TITLE: A STUDY OF CLINICAL PROFILE AND MANAGEMENT OF

PERFORATION PERITONITIS


AUTHOR DETAILS:

1. Dr. Rajshree Mukhiya, Associate Professor, Dept. of General Surgery, R.D Gardi

Medical College, C/O Dept of. General Surgery, R.D Gardi Medical College, Agar

Road, Surasa, Ujjain, M.P, 456001. Email – drspmukhiya@yahoo.co.in

2. Dr. Satyendra Prasand Mukhiya, Professor, Dept. of General Surgery, R.D Gardi

Medical College, C/O Dept of. General Surgery, R.D Gardi Medical College, Agar

Road, Surasa, Ujjain, M.P, 456001. Email – drspmukhiya@yahoo.co.in

3. Dr. Madhav Tiwari, Junior Resident – II, Dept. of General Surgery, R.D Gardi

Medical College, C/O Dept of. General Surgery, R.D Gardi Medical College, Agar

Road, Surasa, Ujjain, M.P, 456001. Email – madhavtiwari@ymail.com

ABSTRACT: Esophageal malignancy is a deadly disease in transition. While some

patients can be cured, the treatment is usually protracted, diminishing the quality of

life and more often than not, lethal for the patient. The most common type being

squamous cell carcinoma, however, in recent years there has been a significant

increase in adenocarcinoma of the esophagus. Smoking and heavy alcohol use

increases the risk of esophageal squamous cell carcinoma, while gastro esophageal

reflux disease and Barrett esophagus may increase the risk of esophageal

adenocarcinoma. Endoscopic biopsy remains the gold standard method for

confirmation of diagnosis.

KEYWORDS: Esophageal; Malignancy; Dysphagia; Endoscopy; Cancer

AFFILIATION: None

CONFLICT OF INTEREST: None

INTRODUCTION

Perforation peritonitis is the most common surgical emergency across the world as

well as India. The spectrum of etiology of perforation in India continues to be

different from rest of world and there is paucity of data from India regarding its

etiology, prognostic indicators, morbidity & mortality.

Perforation peritonitis, in tropical countries like India most commonly affects men as

compared to the studies in the west where incidence in women is the mean age is

between 40 - 50 years. In majority of cases present late in hospital after taking

massage on counter medication , and treatment from local practioner and presented

with well established generalized peritonitis with purulent & fecal contamination and

varying degree of septicemia.

The signs & symptoms are typical and, it is possible to make a clinical diagnosis of

peritonitis in all patients by using clinical examination, USG abdomen, X – ray chest

and abdomen.

Instead of many advances in surgical techniques, antimicrobial therapy & intensive

care support, management of peritonitis continues to be highly demanding, difficult &

complex.

A critical analysis of the cases of gastrointestinal perforation brings forth a conclusion

of utmost importance that prognosis is related with age of patient, duration, and cause

of perforation, line of treatment and complications.

REVIEW OF LITERATURE
Oesophageal cancer is diagnosed in about 4,00,000 patients each year making it the

9th most common malignancy worldwide and the 6Th in the list of cancer mortality

cause. 3,41,43,44

The true incidence is difficult to calculated 3 as the distal oesophageal growth,

particularly around the GE junction can be either classified as oesophageal

cancer or cancer of the gastric cardia.

Epidemiology

The incidence of oesophageal cancer is high in Western Europe, South Central Asia,

Eastern Africa and parts of South America. In the western world the incidence is

highest in the UK followed by France, Ireland and the USA. Men are more affected

than women especially in France and Slovakia.

The highest incidence rates for males (more than 15 per 100,000 person-years)

reported from population-based tumor registries were in Calvados, France, Hong

Kong and Miyagi, Japan; and the highest rates for females (more than 5 per100,000

person-years) were in Bombay, India; Shanghai, China; and Scotland.

There has been a large increase in the EAC and a modest decrease in ESCC in the so-

called ‘developed countries’. This increase in rates may be partly due to a diagnostic

shift. Rates may also increase with an earlier endoscopy based diagnosis. But survival

has consistently been poor even with patients with localized disease.

A cohort study in the Netherlands showed that the incidence of EAC increased from

1.7 per 100,000 (95% confidence interval [CI] 3.5 – 5.4) in 1997 to 6.0 per 100,000 in

2002 (95% CI 3.3 – 10.2).3

Similarly the incidence of BE, the main precursor of EAC increased from 14.3 in

100,000 in 1997 to 23.1 per 100,000 in 2002. The increase in the incidences of EAC
and BE was independent of the number of endoscopies performed, because this

number decreased from 7.2 in 100 in 1997 to 5.7 per 100 in 2002.3

These observations suggest that the increase in EAC is real and may reflect changes

in the prevalence of risk factors. It is also interesting to observe that the mortality has

also shown the same trend.

MATERIALS & METHODS

STUDY SETTING - This study was carried out at R.D.Gardi Medical College;

C.R.Gardi Hospital & allied Hospitals Ujjain, MP.

STUDY DURATION - This study was carried out for a period of 2 year 2 month

from June 2011 to August 2013.

STUDY DESIGN – Prospective Observational Study of Dysphagia.

SOURCE OF DATA – The patients presenting with signs & symptoms suggestive of

Dysphagia in Department of Surgery, C.R. Gardi Hospital and allied Hospitals,

Ujjain.

INCLUSION CRITERIA –

1. All cases of all age groups and both genders were included in this study, with

complaints of dysphagia.

2. Well informed patients, willing to comply with the study protocol

EXCLUSION CRITERIA–
 1. All cases that have had prior antineoplastic treatment were excluded.

2. Patient unable or unwilling to comply with follow-up schedule.

3. METHOD OF COLLECTION OF DATA-

A detailed history was taken of all patients.

Past illness particularly relating to corrosive intake, any chronic illness and history of

jaundice, was asked for personal history especially for dietary habits and addictions

like tobacco chewing, smoking and alcohol were recorded.

A general examination of patient was carried out to detect any signs of anemia, a

record of pulse, blood pressure, respiration, and temperature was kept.

Local examination of abdomen was done and ENT Examination was carried out.

Other systems of body were examined with a view to detect pulmonary

complications, & any associated systemic disease.

INVESTIGATIONS-

1. Upper GI endoscopy was done and biopsy from the lesion was taken and sent

for histopathology examination.

2. Histopathological examination of biopsy material taken from edge of lesion

was done in relevant cases.

On the basis of clinical findings, investigations and histopathological report the

diagnosis was established and data was recorded in specially designed proforma. The

data was analyzed by Statistical Methods.

OBSERVATION & RESULT

Our study is a prospective study, where an endoscopic examination for patients

presenting with dysphagia was done for diagnosing various esophageal diseases

including carcinoma esophagus at C.R.G.H. and U.C.T.H, R.D.Gardi Medical

College. All 100 patients with presenting symptom - dysphagia underwent endoscopic

examination.

An attempt was made to study the incidence of various esophageal diseases with

respect to age, sex, personal history etc. Our aim was to study occurrence of

esophageal malignancies in cases of dysphagia by endoscopic biopsies and

histopathological examination.

As per our study it was observed under various points stated below –

1. Age wise distribution of patients

2. Sex wise distribution of patients

3. Personal history/risk factor wise distribution of patients

4. Symptom wise distribution of patients

 5. Endoscopic finding wise distribution of patients

6. Anatomical site wise distribution of patients

7. Diagnosis wise distribution of patients

1. Age wise distribution of patients

FIGURE - 1

Age No. Of Patients Percentage Of Patients

<20 00 00

21- 30 11 11

31-40 09 09
41-50 27 27

51-60 14 14

61-70 33 33

>71 06 06

Minimum Age 22 22

Maximum Age 80 80

Average Age 53.04 53.04

In our study we had 100 patients, majority of whom i.e. 33%, belonged to 61 – 70

years age interval and average age was 53.04 years.

2. Sex wise distribution of patients

FIGURE -2

Sex No. Of Patients Percentage Of Patients

Male 65 65

Female 35 35

Ratio 1.85
In our study there were 65% male subjects and 35% female subjects with male to

female ratio 1.85.

3. Personal history/risk factor wise distribution of patients

FIGURE - 3

Personal Histroy No. Of Patients Percentage Of Patients

Smoking 40 40

Alcohol 15 15

Tobacco Chewing 47 47

Vegetarian 49 49

Mixed Diet 51 51

Among 100 patients 40 % were smokers and 15 % were alcoholics. History of

tobacco chewing and mixed diet was found in 47 % and 51 % of patients respectively.

4. Symptom wise distribution of patients

FIGURE - 4

Symptom No. Of Patients Percentage Of Patients

Dysphagia 100 100

Pain 28 28
Vomiting 33 33

Change In Voice 05 05

Patients with complaint of Dysphagia were selected in our study, along with

Dysphagia, 33 % patients presented with vomiting, followed by 28 % patients with

pain during deglutition and 5 % as change in voice.

5. Endoscopic finding wise distribution of patients

FIGURE - 5

Endoscopy Finding Frequency Percentage

Normal 20 20

Abnormal 80 80

Among 100 study subjects who underwent endoscopic examination, in 80 %

pathology was found and in 20 % examination was normal.

FIGURE - 6
 Endoscopic Finding Wise Distribution Of
Patients
Abnormal
20

80

Normal

6. Anatomical site wise distribution of patients

FIGURE - 7

Ulcero-proliferative Ulcerative GEJ

Growth Lesion Foreign Body Inflammation Polypoid Lesions Normal

3 10 03 00 00 01 85

3 10 06 01 00 00 79

3 14 10 00 05 00 64

In our study 15 % of patients had carcinoma esophagus in lower third of esophagus,

while 10 % of patients had ulcero-proliferative growth in upper third and 10% in the

middle third.
FIGURE – 8

Endoscopic Finding As Per Anatomical

Percentage Of Patients

Normal Findings
100
Polypoid Lesions
80
GEJ Inflammation
60

40 Forgein Body

20 Ulcerative Lesion

0 Ulceroproliferative
Upper 1/3 Middle 1/3 Lower 1/3 Growth

Anatomical Site

7. Diagnosis wise distribution of patients

FIGURE - 9
Esophageal Disease Frequency Percentage

Carcinoma Esophagus 35 35

Reflux Esophagitis 32 32

Biliary Gastritis 04 04

Esophageal Candidiasis 10 10

Hiatus Hernia 08 08

Duodenitis 04 04

Esophageal Stricture 04 04

Vocal Cord Palsy/Edema 02 02

Foreign Body 01 01

Among 100 patients 35 % had Carcinoma esophagus, followed by reflux esophagitis

in 32 % patients.

Esophageal candidiasis was found in 10 % of cases.

Hiatus Hernia was found in 8 % of the study subjects.

Biliary gastritis, duodenitis and esophageal stricture, each was found in 4 % of cases.

In 1 % of the patients Dysphagia was due to a foreign body in esophagus.

DISCUSSION
Our study was conducted in C.R.G.H. and associated Hospitals at R.D. Gardi Medical

College, Ujjain from 2nd June 2011 to 28th August 2013. 100 patients were included

in the study who presented with complaint Dysphagia. They were subjected to

endoscopic examination as inpatients or on OPD basis.

In this study 65% were males and 35% females, with male to female ratio 1.85 and

mean age being 53.04 years.

There were 35 (35%) patients with malignant changes and 65 (65%) with benign

causes.

Among the group with benign causes, majority [32 (32%)] were diagnosed as Reflux

oesophagitis. (Table – 7)

Hiatus Hernia was diagnosed in 8 (8 %) of patients and Benign Stricture in 4(4%) of

patients. (Table – 7)

In the 35 subjects with malignant causes for Dysphagia, 25(71.4%) patients were

histopathologically diagnosed as squamous cell carcinoma while 10 (28.5%) patients

as adenocarcinoma. This was in contrast to worldwide study where now

adenocarcinoma has overtaken squamous cell carcinoma as the dominant histological

variant .3,20

4 (4%) patients underwent endoscopic esophageal dilatation for Dysphagia due to

benign strictures (16Fr-20Fr) .The results of dilatation were excellent and all the

patients had good swallowing after the procedure. This is comparable to other studies,

where the success rate is 60% to 80%, at 6 months follow up.46a,54a

In our study the ratio of males (65%) undergoing upper GI endoscopies were more

than the number of females (35%). Similar findings were found in the European study

by David A Liberman et al 58 and Florian Froehlich et al.59a

In all the studies the men out numbered women for Carcinoma Esophagus due to the

increase prevalence of smoking, alcohol intake and stressful life. It was observed that

patients of our study group shared the same habits.

In addition in our study it was found that chewing tobaccos in the form of pan

masalas, tobacco leaves and heavy in take of beverages such as tea, coffee spicy food

and irregular eating habits between the meals contributed for higher ratio in males.

The high female incidence in studies as compared to our study may be attributed to

the higher prevalence of smoking, alcoholism and stressful life in western women as

compared to Indian women.

The second most common symptom (33%) was vomiting. Invariably these patients

had pathology in the esophagus. The study done by Zou D, et al 61 shows only 28.8%

of participants with reflux esophagitis had vomiting and/or regurgitation symptoms.

In our study the patients undergoing upper GI endoscopy for Dysphagia had other

esophageal associated complaints such as vomiting, retrosternal pain, heartburn.

The previous studies have individualized the symptoms in patients who underwent

endoscopy; hence the ratio of other esophageal-associated complaints such as

vomiting, retrosternal pain and heartburn is higher in our study.

In our study it was found that tobacco chewing (47%) and smoking (40%) were the

primary habitual factors for esophageal symptoms. Whereas alcohol was the primary
habitual factor and smoking was the second most common factor in the study done by

William K. Hirota et al.60a

In the present study it was found that the tradition of spicy food and chewing of

tobacco in the form of pan masala and tobacco leaves with betel nut after food was a

significant factor in females who were diagnosed to have Carcinoma esophagus with

no history of smoking or alcoholism, where as these factors were not considered in

the Western studies as contributing factors.

CONCLUSION

In this study 100 cases of Dysphagia were examined by Upper GI endoscopy and the

results analyzed.

The occurrence of Carcinoma esophagus in this study was 35 %.

The majority of patients were males 65 % than females 35% with male to female ratio

1.85 and mean age being 53.04 years.

The most common habitual factor in the our study was found to be Smokeless

tobacco, followed by smoking, in particular the beedies among males.

Whereas tobacco chewing followed by spicy food were common habitual factors in

women.

Among 100 patients 40 % were smokers, 15 % were alcoholics and 47 % were

tobacco chewers.

In our study:

15 % of patients had Carcinoma esophagus in lower third of esophagus,

10 % of patients had Carcinoma esophagus in middle third,

And 10 % of patients had Carcinoma esophagus in upper third.

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