it may be regarded as the localized equivalent of the systemic inflammatory response seen after any trigger of inflammation , which recently has been described as systemic inflammatory response syndrome .
the complex nature of surgical infections , the multifaceted aspects of treatment , and the complexity of intensive care unit ( icu ) support makes evaluation of new diagnostic and therapeutic advances in this field very difficult .
mannheim peritonitis index ( mpi ) is a scoring system used in peritonitis which is simple and cost - effective .
mpi was originally derived from data collected from 1253 patients with peritonitis treated between 1963 and 1979 and was developed by discriminant analysis of 17 possible risk factors , by wacha , 8 of these were of prognostic relevance and was currently employed widely for predicting mortality from peritonitis .
the information is collected at the time of admission and first laparotomy [ tables 1 and 2 ] .
the study was done in fifty patients with peritonitis who presented at government medical college , amritsar , and were operated after taking informed consent .
patients were followed up for the final outcome , and results were analyzed with the score of mpi .
in this study , majority of patients belonged to age group of 21 - 50 years .
the youngest patient was 8-year - old female , whereas to oldest was a 65-year - old male .
there were 82% male patients and 18% female patients with the male to female ratio being 4.6:1 [ figure 1 ] .
it was further found that mortality for female patients was 55.56% , and for male patients , it was 9.76% . in patients with localized peritonitis , there was no mortality as compared to diffuse peritonitis which had mortality of 20.45% .
majority of the patients presented to hospital after 24 h ( 86% ) , and most commonly during 48 - 72 h ( 44% ) .
the mortality of patients was highest ( 66% ) who were presented to hospital after 72 h , and it was 33% who were presented between 48 and 72 h. there was no mortality for patients who presented within 48 h. the mortality of patients who had clear , cloudy , and fecal character of exudates was 12.5% , 15% , and 100% , respectively . for patients with no malignancy ,
patients having no organ failure preoperatively , mortality was 7.14% as compared to patients having organ failure , mortality was 75% [ table 3 ] .
summary of risk factors of mannheim peritonitis index and mortality the study showed that mortality steadily increases with increase in mpi score showing statistically significant results [ p < 0.001 , figure 2 ] .
various postoperative complications seen in the study group were wound sepsis , wound dehiscence , acute renal failure , pneumonitis , acute respiratory distress syndrome , and shock .
the study also showed that morbidity steadily increases with mpi score [ p < 0.001 , figure 3 ] .
mortality and mannheim peritonitis index score morbidity and mannheim peritonitis index score for a score of 27 , the sensitivity was 66.67% , specificity was 100% , and positive predictive value for mortality is 100% at an accuracy of 94% [ p < 0.001 , table 4 ] . sensitivity and specificity of mannheim peritonitis index score 27
peritonitis , inflammation of serosal membrane lining the abdominal cavity and abdominal viscera , is associated with high mortality rate .
peritonitis remains a hot spot for the surgeons despite advancements in surgical technique and intensive care treatment .
various factors such as age , sex , duration , site of perforation , extent of peritonitis , and delay in surgical intervention are associated with morbidity and mortality .
bacteria and digestive enzymes act on the peritoneal serosal surface lead to enzymatic digestion and necrosis and an outpouring of serum protein and electrolytes from the blood to the cavity .
there is formation of exudate rich in granulocytes , which may be diffuse or confined to an abscess .
systemically , there is paralysis of the bowel , hemoconcentration occurs , and alterations of the cardiac output due to the shift of fluids and later acidosis .
intrapulmonary shunting , hypo- or hypercapnia , hypoxemia , progressive azotemia , acute tubular necrosis , weight loss by protein consumption , fall of body temperature , loss of heat production , and exhaustion are other complications that may lead to the death of the patient , if the process is not interrupted .
a successful outcome depends on early surgical intervention , source control , and exclusive intraoperative peritoneal lavage .
it may also depend on exact recognition of the seriousness of the disease , an accurate assessment , and classification of the patient 's risks . despite the surgical treatment and sophisticated icus , last generation antibiotics and a better understanding of pathophysiology of peritonitis mortality rate are still very high , i.e. , 1020% even in good institutions .
early prognostic evaluation is necessary to select high - risk patients for more aggressive therapeutic procedures such as radical debridement , lavage systems , open management , and planned reoperations .
classification of the severity of disease means the definition of groups by risk , and it is of confirmed value in both controlled and uncontrolled clinical trials . an accurate risk index classification is only method to settle a standard of comparison between groups of patient and different treatment methods which would allow further prospective adequate comparative study .
the mpi has a definite score for an individual , which has a good accuracy .
mpi can be used to define risk groups as well as predict outcome in patients with peritonitis , as indicated by various studies .
showed patients who obtained < 21 points and more than 29 points , mortality rate was 6% and 50% , respectively .
showed mortality at score of above 21 and 29 of 60% and 100% , whereas fgger et al . showed below 21 , no mortality ; between 21 and 29 , mortality was 29% ; and more than 29 , it was 100% .
studies showed mortality among patients who obtained < 21 points varied between 0% and 2.3% , in the 2129-point group between 3.85% and 60% , and in patients with score of > 29  between 15% and 100% .
billing 's meta - analysis showed the following mean mortality rates in the groups with < 21 points , between 21 and 29 points , and above 29 points : 2.3% ( 011% ) , 22.5% ( 10.650% ) , and 59.1% ( 4187% ) , respectively .
other studies have also shown statistically significant relation of morbidity and mortality with increasing mpi score .
yoshiko and masayuki showed patients with mpi score of 26 or less have mortality of 3.8% , whereas score of 26 or more had mortality of 41% .
such difference in cutoff values might be due to different demographics and therapeutic options offered to patients at different institutions . in our study ,
score of 27 showed the sensitivity , specificity , and positive predictive value at 66.67% , 100% , and 100% , respectively , at an accuracy of 94% . in our study showed mortality rate with score < 21 , 21 - 27 , and > 27 was 0% , 27.28% , and 100% , respectively .
similarly , morbidity rate for patients with a score < 21 , 21 - 27 , and > 27 was 13.33% , 65.71% , and 100% , respectively .
the predictions resulting from mpi were reliable , indicating stratification of risk groups can be done by probability intervals .
study showed that age > 50 years out of a total of 79.3% death was seen in 85.2% and survival in 67.6% and p = 0.04 , thus showing that age > 50 years is a significant risk factor . in our study , patients < 50 years , mortality rate is 13.16% , and for patients more than 50 years , the mortality rate is 33.33% although it did not reach statistically significant values ( p = 0.113 ) .
wittmann showed in his study , a high mortality rate ( 50% ) when the diagnosis of peritonitis was made after 48 h. the observed high frequency of patients with preoperative peritonitis duration longer than 24 h ( 65.5% ) was correlated with high death rate .
our study also showed similar results with mortality of patients who presented between 48 and 72 h was 33% and > 72 h was 66% as compared to no mortality who presented within 24 and 48 h ( p < 0.001 ) .
a study by basnet and sharma , out of the fifty patients included in the study , 21 ( 42% ) were female and 29 ( 58% ) were male .
about 24.1% of the males and 19% of females requiring relaparotomy expired in the study , making female sex not a bad prognosticator in their study ( p = 0.100 ) .
mortality for female patients was 55.56% as compared to male patients having mortality of 9.76% ( p = 0.001 ) .
the study by notash et al . had mortality 17.5% mostly due to organ failure and septicemia .
our study also showed organ failure , a significant risk factor as patients having organ failure had mortality of 75% as compared to no organ failure having mortality of 7.14% ( p < 0.001 ) .
another study concluded that with age more than 50 years , late presentation , diffuse peritonitis , purulent exudate , noncolonic pathology , and organic failure associated with high mpi score and more mortality .
this study proves that mpi scoring system is a simple and effective tool for assessing the morbidity and mortality in patients with peritonitis with statistically significant results .
duration of pain > 24 h , organ failure on admission , female sex , and feculent exudate were found to be independently significant factors in predicting the mortality .
such patients should be monitored closely with close attention to be given to support the vital systems . to conclude , mpi is a simple and reliable tool in predicting the outcome in cases of peritonitis .
 introduction : peritonitis is one of the most common problems in general surgery practice with high mortality rate 
 . one of the reasons for high mortality is that peritonitis affects the general condition and leads to complications causing multiple organ failure , renal failure , sepsis , and postoperative ventilatory support . 
 early prognostic evaluation of patients with peritonitis is desirable to select high - risk patients for intensive management and also to provide a reliable objective classification of severity and operative risk.patients and methods : fifty cases with diagnosis of peritonitis coming to government medical college , amritsar , were studied . 
 stratification of these patients was done according to mannheim peritonitis index ( mpi ) , and their outcome was examined.results:mortality steadily increases with increase in mpi score . for patients with a score < 21 , 
 the mortality rate was 0% ; for score 2127 , it was 27.28% ; and for score > 27 , it was 100% ( p 
 < 0.001 ) . 
 for patients with a score < 21 , the morbidity rate was 13.33% ; for score 21 - 27 , it was 65.71% ; and for score > 27 , it was 100% ( p < 0.001 ) . 
 duration of pain > 24 h , organ failure on admission , female sex , and feculent exudate were found to be independently significant factors in predicting the mortality among the study population . for a score of 27 , 
 the sensitivity was 66.67% , specificity was 100% , and positive predictive value for mortality is 100% at an accuracy of 94%.conclusion : this study proves that mpi scoring system is a simple and effective tool for assessing the morbidity and mortality in patients with peritonitis . 
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