perforated peptic ulcer appeared to be the most significant contributor to in-hospital mortality in patients with peritonitis.
The study emphasizes the significance of organ failure for fatal outcome in peritonitis. Patients with short history and without signs of organ failure could be successfully treated in low-volume rural surgical hospitals which have an uninterrupted access to the operating theatre. MPI is a highly useful and informative tool for predicting patients’ outcome.
Larger-scaled and prospective studies are needed to further validate the findings obtained in this study and develop recommendations for surgeons working in rural areas.
The author declares that he has no competing interests.
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