PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
Name of the candidate
(in block letters)
Dr YOUSUF MOHSIN BARI SIDDIQUI.
HOUSE NO. 172 B, LANE NO 7,
ZAKIR NAGAR, OKHLA, NEW DELHI 110025.
Name of the institution
MVJ MEDICAL COLLEGE AND RESEARCH HOSPITAL.
Course of study and subject
M.S. (GENERAL SURGERY)
Date of admission to course
1ST JUNE 2012
Title of the Topic : CLINICAL STUDY AND MANAGEMENT OF ACUTE PERITONITIS .
Brief resume of the intended work:
6.1. Need for the study:
Acute peritonitis is one of the most common surgical emergencies. The causes for acute peritonitis are varied and present a diagnostic challenge. It requires a thorough clinical evaluation supplemented by investigations to arrive at an accurate diagnosis. The management of acute peritonitis is a surgical challenge with high morbidity and mortality. Therefore it is necessary to study and evaluate factors which prognosticate increased morbidity and mortality and assess the validity of various scoring system such as the Mannheim peritonitis index score.
6.2. Review of literature:
Peritonitis has been a well known entity from the days of Hippocrates that is 400 BC. He described the Hippocrates facies, which is also well known. Since then the pendulum has swung between the non operative management to the most aggressive approach of today. Till today, peritoneal sepsis remains a challenge to modern day surgeons. Severe diffuse peritonitis is still a Giant killer1 Peritonitis is a common emergency encountered by surgeons the world over. Overall, perforations of the gastro duodenum are the most common cause of peritonitis, with duodenal perforations range from 76.2%- 95.7%, gastric ulcer perforations from 2.1%- 23.8% followed by small bowel perforations ranging from 6% - 42%, followed by appendicular perforation. The overall mortality ranges between 6 – 27%, peritonitis can occur secondary to pancreatitis, diverticulitis and trauma to abdominal cavity. However peritonitis can develop without any hollow viscus perforation such as spontaneous peritonitis usually a complication of liver disease such as cirrhosis2. The outcome of abdominal infections depends on complex interactions of many different factors and success is obtained with early onset of specific therapies and procedure, the Mannheim Peritonitis Index (MPI) incorporates information regarding age, gender, organ failure, cancer, duration of peritonitis, involvement of colon, extent of spread with in the peritoneum and character of peritoneal fluid. Score ranges from zero to 463. MPI score between 21 and 29, had a mortality rate of 60% and almost100% if MPI more than 29, and the accuracy of MPI was slightly superior to that of other sepsis classifications4.
Laparoscopy is nowadays suggested to be feasible and safe in peritonitis. It is found to be effective in appendicular and gastro duodenal perforations. In a study with non traumatic peritonitis, post laparoscopy group showed a positive nitrogen balance and reduced septic morbidity5. In another study of 147 patients with acute peritonitis operated laparoscopically, 68 were lower quadrant peritonitis, 17 gastro duodenal perforations and 62 cases of acute cholecystitis. Definitive diagnosis was accomplished by laparoscopy in 93.1% of the cases and 85.7% of the patients were successfully treated by emergent laparoscopy in same sitting and unnecessary laparotomy was avoided in 17% of cases.. The morbidity rate was 4.0% with a postoperative mortality rate of 0.68%6.
6.3 Objectives of the study:
1. Analysis of various causes of acute peritonitis with respect to morbidity and mortality.
2. Mannheim peritonitis index scoring system as a predictor of prognosis in acute peritonitis.
3. To assess the role of laparoscopy as diagnostic and therapeutic modality in acute peritonitis.
Materials and Methods:
7.1. Source of data:
Clinically suspected cases of acute peritonitis seen at MVJMC & RH.
7.2. Materials and Method of collection of data (including sampling procedure, if any)
Definition of a study subject:
Any individual who presents with acute onset of abdominal pain along with symptoms and signs of peritonitis.
Individuals above the age of 18 years, who present with features of acute peritonitis.
1. Obstetrical / gynecological causes for acute peritonitis.
2. Peritonitis secondary to peritoneal dialysis.
Period of study
The study will be conducted over a period from November 2012 up to July 2014 on all patients of acute peritonitis satisfying the specified criteria.
Method of study:
.History with relevant investigations and consent for inclusion in the study.
. The cause of peritonitis will be determined and according to diagnosis, patients will be managed either conservatively or surgically.
. Mannheim Peritonitis Index scoring system will be used and risk stratification will be undertaken.
. Those found to have scores more than 20 will be managed in intensive care unit.
. Patients will undergo laparoscopy for diagnosis in equivocal cases,
. In-hospital complications and morbidity will be studied.
. Follow up for a period of 3 months will be done after discharge.
7.3. Does the study require any investigation or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.
Yes, routine investigations will be conducted on patients for assessment of their fitness for anesthesia and surgery. The following investigations are necessary :
Complete blood count, erythrocyte sedimentation rate, platelet count, bleeding and clotting time and blood grouping.
Renal function test.
Serum amylase/ lipase.
Peritoneal fluid analysis.
Arterial blood gases.
Blood sugar levels.
X ray abdomen (Erect/ Supine).
Liver function test.
Prothrombin Time, Partial thromboplastin time, INR.
7.4. Has ethical clearance been obtained from your institution in case of 7.3?
List of references:
1. Jeremy Thompson. The peritoneum, omentum, mesentery and retroperitoneal cavity. In Williams, Bulstrode, O’Connell (eds). Bailey and Love’s Short Practice of Surgery.25th Ed. London, Edward Arnold; 2008: 944.
2. Sanjay Gupta, Robin Kaushik. Peritonitis – The Eastern Experience, World J Emerg Surg [Internet]. 2006[updated 2006 Apr 26; cited 2006 Mar 22].
Available from: http://www.wjes.org/content/I/I/I3
3. Prajakt V. Patil , Manmohan M Kamat, Milan M Hindalekar. Spectrum of perforative peritonitis, A prospective study of 150 cases. Bombay Hospital Journal.2012; (54):38-50.
4. Ali Yaghoobi Notash , Javad Salimi , Hosein Rahimian , Mojgan sadat Hashemi Fesharaki , Ali Abbasi. Evaluation of Mannheim Peritonitis Index and multiple organ failure score in patients with peritonitis. Indian J.of Gastroenterol. 2005; (24): 197-200.
5. Navez B, Tassatti V, Scohy JJ, Mutter D, Guiot P, Evrard S, Marescause J. Laparoscopic management of acute peritonitis. Br J Surg. 1998; 85(1): 32-36.
6. Ates M, Coben S, Sevil S, Terzi A. The efficacy of laparoscopic surgery in patients with peritonitis. Surg Laparosc Endosc Percutan Tech.2008; 18(5): 453-6.
Acute peritonitis is the most common surgical emergency encountered in day to day practice. It is a challenge not only to diagnose but also to manage such patients. Since the prognosis is guarded in these patients, a scoring system such as the Mannheim peritonitis index score can be put to good use. With the advent of laparoscopy, role of minimal access surgery in patients with acute peritonitis is increasing. Hence it is a good study to evaluate patients with acute peritonitis.
Name & Designation of : Prof. Dr ANANTHARAMAN D. ( MS GENERAL SURGERY)