
 gastrointestinal perforations constitute one of the commonest surgical emergency encountered by surgeons [ 1 , 2 ] .
management of these patients continues to be highly demanding despite the advances made in diagnosis and surgical therapy .
the etiological spectrum of perforation peritonitis in india differs significantly from its western counter parts [ 35 ] .
our study was carried out to highlight the spectrum of perforation peritonitis ( diffuse ) in a single unit at lok nayak hospital , a tertiary care hospital in delhi .
the retrospective study was conducted at the department of surgery , maulana azad medical college and associated lok nayak hospital , delhi , from may 2010 to june 2013 .
the study population included 400 patients of perforation peritonitis ( diffuse or localized ) presenting to the surgical emergency of lok nayak hospital , delhi , who underwent exploratory laparotomy .
cases were studied with respect to clinical features at the time of presentation , comorbid conditions , radiological investigations , operative findings , and postoperative course . after establishing the clinical diagnosis of perforation peritonitis
on performing exploratory laparotomy , the operative findings were noted and the source of peritonitis was found and managed accordingly .
all patients were then treated in the postoperative ward initially under the cover of parenteral broad spectrum antibiotics and fluids ; orals were started on the appearance of bowel sounds .
98% patients presented with the history of abdominal pain , 62.5% with altered bowel habit , 41.5% with nausea and vomiting , and 28% with abdominal distention .
15% patients had positive history of nsaid intake for more than 6 months ( table 1 ) . in our study ,
the commonly associated comorbidity was chronic obstructive pulmonary disease followed by renal disease , diabetes , and hypertension .
multiple air fluid levels on abdominal x - ray in erect position were present in 28% patients .
electrolyte imbalances included hyponatremia in 21% , hypokalemia in 19% and elevated serum creatinine in 18% patients .
most of the patients were operated within 24 hours of presentation under the cover of broad spectrum antibiotics after adequate resuscitation and correction of electrolyte imbalances .
the commonest cause of perforation peritonitis in our study was gastroduodenal perforation due to acid peptic disease ( 45% ) followed by appendicitis ( 18.5% ) , typhoid fever ( 12% ) , tuberculosis ( 10% ) , and trauma ( 9% ) , ( table 2 ) .
patients of peptic ulcer perforation usually had a short history of pain starting in epigastrium followed by generalized tenderness .
175 such were managed by an omental pedicle repair , in the other 4 cases a feeding jejunostomy was also done due to the large size of the perforation .
8% of these patients were managed by a limited resection with ileo - ascending anastomosis due to associated unhealthy caecum .
patients of typhoid perforation had an initial history of high grade fever prior to abdominal complaints .
of the 40 patients of tubercular perforation , 60% had previous history of tuberculosis and 50% of these patients took antitubercular therapy for < 6 months . in cases of traumatic perforation ,
the most common site was jejunum ( 49% ) followed by ileum ( 42% ) .
the most commonly performed procedure was omental pedicle closure of peptic ulcer perforation ( 43.75% ) , followed by exteriorization of the gut in the form of ileostomy or colostomy ( 22.5% ) .
appendectomy was the third most common procedure ( 17% ) , ( table 2 ) .
the most common complication was wound infection followed by dyselectrolytaemia , abdominal collection , and respiratory complications .
the morbidity rate was higher in the patients with intestinal perforation ( 58% ) than those with gastroduodenal perforation ( 32% ) .
factors involved in death included septicemia due to fecal peritonitis , respiratory complications , pulmonary embolism , and late presentation .
it is commonly seen in a younger age group in the tropical countries ( mean age in our study was 37.8 years ) as compared to the studies in the west [ 79 ] .
more commonly the perforations involve the proximal part of the gastrointestinal tract ; [ 1013 ] this being in contrast to studies from the western countries , where perforations are common in the distal part [ 1416 ] .
etiological factors also show a wide geographical variation . according to a study from india ,
infections formed the most common cause of perforation peritonitis , around 50% cases in this study were due to typhoid . in our study 22% of the cases were due to typhoid and tuberculosis .
in contrast to this , noon et al .   from texas in their study reported only 2.7% cases due to infections .
also studies from the west have shown that around 1520% cases are due to malignancy [ 19 , 20 ] , this being in stark contrast to our study where malignancy was ascertained to be the cause of perforation peritonitis in only 3% of the cases .
this shows that malignancy is not a common cause of perforation peritonitis in our setup as compared to our western counterparts .
adequate preoperative resuscitation ( with fluids , etc . ) , correction of electrolyte imbalances followed by an early surgical intervention , to remove the source of infection and stop further contamination , is imperative for good outcomes minimizing morbidity and mortality .
peptic ulcer perforation , perforating appendicitis , typhoid , and tubercular perforations are the major causes of gastrointestinal perforations .
early surgical intervention under the cover of broad spectrum antibiotics preceded by adequate aggressive resuscitation and correction of electrolyte imbalances is imperative for good outcomes minimizing morbidity and mortality .
 
 background . 
 perforation peritonitis is the one of the commonest emergency encountered by surgeons . 
 the aim of this paper is to provide an overview of the spectrum of perforation peritonitis managed in a single unit of a tertiary care hospital in delhi 
 . methods . 
 a retrospective study was carried out between may 2010 and june 2013 in a single unit of the department of surgery , lok nayak hospital , delhi . 
 it included 400 patients of perforation peritonitis ( diffuse or localized ) who were studied retrospectively in terms of cause , site of perforation , surgical treatment , complications , and mortality . 
 only those patients who underwent exploratory laparotomy for management of perforation peritonitis were included . results . 
 the commonest cause of perforation peritonitis included 179 cases of peptic ulcer disease ( 150 duodenal ulcers and 29 gastric ulcers ) followed by appendicitis ( 74 cases ) , typhoid fever ( 48 cases ) , tuberculosis ( 40 cases ) , and trauma ( 31 ) . 
 the overall mortality was 7% . 
 conclusions . 
 perforation peritonitis in india has a different spectrum as compared to the western countries . 
 peptic ulcer perforation , perforating appendicitis , typhoid , and tubercular perforations are the major causes of gastrointestinal perforations . early surgical intervention under the cover of broad spectrum antibiotics preceded by adequate aggressive resuscitation and correction of electrolyte imbalances is imperative for good outcomes minimizing morbidity and mortality . 