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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 28  |  Issue : 2  |  Page : 169-173

Validation of Boey's scoring system in predicting short-term morbidity and mortality in peptic ulcer perforation peritonitis


Department of General Surgery, Government Medical College, Kottayam, Kerala, India

Date of Submission28-Nov-2022
Date of Decision30-Nov-2022
Date of Acceptance03-Dec-2022
Date of Web Publication30-Jan-2023

Correspondence Address:
Dr. Geethu Saiphy
Department of General Surgery, Government Medical College, Kottayam - 686 008, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_48_22

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  Abstract 


Aim: This study aims to assess the validation of Boey's scoring system in predicting short-term morbidity and mortality amongst patients with peptic ulcer perforation (PULP) peritonitis. Methodology: 110 patients with PULP peritonitis were included in this study. Boey's score was calculated based on three parameters, pre-operative shock, concomitant medical illness and duration of perforation >24 h. All patients with PULP were treated with exploratory laparotomy with peritoneal lavage and omental patch repair and the patients were then followed up throughout the data collection period to look for clinical outcomes. The main outcomes assessed were mortality and short-term morbidity (1 month). Data were analysed using SPSS (IBM, Delhi, India). Chi-square test was used to check for the association between the outcome variables and the categorised Boey's score. The level of statistical significance was assigned as a P < 0.05. Results: Amongst the 110 patients, half belonged to the age group of 31–50 years, and 90% were male. The most common site of perforation was the first part of duodenum (78%). The rate of mortality was 10%. With respect to the distribution of the Boey's score, the percentage of patients with Boey's score 0, 1, 2 and 3 was found to be 12.75%, 58.2%, 24.5% and 5%, respectively, and their corresponding mortality was found to be 0%, 4.7%, 25.9% and 40%, respectively. Their morbidity at 1 week was found to be 21.4%, 42.6%, 80% and 100%, respectively, and morbidity at 1 month was found to be 0%, 39.3%, 75% and 100%, respectively. Conclusion: There was a significant association between mortality and morbidity at 1 week and at 1 month with the distribution of Boey's score. This highlights the importance of Boey's score in determining the outcome amongst perforated peptic ulcer patients. Boey's score being an easily applicable score for day-to-day clinical practice can aid clinicians in predicting the outcome amongst perforated ulcer patients. Several studies have also shown better accuracy with Boey's scoring system when compared to the other scoring systems.

Keywords: Boey's score, peptic ulcer perforation peritonitis, prognosis


How to cite this article:
Saiphy G, Sunil S. Validation of Boey's scoring system in predicting short-term morbidity and mortality in peptic ulcer perforation peritonitis. Kerala Surg J 2022;28:169-73

How to cite this URL:
Saiphy G, Sunil S. Validation of Boey's scoring system in predicting short-term morbidity and mortality in peptic ulcer perforation peritonitis. Kerala Surg J [serial online] 2022 [cited 2023 Mar 24];28:169-73. Available from: http://www.keralasurgj.com/text.asp?2022/28/2/169/368605




  Introduction Top


Peptic ulcer disease (PUD) is one of the most commonly prevalent gastrointestinal diseases accounting for a prevalence ranging from 5% to 15%.[1] It almost affects 4 million people every year globally, of which around 10%–20% develop some of the other moderate-to-severe complications, with a mortality rate ranging from 2% to 14%.[2] Haemorrhage, perforation and gastric outlet obstruction remain to be the most common complications encountered with PUD, amongst which perforation occurs in about 2%–10% of the cases, where mortality following perforation can be as high as 25%–30%.[3] Surgery remains the most preferred management option for perforations causing peritonitis. Earlier procedures such as vagotomy with drainage procedure or without it were considered a mainstay of treatment due to its acid-reducing property. The preferred treatment is primary repair with interrupted suture and omental packing.[4]

The incidence of PUD has increased substantially over the past few decades.[5] Poor outcomes during surgery are often linked to the increasing age of the patients, delay in diagnosis and start of treatment, presence of co-morbidities and intraoperative complications during surgery.[6] Several scoring systems have been introduced and validated for the prediction of outcomes in PUD.[7]

Despite, the development of various scoring systems for predicting the outcome, yet none appear to be superior and most are investigated in isolation, Boey's score and the more recently introduced peptic ulcer perforation (PULP) score.[8] However, only the Boey's and PULP scores are designed specifically for the prediction of mortality for PPU patients.[9] The Boey's score is now currently the commonly used score, but with varying degrees of accuracy. The PULP score though appears to be more accurate yet is more complex and has not been validated outside the original cohort.[10]

The Boey's score predicts mortality based on the presence of the following factors such as major medical illness, preoperative shock and perforation longer than 24 h. Despite several attempts to recalculate the findings or the original scores, all proved to be in vain with varying prediction abilities. The Boey's score is quite simple and easy to calculate, with only three parameters, with specific reference to being used amongst patients with PPU only. One study has reported that the predicting capacity of this score in predicting mortality was found to be as high as 93.9%.[11] Despite this evidence, its accuracy across different study settings is still questionable.[12] Nevertheless, the PULP score includes seven factors with weighted points, ranging up to 18 points and is now commonly studied upon. To improve outcomes in perforated peptic ulcer patients, it is important to stratify the patients into different categories based on morbidity and mortality and provide suitable risk-group-based management. Three prognostic factors, namely preoperative shock, long-standing perforation and associated medical diseases, were identified in patients with perforated peptic ulcer by Boey et al. in 1986 and validated in 1987.[13] Multiple studies have assessed the utility of Boey's scoring system in predicting the morbidity and mortality in PULP patients and found that it can be used for the classification of patients into different risk categories that subsequently facilitate the appropriate management of hospital resources.[8] Despite this evidence, studies supporting the use of this scoring system from India, especially from a south Indian setting, are still lacking. Thus, this study analyses the ability of Boey's scoring system in risk stratification of perforation peritonitis patients and its prognostic significance.


  Methodology Top


The aim of the study was to validate Boey's scoring system in predicting short-term morbidity and mortality amongst patients with PULP peritonitis, who are admitted and diagnosed with PULP peritonitis during the study, to find out the efficiency of Boey's scoring system in risk stratification, evaluating the prognosis of perforation peritonitis in patients admitted and operated with a diagnosis of perforation peritonitis and to stratify the patients into different categories based on Boey's score and to improve outcome by providing a suitable risk group-based management.

It was a hospital-based prospective observational study on patients with a clinical diagnosis of perforation peritonitis of age more than 18 years, regardless of sex in a tertiary care hospital between August 2020 and December 2021. We determined the validation of Boey's scoring system in predicting short-term morbidity and mortality amongst the patients. The sample size was calculated based on the study 'A study of clinical presentation and accuracy of the scoring system (based on Boey's) in predicting postoperative morbidity and mortality of perforated peptic ulcers' by Lee et al.[1] According to the formula, sample size = Z × Z × pq/d × d = (1.96 × 1.96) × 45 × 55/(9 × 9) = 110.

Boey's scoring system was used for outcome prediction in PULP peritonitis patient and was based on three prognostic factors, preoperative shock, concomitant medical illness and duration of perforation >24 h, each having a score of 1. The shock was defined as persistent hypotension with systolic blood pressure <90 mmHg and mean arterial pressure <60. The duration of perforation was determined by the time interval between the onset of symptoms of severe abdominal pain and time of starting surgery. Concomitant severe medical illnesses included heart disease, lung disease, liver failure, renal failure and immune-compromised patients. Patients below 18 years of age, those with primary peritonitis, perforation due to other causes as corrosive acid perforation, those with associated traumatic injury to other organs and those whose follow-up was difficult were excluded from the study.


  Results Top


We studied 110 patients. [Table 1] depicts the clinical and general details of the study participants. Forty-six per cent of the participants belonged to the age group of 31–50 years, with a mean age of 47.2 (12.2) years. Fifty-eight per cent had abdominal pain for <1-year duration and almost 78% of the study participants were male. Almost three-fourth of the study participants had perforations located in the first part of the duodenum. Diabetes was the most common co-morbidity (45%), followed by hypertension (38%) and bronchial asthma (12%).
Table 1: Clinical and general characteristics of the study participants (n=110)

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The distribution of Boey's score of study participants showed that most of the study participants i.e., 64 (58.2) had a Boey's score of one, followed by 27 (24.5%) had a score of two and 5 (4.5%) had score of three. The score was 0 in 14 (12.7%).

Of the 110 participants, 12 people (11%) succumbed to death during the follow-up. Morbidity amongst study participants at 1 week of follow-up was that of the 98 participants who survived, 48 people (49%) had co-morbidities.

[Table 2] explains the distribution of morbidity amongst study participants at 1 week of follow-up. We found that of the 98 participants who survived, the most common morbidity to be found at 1 week of follow-up was surgical site infections (46%) followed by pulmonary complications (33%).
Table 2: Distribution of morbidity amongst study participants at 1 week (n=48)

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Morbidity amongst study participants at 1 month of follow-up showed that of the 98 participants who survived, around 42 people (43%) had co-morbidities.

[Table 3] explains the distribution of morbidity amongst study participants at 1 month of follow-up. We found that of the 98 participants who survived, the most common morbidity to be found at 1 month of follow-up was surgical site infections (47%) followed by pulmonary complications (28%).
Table 3: Distribution of morbidity amongst study participants at 1 month (n=98)

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[Table 4] explains the association of Boey's score with the mortality of study participants. We found a statistically significant association between Boey's score with mortality of study participants, where more mortality was found to be amongst the score three participants (P = 0.02).
Table 4: Association of Boey's score with mortality of study participants (n=110)

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[Table 5] explains the association of Boey's score with morbidity in 1 week of study participants. We found a statistically significant association between Boey's score with morbidity at 1 week of study participants, where more morbidity was found to be amongst the score three participants (P < 0.001).
Table 5: Association of Boey's score with morbidity at 1 week amongst study participants (n=98)

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[Table 6] explains the association of Boey's score with morbidity at 1 month of study participants. We found a statistically significant association between Boey's score with morbidity at 1 week of study participants, where more morbidity was found to be amongst the score three participants (P = 0.002).
Table 6: Association of Boey's score with morbidity at 1 month amongst study participants (n=98)

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  Discussion Top


Perforated ulcer peritonitis cases are on a rise recently. The morbidity and mortality pattern amongst these cases varies at large depending on the type of ulcer, duration of perforation, size and site of ulcer and other co-morbidity pattern amongst the patients suffering from it.[8] There are several factors that determine the mortality and morbidity. One such scale is the Boey's score which has a scale ranging from zero to three and is validated for long for the outcome prediction amongst perforated peritonitis patients. We have evaluated the predictive nature of Boey's score in finding the association between Boey's score and morbidity and mortality amongst patients at 1 week and 1 month, respectively.

About half the patients belonged to the age group of 31–50 years and almost 90% were male. This finding was found to be in line with studies from various other studies.[14],[15] Majority of our patients were having an incident ulcer pain over a chronic abdominal pain of 1 year. The most common site of perforation was the first part of the duodenum (78%) which was also comparable with the findings from other studies.[15]

The most common abnormalities noted amongst the participants were diabetes followed by hypertension and bronchial asthma which were comparable to other studies.[15]

59% had a Boey's score of one, followed by 25% who had a score of two, which was found to be similar to another study from an Indian setting.[16]

The rate of mortality amongst participants was found to be 10% which is similar to another study by Gulzar et al.[17] This could be due to the fact that our study included many participants from the Boey's score category of one and two (70%).

Almost one in every two individuals had some form or the other morbidity (48%), which was in line with other studies from similar study settings. At 1 week of follow-up, the most common morbidity observed was found to be surgical site infections (46%) followed by pulmonary complications (33%).[18],[19]

At 1 month of follow-up, we found that almost two in every five individuals had some form or the other morbidity (43%), which was in line with other studies from similar study settings. At 1 month of follow-up, the most common morbidity observed was surgical site infection (47%) followed by pulmonary complications (29%). These findings were also found to be similar to other study findings from varied study settings.[17],[19]

The percentage of patients with Boey's score 0, 1, 2 and 3 was found to be 12.75, 58.2%, 24.5% and 5%, respectively, and their corresponding mortality was found to be 0%, 4.7%, 25.9% and 40%, respectively. Their morbidity at 1 week was found to be 21.4%, 42.6%, 80% and 100%, respectively, and morbidity at 1 month was found to be 0%, 39.3%, 75% and 100%, respectively. When mortality was compared with the distribution of Boey's score, we found that the distribution of mortality was significantly associated with the distribution of Boey's score, with more mortality seen commonly amongst the individuals with higher Boey's score (P = 0.02). This finding was already proved by studies from similar study settings which have also shown that a higher Boey's score is often associated with higher mortality.[19],[20]

On comparing morbidity at 1 week with the distribution of Boey's score we found that the distribution of morbidity at 1 week was significantly associated with the distribution of Boey's score, with more morbidity at 1 week seen commonly amongst the individuals with higher Boey's score (P < 0.001). This finding was already proved by studies from similar study settings which have also shown that a higher Boey's score is often associated with higher morbidity.[21]

On comparing morbidity at 1 month with the distribution of Boey's score we found that the distribution of morbidity at 1 month was significantly associated with the distribution of Boey's score, with more morbidity at 1 month seen commonly amongst the individuals with higher Boey's score (P < 0.001). This finding was already proved by studies from similar study settings which have also shown that a higher Boey's score is often associated with higher mortality.[21],[22],[23]

Our results were found to be different from a few studies from India and western countries, which could be because of varying reasons such as differences in the study characteristics, morbidity pattern, type of ulcer and duration of ulcer, delay in reporting, available of critical care management, intensive care unit facilities and resuscitation facilities across the two study settings.[24],[25] In addition to the above several prediction systems are in places such as the Mannheim peritonitis index, Acute Physiology and Chronic Health Evaluation score, Multi-Organ Failure Score, Jabalpur Index and PULP which are widely utilised for outcome prediction amongst perforated ulcer patients, but these scales have not been fully evaluated on a larger audience, especially from an Indian setting. In addition, the management position (MP) scale is not specific for perforated ulcer cases and it requires intraoperative information, thereby making it not fit tool for assessing the preoperative prediction of mortality and morbidity, whereas, the PULP scoring system requires more investigations. When Boey's score is taken into consideration, it could be easily and effectively used for the prediction of outcome and death amongst perforated ulcer patients. This early identification of risk might help clinicians in early diagnosis and follow-up of cases.[26]

Our study had several strengths. Ours was one amongst the very few studies that have estimated the association between Boey's score and mortality and morbidity at 1 week and 1 month amongst perforated peptic ulcer patients from an Indian hospital-based setting. We have utilised all recommended panels of investigations and radiological modalities for the diagnosis of perforated ulcers and estimation of Boey's score. Our study had certain limitations. We neither differentiate nor did a subgroup analysis to estimate the association between Boey's score and mortality separately amongst gastric and duodenal ulcer patients. Limitations of this study are generally attributed to the observational nature of this study and the constraints of the ability to establish causal relationships between the exposure and outcome. The findings are generalisable only to similar study settings, as the study was conducted only from one single centre from south India. We did not also take into account the age, nutritional status of the patients for the outcome assessment. We had a smaller sample size to evaluate the effect.


  Conclusion Top


We found that there was a significant association between mortality and morbidity at 1 week and at 1 month with the distribution of Boey's score. This highlights the importance of Boey's score in determining the outcome amongst perforated peptic ulcer patients. Boey's score being an easily applicable score for day-to-day clinical practice can aid clinicians in predicting the outcome amongst perforated ulcer patients. Several studies have also shown better accuracy with Boey's scoring system when compared to the other scoring systems.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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