Peritonitis is inflammation of the peritoneum and peritoneal cavity. It may be localized or generalized, and may result from infection  or from a non-infectious process. Peritonitis is one of the common cause of ‘acute abdomen’. Primary peritonitis results from bacterial, chlamydial, fungal, or mycobacterial infection in the absence of perforation of the GI tract, Whereas secondary peritonitis occurs in the setting of GI perforation. Frequent causes of secondary bacterial peritonitis include peptic ulcer disease, acute appendicitis, colonic diverticulitis, and pelvic inflammatory disease¹.Primary peritonitis is an infection of the peritoneum without a clear source, often originating from the lower genital tract, upper respiratory tract etc.Typical pathogens include pneumococci, with occasional cases due to streptococci, Haemophilus, gonococcus, and E. coli. The condition rapidly leads to severe illness and septicemia. It can also occur in patients with ascites, those with indwelling peritoneal dialysis catheters, or peritoneovenous shunts, and may be caused by Chlamydia, fungi, or mycobacteria^2-5. Secondary peritonitis is secondary to any intra-abdominal bowel or other visceral pathology, e.g. perforation, appendicitis. E. coli (70%) is the most common organism involved. Other bacteria are aerobic and anaerobic streptococci, clostridium welchii, bacteroides, staphylococci, klebsiella, salmonella typhi^6,7.

Tertiary peritonitis is a persistent or recurrent intra-abdominal infection that occurs despite adequate treatment for primary or secondary peritonitis, typically arising more than 48 hours after initial treatment. It can lead to systemic inflammatory response syndrome (SIRS) or multi-organ dysfunction syndrome and is common in immunosuppressed patients with weakened peritoneal defences. Common pathogens include E. faecalis, E. faecium, S. epidermidis, P. aeruginosa, and C. albicans.Many scoring systems have been designed and used successfully to grade the severity of acute peritonitis like, Acute physiology and chronic health evaluation (APACHE) II score, Simplified acute physiology score (SAPS), Sepsis severity score (SSS), Ranson score, Imrite score, Mannheim peritonitis index (MPI)^8,9.The Mannheim Peritonitis Index (MPI) is a specific score and it has good accuracy. Hence it provides an easy way to predict the individual prognosis of peritonitis patients.This study was designed to determine the efficacy of MPI in predicting the morbidity and mortality in patients with peritonitis admitted in a tertiary care hospital^10,11.

To determine the efficacy of Mannheim peritonitis index. in predicting the morbidity and mortality in patients with secondary peritonitis.

The study is designed as a hospital-based, prospective observational study, set to span 12 months from January 2023 to December 2023, and will be conducted at the Department of Surgery, S.P. Medical College and P.B.M Hospital, Bikaner.

The study aims to include all patients presenting with clinical suspicion of peritonitis. Based on prior research indicating a maximum 20% mortality rate for secondary peritonitis, a minimum sample size of 63 cases was calculated at a 95% confidence interval with a 10% error margin. Accordingly, a total of 100 patients will be recruited who meet the inclusion criteria during the study period. Convenience sampling will be used to select participants.

Inclusion criteria consist of patients over the age of 14 with clinical and investigative evidence supporting a diagnosis of peritonitis due to hollow viscous perforation, confirmed by intraoperative findings. Exclusion criteria include patients under 14 years old, those with perforations due to trauma, individuals with significant comorbidities affecting outcomes, those unwilling to participate, patients managed conservatively, and individuals who test positive for HIV, HBsAg, or HCV.

Statistical Analysis:The recorded data compiled and entered in a spreadsheet computer program (Microsoft Excel 2007) and appropriate tests were applied. For all tests, confidence level and level of significance were set at 95% and 5% respectively. P value <0.05 was considered as significant in this study.

Table 2 : Age Wise distribution of cases

Maximum 32% cases were of 30 – 50 yrs age followed by 25% of 18 – 30 yrs whereas minimum 19% were of >70yrs.Mean age of study population was 43.33 ± 17.87 yrs with age range of 18-75 yrs

Table 3: Distribution of cases according to Chief complaint

In our study, all patients had abdominal pain, 84% cases had distension and 72% cases had vomiting whereas minimum 20% had constipation followed by 57% had fever as chief complaint.

Table 4: Distribution of cases according to Signs

In our study, 98% had tenderness, 92% tachycardia and 57% had guarding and rigidity and 6% had mass

Fig: 1. Distribution of cases according to Organ failure

In our study, on hematological investigations mean value of Serum creatinine was 1.82 ± 0.86 mg/dl, mean serum urea was 100.4 ± 85.4 mg/dl, Po2 was 30.05 ± 7.45 mmHg and Pco2 was 47.75 ± 11.31 mmHg. Maximum 74% cases had urine output >500ml whereas minimum 27% had <500ml output. In our study, 26% had shock and 74% does not had shock.

Table 5: Distribution of cases according to radiological investigation and according to malignancy

In our study, on radiological examination 95% had free fluid in peritoneal cavity whereas 88% had gas under the diaphragm.In our study, 7% had malignancy and 93% were not malignant.

Table 6:Association of outcome with severity of peritonitis

Fig. 2. Type of peritonitis

In our study, all were discharged in mild category, followed by 94.44% in moderate category and 40% in sever category were discharged. In our study, 90% deaths were in sever category and 10% in moderate category. The difference was found to be statistically significant.(p<0.05) Mortality rates were maximum  in sever category whereas minimum 5.6% in moderate group.

Fig:3. Distribution of cases according to type of peritonitis and  according to type of Exudate

In our study, maximum 96% had generalized peritonitis whereas minimum 4% were localized peritonitis. In our study, maximum 62% had purulent exudates whereas minimum 38% were fecal exudates.

In our study, Maximum 32% cases were of 30 – 50 yrs age followed by 25% of 18 – 30 yrs whereas minimum 19% were of >70yrs . Mean age of study population was 43.33 ± 17.87 yrs with age range of 18-75 yrs. Similarly V.T. Arasu et al 2016¹² found that mean age was 41.8 years with a median of 40 years and a range from 14 years and above.

In our study, all patients had abdominal pain, 84% cases had distension and 72% cases had vomiting whereas minimum 20% had constipation followed by 57% had fever as chief complaint and signs as 98% had tenderness, 92% tachycardia and 57% had guarding and rigidity and 6% had mass.

Our study is comparable to study conducted in the Pakistan where majority of the patients 78%, present with the history of pain in abdomen, abdominal distention 45%, altered bowel habit 26.6%, nausea vomiting 21%, Fever 20%(total number of patient included in study was 300)¹³ And another study done by Somani et al., has also similar finding as of current study, where abdominal pain, obstipation, abdominal distension, fever and vomiting were major symptoms¹⁴

In our study, 26% had shock and 7% had malignancy. On radiological examination 95% had free fluid in peritoneal cavity whereas 88% had gas under diaphragm. Maximum 44% had perforation in duodenal followed by 20% gastric and 18% ileal whereas minimum 5% jejunal followed by colonic 6% and appendicular 7% with maximum 62% had purulent exudates whereas minimum 38% were fecal exudates. Maximum 96% had generalized peritonitis whereas minimum 4% were localized peritonitis. Similarly Ranjith Cheriyan et al. 2020¹⁵ found that Local peritonitis was found in 48 cases while general peritonitis was found in 52 cases and bulk of the local peritonitis was due to appendicitis (47 %). Most common cause of general peritonitis was duodenal perforation (34 %).

In our study, as per MPI score maximum 36% had moderate (21 - 29) peritonitis followed by 34% had mild (<21) whereas minimum 30% had severe peritonitis (>29). Similarly V.T. Arasu et al 2016¹² found that maximum were in mild peritonitis (<21). Also Dr.N.VenkataBhaskarachari et al. 2018¹⁶ found that out of 62 patients, 64% of patients had mild peritonitis (MPI score less than 21).

In our study, all were discharged in mild category, followed by 94.44% in moderate category and 40% in sever category were discharged. In our study, 90% deaths were in severe category and 10% in moderate category. The difference was found to be statistically significant.(p<0.05). mortalityratemiximun 60% in severe category whereas minimum 5.6% in moderate group.  Similarly V.T. Arasu et al 2016¹² Among surviving patients, maximum were mild and among nonsurvivors, maximum were sever peritonitis. Also Vivek A. Patil et al 2016¹⁷ The morbidity and mortality rate were higher in patients with severe category (MPI >29). Our study was in line with Dr.N.VenkataBhaskarachari et al. 2018 37 of 62 patients, 64% of patients had mild peritonitis with 0 % mortality (MPI score less than 21), 27.4% of patients with moderate peritonitis (MPI score 21 to 29) had 17.6 % mortality and those patients with severe peritonitis (MPI score 30 and more) had the highest mortality i.e. 80%. Similarly Ranjith Cheriyan et al. 2020¹⁵ MPI scores below 21 had good prognosis and 0 % mortality. Scores between 22 and 29 showed highest morbidity and mortality of 45 %. While patients with scores ≥ 30 showed highest (90 %) mortality rate (p = 0.001).        

Mannheim Peritonitis index (MPI) is simple and objective scoring system to predict the morbidity and mortality in patients with peritonitis. It appears more practical than other scoring systems. MPI provides an easy and reliable means of risk evaluation and classification for patients with peritoneal inflammation for early intensive management for better outcome of patient.

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