|Year : 2022 | Volume
| Issue : 2 | Page : 123-128
Effectiveness of acute physiology and chronic health Evaluation-II scoring in predicting outcomes of perforation peritonitis
Goutham P Sathyapal, Alex Oommen
Department of General Surgery, Government Medical College, Kozhikode, Kerala, India
|Date of Submission||20-Nov-2022|
|Date of Decision||30-Nov-2022|
|Date of Acceptance||02-Dec-2022|
|Date of Web Publication||30-Jan-2023|
Dr. Goutham P Sathyapal
Poovathumkandi House, Panniyankara Kallai Post, Kozhikode - 670 003, Kerala
Source of Support: None, Conflict of Interest: None
Introduction: Several scoring systems have been developed for predicting the severity and outcomes of peritonitis, such as the Acute Physiology and Chronic Health Evaluation (APACHE-II) score, Ranson's score and Mannheim's peritonitis index. The aim of the study was to evaluate the performance of the APACHE-II scoring system in predicting mortality and morbidity in patients with perforation peritonitis. Methods: Diagnostic test evaluation was done from June 2020 to December 2021, including 168 patients with hollow viscous perforation, excluding appendicular abscess perforation, who attended the casualty and underwent surgery. Data were collected by meticulous history, clinical examination, radiological, histopathological and serological investigation, operative findings and follow-up till discharge or death. The outcome of the study is based on an analysis of mortality and morbidity due to perforation peritonitis and its correlation with the scores obtained based on APACHE-2 scoring system. Results: The commonest age group of perforation peritonitis was 41–50 years of age (21.4%), with male preponderance. The most common site of perforation was gastric in all age groups, and the most common aetiology was peptic ulcer, followed by malignancy. The mortality rate was 10.7%, and the rates are higher for females, older age groups, and malignancies. There was a statistically significant association for APACHE-II score in predicting the mortality, complications and morbidity associated with perforation peritonitis. The average APACHE-II score in this study was 6.17 and the average score among survivors was 4.33 and non-survivors 21.44. Morbidity and mortality increased as the score increased; a score above 15 had a sensitivity of 99% and specificity of 94.4% in predicting mortality, the complication rates were more in scores above 10. The low-risk categories (0–5 and 6–10) had a favourable outcome in terms of morbidity and mortality. Conclusions: The mean age was 46.6 years with male preponderance. The most common aetiology was peptic ulcer perforation, followed by perforation due to malignancies and site of perforation being the stomach, followed by colon. There was a statistically significant association for APACHE-II score in predicting the mortality, complications and morbidity associated with perforation peritonitis and score above 15 has a sensitivity of 99% and a specificity of 94.4% in predicting mortality associated with secondary peritonitis.
Keywords: Acute physiology and chronic health evaluation-II scoring system, morbidity, mortality, peritonitis
|How to cite this article:|
Sathyapal GP, Oommen A. Effectiveness of acute physiology and chronic health Evaluation-II scoring in predicting outcomes of perforation peritonitis. Kerala Surg J 2022;28:123-8
|How to cite this URL:|
Sathyapal GP, Oommen A. Effectiveness of acute physiology and chronic health Evaluation-II scoring in predicting outcomes of perforation peritonitis. Kerala Surg J [serial online] 2022 [cited 2023 Mar 24];28:123-8. Available from: http://www.keralasurgj.com/text.asp?2022/28/2/123/368600
| Introduction|| |
Peritonitis is defined as the inflammation of the peritoneum, which is the membrane that lines the cavity of the abdomen and visceral organs. Peritonitis is classified based on aetiology into primary peritonitis, infection without any visceral perforation, secondary peritonitis following an intraperitoneal source, usually from perforation of a hollow viscus and tertiary peritonitis, which develops following treatment failure of secondary peritonitis. Secondary peritonitis is a common surgical emergency in most of the general surgical units all over the world. It is often associated with significant morbidity and mortality.
Diagnosis is mostly based on clinical grounds; plain erect abdominal X-ray showing free gas under the diaphragm for generalised peritonitis, ultrasound and computed tomography are used to aid diagnosis in doubtful situations. Multiple scoring systems are available to prognosticate the outcomes of perforation peritonitis, which are broadly divided into peritonitis specific such as Mannheim's peritonitis index and colonic perforation index and disease-independent clinical scores such as Acute Physiology and Chronic Health Evaluation (APACHE-II) and Simplified Acute Physiology Score-II. APACHE-II is a clinical scoring used to predict mortality and prognosis for critically ill conditions such as pancreatitis, pneumonia, and perforation. It is calculated by considering 13 physiological variables, age, and chronic health points. Many studies showed that this score has a statistically significant mortality and morbidity predictive value. APACHE-II scoring and its effectiveness in predicting the outcomes of perforation peritonitis are evaluated based on this study conducted in a high-volume tertiary hospital. This article was intended to evaluate the performance of the APACHE-II scoring system in predicting mortality and morbidity in patients with perforation peritonitis.
| Methods|| |
It was a diagnostic test evaluation conducted for 1½ years on patients presenting to a tertiary care center with features suggestive of perforation peritonitis. Data were collected by meticulous history taking, careful clinical examination, appropriate radiological, histopathological and serological investigations, operative findings and follow-up of the cases for a period of discharge from the hospital or expiry. The outcome of the study was based on an analysis of mortality and morbidity due to perforation peritonitis and its correlation with the scores obtained based on APACHE-2 scoring system. Morbidity following perforation includes wound infections, fistulas, burst abdomen, need for relaparotomy, etc.
Patients presenting to the hospital with features of perforation peritonitis meeting the following inclusion and exclusion criteria are included in the study after taking their informed consent. Patients with features of secondary perforation peritonitis belonging to both sexes over 18 years were included. Patients with peritonitis due to ruptured liver abscess or appendicular abscess and patients not giving consent for the study were excluded. The sample size was calculated using the formula:
Sensitivity values were based on APACHE-II score as a tool to guide management strategies on the ileal perforation.
| Results|| |
The study sample had 168 patients with generalised peritonitis who underwent emergency surgery and were admitted to surgical wards and intensive care unit.
The most common age group was 41–50, followed by 51–60 group [Table 1].
About 84.5% of the total cases of perforation were males (142) and 15.5% were females (26) Overall perforation peritonitis had a male pre-dilection.
Site of perforation
The most common site of perforation is the gastric, followed by the colon and ileum [Table 2].
The most common aetiology is peptic ulcer, followed by malignancy, then tuberculosis (TB) [Table 3].
The most common procedure being done is the Graham's omental patch for gastric and duodenal perforations. Resection with anastomosis was done for 36 cases and for seven cases, resection without anastomosis (colostomy/ileostomy) was done [Table 4].
Most of the perforation cases were among native population, but 14.3% of cases of perforation (24) occurred among non-Keralites, most of them were migrant labourers and the most common aetiology noted was peptic ulcer perforation (95.3%).
Outcome of patients
Out of the total 168 patients, there were 18 deaths accounting for a 10.7% mortality rate.
Sex and mortality
The mortality rates were higher among females (9%–34%) than males (9%–6.3%) with P = 0.00, statistically significant.
Age versus mortality
Mortality rates were higher as age advances. P = 0.00, significant.
Site of perforation and mortality
P value on Chi-square test is >0.05, and no statistically significant association was made between the site of perforation and mortality.
Aetiology versus mortality
P > 0.05, no statistically significant association between aetiology and mortality. Mortality rates are higher among malignant perforation than due to peptic ulcer perforation.
Acute physiology and chronic health evaluation-II score distribution
Most of the cases have score between 0 and 5 which is favourable.
The most common encountered complication is wound infection, followed by pneumonia.
Acute physiology and chronic health evaluation-II score and incidence of complications
Incidence of complications increased as the score increased.
Acute physiology and chronic health evaluation-II score and mortality
Mortality increased as the score increased.
Acute physiology and chronic health evaluation -II score and in-hospital stay
Higher scores are associated with an increased hospital stay for scores up to 15. Scores higher than 15 have lesser duration of hospital stay due to a high mortality rate. The various results of the analysis are given in [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12].
|Table 8: Acute Physiology and Chronic Health evaluation II score distribution|
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|Table 10: Acute Physiology and Chronic Health evaluation II score and incidence of complications|
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|Table 11: Acute Physiology and Chronic Health evaluation II score and mortality|
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|Table 12: Acute Physiology and Chronic Health evaluation II score and in-hospital stay|
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| Discussion|| |
Perforation peritonitis is a very common entity dealt with in our surgery Department on a day-to-day basis. Early prognostic evaluation of peritonitis is desirable to select high-risk patients for more aggressive therapeutic procedures and to improve outcomes.
Various factors such as age, sex, duration, site of perforation, aetiology, and surgical interventions are associated with morbidity and mortality. APACHE-II is an independent, objective and effective scoring system for predicting mortality and morbidity.
The purpose of this study was to validate APACHE-II for the prediction the outcomes in patients with perforation peritonitis. The rationale behind this study was to establish a prognostic index for accurate assessment and classification of the patient's risks.
In the present study, 168 cases of secondary peritonitis from those who attended a tertiary care centre from June 2020 to December 2021 were included, with ages ranging from 18 to 83 years and fulfilling the inclusion and exclusion criteria.
The most common site of perforation is gastric in all age groups and most common aetiology was peptic ulcer, followed by malignancy. This is in part due to the increased prevalence of the aetiological risk factors such as smoking, alcoholism and Non-steroidal anti-inflammatory drug abuse in this age group.
This data are in partial concordance with the study done by Schein M et al. In his study majority of patients were aged above 40 for peptic ulcer perforations.
According to Bylapudi et al., the most common aetiology is peptic ulcer followed by appendicular perforation.
Out of the total 168 patients, 142 were male and 32 were female. The aetiology of perforation peritonitis in this study is markedly varied as well as the site of perforation. The most common site of perforation was gastric; the perforations occurred in the antrum, pylorus and body of the stomach, among which the most common site was the pylorus of the stomach in the current study. The most common aetiology of gastric perforation is peptic ulcer perforation, accounting for 71.4% of cases, followed by malignancy, and the perforation due to malignancy is seen mostly in the body of the stomach. Most cases of malignant perforations were in the colon in this study.
There were 29 cases of small intestinal perforation; most of the cases were ileal (14 cases), 9 duodenal and 6 cases of jejunal perforations. Most of the ileal perforations were due to TBs. Traumatic were mostly jejunal in this study.
The most common procedure done for perforation is Graham's omental patch repair, which is done for peptic ulcer perforations in the stomach and duodenum and malignant perforations required resection with or without anastomosis.
Most of the cases of perforation occurred among the native people, but a significant number of gastric perforations occurred among the migrant labourer population, with the aetiology being peptic ulcer perforation. This may be attributed due to their habit of eating spicy foods and poor socio-economic conditions.
Out of the total 168 patients, 18 patients expired, the mortality rate of 10.7% is lower than the mortality rates observed by the study of Kulkarni et al., where the observed mortality rate was 16%.
The mortality rate among males is 6.3% and females 34%, so the percentage mortality is more among females in this study. However, majority of the cases of perforation occur among males and are mostly due to peptic ulcer perforation, but in females, the total number of cases is significantly less and the aetiology is mostly malignant and the age group is elderly.
The mortality rate associated with malignancy is higher than the mortality rates due to other reasons, such as peptic ulcer perforation. The percentage mortality rate of is malignancy in this study is 34%, whereas for peptic ulcer, its only 6%, even though it is the most common aetiology.
The mean APACHE-II score in this study is 6.17, which is lower than the score obtained for the study conducted by Schein et al., for analyzing and interpreting the results, APACHE-II score obtained is made into categories of 5. The mean APACHE-II score among survivors is 4.33 with a standard deviation of 3.69, and the mean score among the non-survivors is 21.44 with a standard deviation of 4.34. In studies conducted by Adesunkanmi et al. and Agarwal et al., the mean apache among survivors was 8 and non-survivors was 22.4. All these studies point towards a higher score associated with greater mortality.
In this study, the most common complications encountered were wound infections, pneumonia, burst abdomen and enterocutaneous fistula. Of the total number of patients, 39 patients developed complications, i.e., 23.2%.
The incidence of complications increased as the APACHE-II score increased.
Most of the patients belonged to the low score group, i.e., between 0 and 5, among the 102 individuals belonging to this group only 7 developed complications, i.e., 6.8%, and the rate of complications significantly increased in the next subgroups. 6–10 scores had a complication rate of 44%; in scores group 11–15, 84% developed complications and every individual in >15 subgroup developed complications.
There is a statistically significant correlation between APACHE-II score of the patients and the development of complications as the P < 0.01 by Chi-square analysis. A similar result was shown by Sahu et al. in which APACHE-II score as measured before the treatment of secondary peritonitis correlated significantly with the outcome of the disease with respect to mortality and morbidity.
The relationship between APACHE-II score and in hospital stay is also evaluated in this study which helps to have an idea of morbidity. It was found that the mean in hospital stay for low-risk group (score 0–5) is 6 days, whereas for 6–10 group, the mean hospital stay is 8.2 days with a standard deviation of 4, and for 11–15 score category the duration of stay is 15.8 days with a standard deviation of 7.6. The higher duration of in-hospital stay in this group is due to the higher rate of complications requiring in hospital management.
For patients with a score above 15 scores, the mean duration of hospital stay is only 4 days with a standard deviation of 4.6. This is because, in patients with APACHE-II score above 15, the mortality rates are high that most of them expire within a few days of admission and surgery.
On Chi-square analysis, P value obtained was 0.000 (<0.05), so there is a statistically significant association between APACHE-II score and duration of hospital stay.
These results are similar to those that found in studies of Agarwal et al., in which the mean days of hospital admission in survivors is 9.14 and non-survivors was 12.
The mortality rates observed in low-risk categories is (0–5 and 6–9) is 0 in this study, in the 11–15 category mortality rate is 15%, and the rate in the 16–20 category is 85%. Above 20, the mortality rate observed in this study is 100%.
Chi-square analysis using the above data showed a significant association between APACHE-II score and mortality (P = 0.000).
In this study, the sensitivity and specificity of APACHE-II score in predicting the mortality in perforation peritonitis is 99.3% and 94.4%, respectively, for scores above 15; this result is similar to the results obtained by the study on perforation peritonitis by Kulkarni et al. in which the APACHE-II scores of 16–20 had a sensitivity and specificity of 87.5% and 100%, respectively.
| Conclusions|| |
The most common age group having secondary peritonitis in this study is 41–50 years, with a mean age of 46.6 years and male preponderance. The most common aetiology for secondary peritonitis is found to be peptic ulcer perforation, followed by perforation due to malignancies. The most common site of perforation is the stomach, followed by the colon and ileum. There is a statistically significant association for APACHE-II score in predicting mortality, complications, and morbidity associated with perforation peritonitis. APACHE-II score above 15 has a sensitivity of 99% and specificity of 94.4% in predicting mortality associated with secondary peritonitis.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Holzheimer RG, Mannick JA, Surgical Treatment: Evidence Based and Problem Oriented. Munich: Zuckschwerdt; 2001. Available from: http://www.ncbi.nih.gov/books/NBK6880
. [Last accessed on 2020 Dec 16].
Hranjec T, Watson CM, Sawyer RG. Peritonitis: Definitions of primary, secondary, and tertiary. In: Vincent JL, Hall JB. (eds). Encyclopedia of Intensive Care Medicine;Berlin, Heidelberg:Springer. [Doi: https://doi.org/10.1007/978-3-642-00418-6_84
Troidle L, Finkelstein F. Treatment and outcome of CPD-associated peritonitis. Ann Clin Microbiol Antimicrob 2006;5:6.
Schein M, Gecelter G, Freinkel Z, Gerding H. APACHE II in emergency operations for perforated ulcers. Am J Surg 1990;159:309-13.
Bylapudi SK, Nanjan S, Ramasamy S, Kannan A, Kantamaneni K, Nangireddi S, et al.
Role of acute physiology, age, and chronic health evaluation (APACHE) II score in predicting outcomes of peritonitis due to hollow viscous perforation: A prospective observational study. Cureus 2021;13:e20155.
Kulkarni SV, Naik AS, Subramanian N Jr. APACHE-II scoring system in perforative peritonitis. Am J Surg 2007;194:549-52.
Adesunkanmi AR, Badmus TA, Fadiora FO, Agbakwuru EA. Generalized peritonitis secondary to typhoid ileal perforation: Assessment of severity using modified APACHE II score. Indian J Surg 2005;67:29-33.
Agarwal A, Choudhary GS, Bairwa M, Choudhary A. Apache II scoring in predicting surgical outcome in patients of perforation peritonitis. Int Surg J 2017;4:2321-5.
Sahu SK, Gupta A, Sachan PK, Bahl DV. Outcome of secondary peritonitis based on Apache II score. Internet J Surg 2008;14:2.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]