48uep6bbphidcol2|ID

48uep6bbphidvals|3026

48uep6bbph|2000F98CTab_Articles|Fulltext

Perforation peritonitis is one of the most common surgical emergencies in developing countries. Perforation leads to seeping of gastric contents into the peritoneal cavity, in turn leading to inflammation. This causes electrolyte disturbances and septic shock, leading to multi organ failure. These sequence of events leads to increased morbidity and mortality. The events can be modified to decrease mortality through early interventions. Decreasing mortality also depends on recognition of the seriousness of disease, and an accurate assessment andclassification of patient’s risks.^1,2

Scoring systems like the Mannheim peritonitis index, BOEY, HACETTEPE SCORE, PULP, and APACHE II have been created for risk assessment. These scoring systems require sophisticated investigations like ABG, specialized computer software,and manpower.They are difficult to perform at all centres. To overcome these problems, Jabalpur peritonitis index was made.^3-7

Jabalpur scoring system was developed by Mishra et al. at Jabalpur district of Madhya Pradesh.⁸ This was based on retrospective analysis of data from 140 patients with peritonitis. The factors associated with mortality were age, presence of co-morbid illness, perforation-to-operation interval, preoperative shock, heart rate, and serum creatinine. The mean score in survivors (4.9) was less than that in those who died (12.5; p<0.0001). Low Jabalpur scores (range 0 - 21)  indicate significantly lower mortality while higher values predict more complications. This study was undertaken to see the accuracy of the scoring system to predict mortality among patients.This study evaluated the role of Jabalpur scoring systemin predicting mortality in patients of peritonitis secondary to rupture of peptic ulcer.

This prospective observational study was conducted on patients  of peritonitis secondary to rupture of peptic ulcer. All the patients attending the surgery out patient and emergency department in K R Hospital under MMC & RI , Mysore, Karnataka, India, from period of January 2018 - August 2019 were considered for recruitment. The study was included all patients above the age of 18 years who had peritonitis secondary to perforation due to peptic ulcer.

A detailed history and physical examination was performed for all enrolled patients. Hemogram, renal function test, random blood sugar, and serum electrolytes were done. Resuscitation with intravenous fluids, antibiotics, analgesics, nasogastric decompression, and appropriate surgical intervention was done in all the cases as per protocol. Resuscitation  and ICU care was continued as per need. Patients were followed up postoperatively, and the outcome was noted. Data obtained was analysed for predicting mortality.

The current study had six deaths among the patients. (Table 1) The association was of death and age group approached significance (p = 0.053). The study population was predominantly males (40, 80%). Four out of the six deaths occurred in males, but the difference was not significant (p = 0.586). 

The other factors used in the Jabalpur scoring system are serum creatinine, heart rate, systolic blood pressure and operation interval. (Table 2)

There was significant (p=<0.001) association seen between serum creatinine and mortality with higher mortality in patients with serum creatinine levels of >1.5mg/dl. Mortality was more among patients who were taken for surgery after 24 hours of peritonitis. (p = 0.016)

Significant (P=<0.001) association was seen between heart rate and mortality. Mortality was more among patients who had Jabalpur score of 3 and 4. There was significant (P=<0.001) association seen between mean systolic blood pressure and mortality with higher mortality in patients who had Jabalpur score of 2 and 3.

The current study had mean scoring of 5.22 (Range 1-16). Table 3 shows the association of score and mortality. There is increased mortality as the score increased. There is significant association between score and mortality. 

The sensitivity of the Jabalpur score was tested at score of 9 in the current study and we found a sensitivity of  95.45% and specificity of 100% (Table 4).

Perforation peritonitis is a challenging surgical emergency there is need for accurate triaging of patients for appropriate management. The aimis to decrease the morbidity and mortality among patients. Scoring system aid in early and effective decision making. 

Patients with peptic ulcer with perforations have clinical features of severe pain in the epigastric region, vomiting, abdominal distension, fever which is usually low grade. Examination of the abdomen, shows increased temperature and tenderness, this is usually associated with guarding and rigidity and decreased bowel sounds. There is associated tachycardia and hypotension, tachypnoea. The patient due to leaking of contents of gastrointestinal tract acquire bacteria from the gastrointestinal tract leading to diffuse bacterial peritonitis further leading to septicaemia and circulatory failure. Also the peritoneum secrets excess fluid leading to hypotension.

In the current study there was association seen between factors like serum creatinine, delay of surgery, heart rate and mean systolic blood pressure with mortality. The study also noted good sensitivity and specificity of the Jabalpur scoring with diagnostic accuracy of 96% for predicting mortality. Jagdeesh et al. showed that that JPI score was accurate in predicting mortality, with similar mortality rates and results as our study.⁹ The study by Hemant¹⁰ et al., had majority males similar to the current study. The mortality was 20.7% while in the current study it was 12%. They found that mortality increased with higher Jabalpur scores,  similar to the current study. The study by Sumitoj Singh¹¹ et al., had majority males (88%) like our study. The study found that a Jabalpur score of 9 had a  sensitivity of 85.7% and specificity of 90.7% for predicting mortality, while in our study these were higher and were 95.4% and 100% respectively.

The Jabalpur score has a high sensitivity and specificity in predicting mortality in patients of perforation peritonitis due to peptic ulcer disease and may be used in resource limited settings.