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Official Journals By StatPerson Publication

Table of Content - Volume 12 Issue 3 - December 2019


 

Effectiveness and evaluation of Mannheim peritonitis index scoring system for prediction of mortality and morbidity in patients with peritonitis following hollow viscus perforation

 

Jagrutkumar Patel1, Digant Patel2*

 

1,2Assistant Professor, Department of Surgery, SSG Hospital and Medical College Baroda, Vadodara, Gujarat, INDIA.

Email: dr.saidap@gmail.com

 

Abstract               Background: Despite of various advanced intensive care supports and highest antimicrobial therapy, secondary peritonitis is extremely fatal, if not treated earliest. So earliest assessment by scoring system may aid us in management and prognosis. So it is important to evaluate one of the scoring system Mannheim Peritonitis Index (MPI) in Indian population. Aim: To evaluate and validate Mannheim Peritonitis Index (MPI) for prediction of morbidity and mortality. Materials and Methods: This was a prospective, observational and open study conducted on 100 patients who were presented with peritonitis following hollow viscus perforation at Department of Surgery at SSG Hospital, Vadodara. Mannheim Peritonitis Index (MPI) was calculated. Results: Our study population was divided into 3 groups according to Mannheim Peritonitis Index (MPI) range (< 21, between 21 to 29, and >29). In < 21 MPI score, morbidity in form of wound infection was (3)5.8% and (0)0% mortality and (49)94.2% were survivors out of 52(52%) patients. In MPI score between 21 to 29, morbidity in form of wound infection was (12)41.4% and mortality was (12)41.4 % and (5)17.2% were survivors out of 29(29%) patients. In > 29 MPI score, morbidity in form of wound infection was (3)15.8% and mortality was (16)84.2 % and (0)0% survivors out of 19(19%) patients. Conclusion: Mannheim Peritonitis Index (MPI) is good predictor of morbidity and mortality in cases of peritonitis following hollow viscus perforation.

Key Words: Hollow viscus perforation, Mannheim Peritonitis Index, Morbidity, Mortality, Peritonitis

 

 

INTRODUCTION

In era of recent advances in areas of medicines, the surgeon must be familiar with management of secondary peritonitis from gastro-intestinal perforation, recognition of patients with persistent intra-abdominal sepsis or tertiary peritonitis with multi-organ failure and depressed immune system. Despite advance in anti-microbial therapy and highest intensive care, mortality from diffuse peritonitis remains exceptionally high. The causes may vary from requiring immediate surgical intervention to requiring conservative management. So accurate diagnosis and management is a challenge to every surgeon. So scoring system that provides objective descriptions of patient’s conditions at specific points in disease process help us to understand these problems. So current trend is to recognize these at the earliest and institute an aggressive therapy because after multi-organ failure sets in the outlook appears dismal whatever the line of management is. Fry and associates in 19801 showed that death after major operative procedures or severe trauma was usually due to infection and became more likely as the number of failed organs increased. In 1982 Knaus and others2,3 proposed a scoring system to be used for classifying patient admitted to ICU. They devised a 2 parts scale. The first part included physiological portion, APS-34 (Acute Physiological Score), examines abnormality among 34 possible physiological assessments, which were obtained on first day of admission. The second part included Chronic Health evaluation (CH). This examines patient’s pre-admission health status by reviewing the medical history for detail concerning functional status, productivity and medical attention during 6 months before admission. The combination is called APACHE (Acute Physiological and Chromic Health Evaluation). This system is not specific for intra-abdominal infection. It was later modified using only 12 values the APACHE II (Acute Physiological And Chromic Health Evaluation-II), which incorporated value like temperature, mean arterial pressure, white blood count, heart rate, respiratory rate, arterial pH, serum sodium, serum potassium, hematocrit(%), sodium bicarbonate. It is complex and time consuming. So use of APACHE II (Acute Physiological And Chromic Health Evaluation-II) score in under-staffed and under equipped circumstances is not practical. In 19834 Elebute and Stoner published grading of severity of sepsis. They divided clinical feature of septic state into 4 classes depending on degree of severity on an analogue score. The attributes were local effects of tissue infection, degree of temperature elevation, secondary effect of sepsis and lab data. Pine and associates(1983)5 confirm above findings. They additionally found the risk factors like malnutrition, alcoholism and age as important predictive factors that thought to influence development of organ failure and death. Teichmann and associate(1986)6 in a report concerning scheduled reoperation for diffuse peritonitis. Wacha and coworkers(1987)7 developed a separate peritonitis index, the Mannheim Peritonitis Index(MPI). With incorporated information regarding age, gender, organ failure, cancer, duration of peritonitis, involvement of colon, extent of spread within the peritoneum and character of peritoneal fluid to define risk. Score ranges from 0 to 46. In 1988, V. Kohli8 and others evaluated prognostic factors in 50 cases of peptic ulcer. They found general health, concurrent illness, arterial hypotension at time of admission, delay in surgery and severity of peritoneal contaminations contributing to post-operative morbidity and mortality.

In 1990, Verma and others9 in PGI Chandigarh, compared prognostic factors in peritonitis due to trauma. They found pre-operative shock, multiple hollow visceral injuries, septicemia and location of injury(colon and duodenum with high mortality). Rogy M10 studied seventy patients suffering from purulent peritonitis entered this study, 31 of them were taken in prospectively, to contrast two different prognostic scores, the Mannheim Peritonitis Index (MPI) vs. the APACHE II. Moreover, sensitivity and specificity with the MPI are of higher accuracy than calculated with the APACHE II. In 1994, Svanes11 and other did a study of diverse effect of delayed treatment for perforated peptic ulcer and concluded that delay of more than 12 hours increased mortality especially in elderly patient confirming finding of MPI(Mannheim Peritonitis Index). Both APACHE II (Acute Physiological And Chromic Health Evaluation II) and MPI (Mannheim Peritonitis Index) correctly graded intra-abdominal infections and strongly and independently associated with an outcome. However, the MPI (Mannheim Peritonitis Index) has advantages of being easier to calculate12. Multi-organ Failure (MOF) Score: In 1985 Goris et al13 published MOF score that grades patients on a three point scale. It takes into consideration dysfunction of pulmonary, cardio-vascular, hepatic, renal, nervous, hematological and gastro-intestinal system. In recent revision gastro-intestinal and nervous systems have been excluded. This organ dysfunction score correlate strongly with the ultimate risk of mortality due to peritonitis in ICU. Simplified Acute Physiology Score (SAPS): Le Gall et al developed this score. It is composed of 14 easily measured physiological variables and the score ranges from 0-5614. Severity Sepsis Score (SSS):It was published by Elebute and stoner in 1983 consisting of 4 components regarding various effect of sepsis. There is multiple scoring of certain components as both underlying cause and secondary effects included in the scoring4.

MPI (Mannheim Peritonitis Index):

The Mannheim Peritonitis Index is based on data from 1253 patients with peritonitis treated between 1963 to 1979. It was developed by discriminate analysis of 17 possible risk factors. Eight of these were of prognostic relevance and were entered into current index, with a weighting according to the predictive power. MPI (Mannheim Peritonitis Index) was published by Wacha H and Linder based on analysis of risk factors in patients with peritonitis7. Score were calculated at admission or during management. It was calculated for each patient on a pre-designed proforma and the patients were followed up till death or discharge from hospital. Prognosis index is based on patient state at discharge. The MPI (Mannheim Peritonitis Index) has a good accuracy and provides an easy way to handle with clinical parameters. Statistical validation showed the MPI (Mannheim Peritonitis Index) to be an accurate and reliable predictor of surgical mortality, the inclusion of a pathophysiological variable may raise its accuracy15. Score considers clinical risk factors routinely found in pre-operative register.


Mannheim Peritonitis Index Scoring System

RISK FACTORS

WEIGHTING IF PRESENT

Age > 50 years

5

Female sex

5

Organ Failure

7

Malignancy

4

Pre-operative duration of peritonitis > 24 hours

4

Origin of Sepsis Non-colonic

4

Diffuse Generalized Peritonitis

6

Exudates

 

Clear

0

Cloudy

6

Faecal

12

Definition of organ failure; Kidney -- Creatinine level >2.0 mg/dl or 177umol/l; -- Urea level >90mg/dl or 167mmol/l; -- Oligouria: Urine output < 20ml/hour; Lung -- If PO2 < 50 mmHg, PCO2 > 50 mmHg; Shock -- Hypo-dynamic or hyper-dynamic; (Definition according to Shoemaker); Intestinal Obstruction – Paralysis greater than or equal to 24 hours or complete mechanical ileus.


MATERIALS AND METHOD

The study was done in 100 patients with peritonitis due to hollow viscus perforation who presented to Department of surgery, SSG hospital, Vadodara. The study was prospective, observational and open study conducted during the period October 2011 to September 2012. The study was done after obtaining a detail history, complete general examination and systemic examination. The patients were subjected to relevant investigation like X-ray Abdomen (erect posture), chest X-ray, Ultrasonography of abdomen, CECT abdomen and pelvis (if required) and routine investigations like CBC, Urea, creatinine, Serum electrolyte. All investigations and surgical procedures were carried out after proper informed and written consent was obtained. The data regarding patient particulars, diagnosis, investigations and surgical procedure was collected in a specially designed case recording form and transferred to a master chart subjected to statistical methods like Mean, Standard Deviation, Proportion, Percentage calculation and wherever necessary Chi-Square test for proportion was used.

Inclusion criteria:

  • Patient with clinical suspicion and investigatory support for diagnosis of peritonitis due to hollow viscus perforation who are later confirmed by intra-operative findings.

 Exclusion criteria:

  • Hollow viscus perforation due to trauma,
  • Associated injuries to other organs,
  • Associated Vascular, Neurogenic injuries.

Patients were subjected to detailed physical examination to assess general condition. Local examination of abdomen was done and relevant findings were recorded. Rectal examination was done in all cases and per vaginal examination was performed in all female. Requisite investigations were done to established diagnosis. Pre-operatively all patients received corrective treatment for hypotension and electrolyte imbalance. Pre-operative antibiotics covering both aerobic and anaerobe organisms was given. During laparotomy detailed intra-abdominal examination of all organs was conducted in addition to specific pathology. Primary closure, resection anastomosis and exteriorization was performed. Appropriate suture material was used. Thorough peritoneal lavage was given with 3-4 liters of normal saline. Intra-abdominal drains were kept in all patients at required place. Abdomen is closed in layers with non-absorbable (no.1 R.B) suture material with skin closed with non-absorbable (no.(2-0)R.C) suture. MPI(Mannheim Peritonitis Index) scoring was done in all patients and were classified those with score < 21, between 21 to 29 and > 29. Patients were monitored in post-operative period. Input and output charts were maintained. Drains were removed on 7th day and sutures were removed on 15th day. Patients in whom wound infection occurred daily dressing was done till healing of wound or secondary suturing.

 

OBSERVATIONS AND RESULTS

Table 1: Age and Sex wise distribution of study subjects

Age

Male (%)

Female (%)

Total (%)

Less than 15

0(0)

1(100)

1(100)

16-30

11(68.8)

5(31.3)

16(16)

31-45

24(68.6)

11(31.4)

35(35)

46-60

25(65.8)

13(34.2)

38(38)

Above 60

6(60)

4(40)

10(10)

Total

66(66)

34(34)

100

Mean age of patients was 45.72 years which ranges from 13 to 75 years. Majority of patients 38(38%) belonged to age group 46-60 years. There was male preponderance of 66(66%) with male to female ratio of 1.9:1

 

Table 2: Time of presentation since start of symptoms, mortality and survival

Duration of symptoms

Mortality (%)

Survival (%)

Total (%)

1 day

1(7.1)

13(92.9)

14(14)

2 to 5 days

21(26.9)

57(73.1)

78(78)

More than 5 days

6(75)

2(25)

8(8)

Total

28(28)

72(72)

100

Majority of patients 86% (78% + 8%) presented to hospital after 24 hours of onset of symptoms. Mortality rate of 75% and 26.9% was highest in patients who presented after more than 5 days and between 2 to 5 days of onset of symptoms respectively compared to mortality of 7.1% in patients who presented within 24 hours of onset of symptoms. The chi square value of these patients was 11.83 with a significant p value of < 0.003.

 

1

Figure 1: Showing mortality and duration of presentation

Table 3: Distribution of study subjects and MPI Score

MPI Score

Dead(%)

Wound Infection(%)

Survivors(%)

Totall(%)

Less than 21

0(0)

3(5.8)

49(94.2)

52(52)

21 to 29

12(41.4)

12(41.4)

5(17.2)

29(29)

More than 29

16(84.2)

3(15.8)

0(0)

19(19)

Total

28(28)

18(18)

54(54)

100

In study group of MPI < 21, there were 52(52%) patients in which wound infection (WI) was 3(5.8%), mortality of 0(0 %) and 49(94.2%) being normal. In group of MPI between 21 to 29, there were 29(29%) patients in which wound infection (WI) was 12(41.4%), mortality of 12(41.4 %) and 5(17.2%) being normal. In group of MPI > 29, there were 19(19%) patients in which wound infection (WI) was 3(15.8%), mortality of 16(84.2 %) and 0(0%) being normal. The chi square value was 84.13 with significant p value of < 0.002.

 

2

Figure 2: Showing distribution of study subjects and MPI scores

 

Table 4: Etiology and MPI Score

Etiology

MPI Score

Total(%)

 

< 21

>21

 

Caecal

1(50)

1(50)

2(2)

Duodenal

41(58.6)

29(41.4)

70(70)

Appendicular

7(53.8)

6(46.2)

13(13)

Ileal

1(8.3)

11(91.7)

12(12)

Jejunal

2(66.7)

1(33.3)

3(3)

Total

52(52)

48(48)

100

Duodenal perforation was seen in 70% of patients followed by Appendicular (13%), Ileal (12%), Jejunal (3%) and Caecal (2%) as etiologies of peritontis. Among patients with Ileal perforation (12%), 11(91.7%) of them had MPI Score more than 21.

3

Figure 3: Showing etiological distribution

 

DISSCUSION

In our study of 100 patients, mean age was 45.72(SD 14.26) with age ranging from 13 to 75 years. The male preponderance was of 66% with male to female ratio 0f 1.9:1. In our study most common etiology of peritonitis was duodenal perforation (70%) which is consistent with the Ohmann et al16 study report. In our study 86% of patients presented after 24 hours of onset of symptoms and mortality was 31.4% compared to mortality of 7.1% in patients who presented within 24 hours of presentation. Ohmann et al16 also found high mortality of 25% in patients presented after 24 hours of onset of symptoms in their study which are consistent with our study findings. In our study group of MPI < 21, there were 52% patients in which wound infection occurred in 5.8% with mortality of 0% and in MPI between 21 to 29, there were 29% patients in which wound infection occurred in 41.4% with mortality of 41.4 % and in group of MPI > 29, there were 19% patients in which wound infection occurred in 15.8% with mortality of 84.2 %. In study of Billing A, Frohlich D, Schildberg FW17, they found mortality rate up to 2.3%, up to 22.5% and more than 59.1% in patients with MPI less < 21, between 21 to 29 and > 29 respectively. Comparing our study with Billing A, Frohlich D, Schildberg FW17 study, mortality rate was similar in groups with MPI <21 . But there is more mortality in our study with MPI range of 21 to 29 and MPI >29 which could be due to lack early aggressive treatment and poor healthcare infra-structure. In our study mortality rate of 0%, 41.4% and 84.2% in MPI Score <21, 21-29 and >29 respectively ,compared to study of Notash AY, Salimi J, Rahimian H, Fasharaki MH, Abbasi A18 had who had mortality rate of 0%, 7% and 80% with MPI Score <21, 21-29 and >29 respectively. The more rate of mortality with MPI Score 21-29 in our study could be due to lack of recent advance in ICU management. Barrera Melgarejo E, Rodriguez Castro M, Borda Luque G, Najar Trujillo N et al19] study found 60% mortality rate in patient with MPI score >29. Compared to our result of 84.2% in patient with MPI > 29, difference could be due to availability of better healthcare facility there compared to us. A S Ermolov, V E Bagdat’ev, E V Chudotvortseva, A V Rozhnov20 et al did a study and divide patients in to 3 groups. First with MPI 12-20 who had 0% mortality, second with MPI 21-30 who had 42% mortality and third with MPI >30 who had 100% mortality. In comparisons of our study which had 84.2% mortality with MPI >29 with their study of 100% mortality with MPI >30, could be due to better intra-operative and post-operative management , better antibiotic discovery and some sampling error.

 

CONCLUSION

Mannheim Peritonitis Index is good scoring system with good accuracy in predicting mortality in cases of peritonitis following hollow viscus perforation with advantage of easy data collection and easy to calculate compared to other scores. Increase in score indicates poorer prognosis and require prompt early aggressive treatment. So it should be used in all tertiary care hospital.

 

 

 

 

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