Acute Peritonitis at the CSRef of the Commune I in the District of Bamako: Signs, Diagnosis and Treatment ()
1. Introduction
Acute generalized peritonitis is an acute inflammation of the peritoneum. It is most often secondary to perforation of digestive origin and/or the spread of an intra-abdominal septic focus [1] . It is a common surgical pathology requiring therapeutic urgency [2] . Peritonitis ranks 3rd among digestive surgery emergencies in Africa after occlusions and acute appendicitis [3] [4] .
In the USA: Mortality was 48% among children [5] .
IN ASIA: The prognosis: 70% to 80% death in the event of multi-organ failure during the operation [6] .
In France: Peritonitis was due to sexually transmitted infections, 80% of which were caused by Neisseria gonorrhoeae [7] .
In Germany: 58% deaths in 36 patients with severe peritonitis [8] .
In Africa: Frequencies varied from 28.1% in Congo to 49% in Niger in 2005 and 2006 with a mortality of 20.98% and morbidity of 49% [9] [10] .
In Burkina Faso: The late arrival of patients at hospital, coupled with long and complex interventions, contributed to an increase in mortality [9] .
In Tunisia: Patients with risk factors (age over 65 years; associated defects; signs of shock) must benefit from a simple and rapid surgical procedure [10] .
In Mali: The poor prognosis of peritonitis was due to the delay in treatment and the practice of traditional medicine [11] .
The prognosis can be improved by urgent and multidisciplinary care, combining early diagnosis, emergency exploratory laparotomy and early and appropriate resuscitation [4] . The prognosis depends on age, etiology, and time to diagnosis [2] . The diagnosis of acute peritonitis is essentially clinical. In case of doubt, radiological examinations can help with the diagnosis.
Treatment is medico-surgical, combining resuscitation and antibiotic therapy [2] . Nowadays, laparoscopy plays an important role in the diagnostic and therapeutic management of peritonitis [3] .
To date, no study on generalized acute peritonitis in a second level health service in the Republic of Mali has been carried out. The choice of patients was not accidental since we do not have an intensive care unit despite the presence of a general surgery department.
2. Research Methodology
This was a retrospective study which took place in the general surgery unit at the CSRéf of commune I in the district of Bamako, over a period of two years from January 2011 to December 2012. We identified 45 cases of acute peritonitis of which 40 files were usable and complete. To assess pain we used the simple visual scale (EVS).
Inclusion criteria: All patients admitted to the general surgery department for acute peritonitis whose diagnosis was confirmed intraoperatively were included in the study.
Non-inclusion criteria: Were not included in this study:
1) Patients whose clinical and paraclinical examinations have not revealed signs of peritonitis, 2) Patients operated on for an indication other than generalized peritonitis, 3) Patients operated on for localized peritonitis.
The variables studied were sociodemographic (age, sex, profession, residence); physical examination (general, functional, physical signs); additional examinations (ultrasound, x-ray of the abdomen without preparation); emergency biological assessment (Hemoglobin level, Hematocrit, Rhesus group, TP, TCK, Blood sugar) and surgical treatment: technique and short and medium term operative consequences.
The supports used were the patients’ medical files, the outpatient consultation and hospitalization registers, recording the patients’ reports, the individual investigation sheet and the anesthesia protocol.
Data entry and analysis were carried out using Epi-info version 6.5 software; word processing on SPSS software version 17 and Microsoft Word 2010. The comparison tests used are Chi2 and P < 0.05.
3. Results
Forty files of acute peritonitis (N = 40) were collected representing a frequency of 1.8% of consultations, 4.81% of hospitalizations (N = 831), 16.52% of surgical emergencies (N = 242) and 11.73% of surgical interventions (N = 341).
In 2012; 57.5% of patients were operated on and 42.5% in 2011. The age group of 14 to 25 was the most represented with 50% of cases. The average age was 30.1 years with a standard deviation of 12.04 years. The extreme ages were 14 and 60 years. The sex ratio was in favor of men, i.e. 1.22. 72.5% of our patients resided in Bamako, housewives represented 22.5% of cases. Patients received urgently represented 55% of cases. (Table 1) Abdominal pain was the reason for consultation in 90% of cases. This pain was stinging and burning in 50% and 40% respectively. The mode of onset of pain was progressive and sudden in 57.5% and 42.5% of cases. (Table 2)
All patients had generalized abdominal pain, permanent in 72.5% of cases, lasting more than 2 days in 95% of cases and accompanied by fever (87.5% of cases), vomiting (85% of cases), nausea (70% of cases). The factors triggering the pain were absent in 77.5% of cases; the pain was calmed by analgesics in 32.5% of cases. (Table 3)
Body temperature was elevated in 50% of cases. The respiratory rate was normal in 95.5% of cases. The coloring of the conjunctiva was good in 90% of cases; the tongue was saburral in 50% of cases; Abdominal contracture 97.5%; Abdominal defense in 87.5%; Navel cries in 97%; Abdominal dullness 95%; Abdominal pain on palpation 87.5%; Abdominal tympanism 5% of cases; Abdominal mass 5% of cases. The Douglas cul de sac was bulging and painful in 95% of cases. (Table 4)
Abdominal ultrasound was performed in 60% of our patients. The bacteriological examination was in 17.5% of which 12.5% had germs of the genus: E. coli, K. pneumoniae, P. aeruginosa, Tuberculosis bacillus (Mycobacterium tuberculosis).
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Table 2. Distribution of patients according to mode of admission and level of education.
Appendiceal perforations represented 52.5% of surgical indications; gastric perforation 12.5%; intestinal perforation 10%; peritonitis of gynecological origin 22.5% and peritonitis of tuberculous origin 2.5% of cases. (Table 5)
The incision made was the midline above and below the umbilical in 47.5% of cases. The peritoneal fluid was pus in 87.5% of cases; stools in 10% of cases and tuberculous granuloma in 2.5% of cases. The surgical techniques used were
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Table 3. Distribution of patients according to reason for consultation and accompanying signs.
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Table 4. Distribution of patients according to pain characteristics.
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Table 5. Distribution of patients according to accompanying signs and triggering factor.
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Table 6. Distribution of patients according to physical signs.
appendectomy 52.5%; Ileostomy 10%; reviving and suturing digestive perforations 32% of cases. End-to-end anastomosis was performed in 10% of cases. (Table 6)
The antibiotics used were ceftriaxone 1 g, metronidazole infusion, gentamicin 80 mg in all our patients. The analgesics were injectable analgin, injectable paracetamol, acupan 20 mg and or injectable trabar 100. Salt serum, Ringer lactate, 5% glucose serum were used for rehydration. One patient was transfused.
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Table 7. Distribution of patients according to paraclinical diagnosis, bacteriology result and ASA classification.
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Table 8. Treatment and early operative outcomes.
Subumbilical laparotomy was the most practiced, i.e. 52.50% of cases. Appendectomy was the most performed, i.e. 52.50% of cases. The postoperative course was simple in 87.50%; ISO in 10% of cases.
The early operative consequences were: wall suppuration 10% of cases, death 2.5% of cases, simple sequel in 87.5% of cases. The duration of hospitalization was between 4 to 7 days in 80% of cases. Late operative outcomes (one month or more) were simple in 97.5% of cases. (Table 7, Table 8)
4. Discussion
The classification of files by year and by pathology in the department allowed us to easily collect the data on the survey form. Difficulties were encountered during this work, namely: abdominal x-rays without preparation, abdominal ultrasound not possible urgently within the health structure (place of study) and insufficient purchasing power of certain patients for correct care. Quests were often carried out with nursing staff to ensure postoperative care.
Acute generalized peritonitis plays an important role in emergency abdominal pathology. The frequency of acute generalized peritonitis is high in Africa (20% to 28.8%) [11] - [16] . The frequency of the African series is higher than that of I. Lorand who had 3% of generalized acute peritonitis in France [17] [18] (P = 0.005). This difference could be linked to the high frequency of infectious diseases and the delay in consultation in Africa.
The average age in our study was 30; 1 years. The African population is young but subject to several pathologies (appendicitis, peptic ulcers and sexually transmitted infections in young women). This average age is comparable to that of Konaté H. in Mali, 24 years with P = 0.67; Harouna Y.D. in Niger, 23 years with P = 0.5 [17] and Ramachandran C. S. in India, 32 years with P = 0.94 [6] but statistically different from that of Cougard P. in France, 48 years P = 0.0023 [19] .
Several studies have reported that peritonitis occurs more frequently in men than in women [20] [21] [22] . This aspect was found in our study, although gender was not a risk factor. The sex ratio is 1.22 men for 1 woman. It does not differ statistically from that of Dembélé B. in Mali, P = 056 [21] , Hosoglu in Turkey P = 0.62 [20] and Doui D. in CAR with P = 0.67 [22] [23] [24] [25] .
Pain was found in all our patients and as in other authors [3] [8] [16] [26] . Intense, continuous pain with sudden onset was the most constant symptom [15] [23] [24] . The other characteristics of the pain (site, irradiation and type) had a diagnostic orientation value and abdominal contracture is the major physical sign [11] [14] . Vomiting (53% of cases) of food, bile or faecal matter was more frequent in the series by Kunin N. in France (1991), 81% with P = 0.006 [15] and by Akgun Yen Turkey (1995), 70.4% with p = 10−6 [23] ; reflecting paralytic ileus responsible for dehydration and hydro-electrolyte disorders. Early or late cessation of materials and gases (26% of cases) was found in 22% of cases in Sidibé Y. [13] (P = 0.16) and initial diarrhea [12] . The usually high fever has been described in the literature [5] [6] [17] .
The diagnosis of acute generalized peritonitis is primarily clinical in the face of abdominal contracture [11] [14] (97.5% of cases in our series), generalized defense [2] . The rate varies between 20.8% and 31% according to the literature [6] [9] [17] [25] . This difference could be linked to etiologies and delays in consultation. Our rate was comparable to those of Konaté H. in Mali in 2001 P = 0.001 [14] and Kunin N. in France in 1991 P = 0.0025 [15] . Additional examinations (ASP, medical imaging and biology) help with diagnosis but should not delay surgical treatment. At the ASP (10% of our patients), pneumoperitoneum was observed in 2.5% of cases; this rate varies between 8% and 71% in the literature [9] [17] [26] . This difference could be linked to etiology. The absence of this pneumoperitoneum does not eliminate digestive perforation [13] [18] because the hollow organ may be empty of gas and the perforation is obstructed. The hydro-aerial levels (7.5% of our patients), this result differs statistically from the 82% of Sidibé Y. in Mali [11] ; of Cougard P. in France [18] and the 24% of Harouna Y. D. in Niger [17] . This difference is mainly linked to the progression of the disease.
Ultrasound performed in 17 of our patients revealed peritoneal effusion in 35.29% of patients. This result is comparable to the 75% of Sakhri J. in Tunisia (P = 0.56) [10] .
Intraoperative peritoneal fluid collection was systematic in all our patients, but we only had the result in 9 cases. Most interventions are carried out at night and most often on weekends, periods during which the laboratory is not open. Escherichia Coli was the most frequently encountered germ. This corroborates with that of KOUAME B. from Ivory Coast in 2001 [14] and J.Y. MARITANO in France in 2001 [2] .
The therapeutic approach to acute generalized peritonitis depends on the intraoperative diagnosis. Appendectomy was the most commonly performed surgical procedure in our series, i.e. 52.5%. This is understandable because peritonitis due to appendiceal perforation represented the most frequent etiology (depending on the mechanism). Our rate is different from that of SIDIBE Y. 50% (P = 0.59) [11] . Suture excision of the edges of the perforation is particularly effective for single, rounded or punctiform perforations seen early [15] .
Wall suppuration (10%) was the most frequent complication, varying between 17% and 27% in African series [8] [11] [13] . This difference could be linked to the size of the sample and the progressive stage of the disease [3] . Mortality (2.5% in our series) varies between 11.11% and 15.70% in African series [11] [12] [17] . These rates were lower than that of Cougard P. [18] (P = 0.035) where duodenal perforations dominate. The main prognostic factors in the African series would be the delay in treatment and the lack of early diagnostic means. The causes of death in our study (septic shock) have been reported by other authors [6] [15] .
5. Conclusions
Acute generalized peritonitis is a common condition in developing countries and mainly affects young people.
Appendiceal perforation remains the primary cause, i.e. 21 cases out of 40 cases. Reference conditions; financial constitute different parameters which influenced the prognosis of referred patients.
Acknowledgements
To patients who have given their informed consent, to the staff of the general surgery department of the CS Ref of commune I of the Bamako district.