Peritonitis in Children: Our Experience in Benin City,Nigeria

Abstract

Background:

Peritonitis is a surgical emergency of variable etiology with a high mortality rate, particularly in children. This paper reports our experience with the epidemiology and outcome of management of childhood peritonitis in an African setting.

Patients and Methods:

Consecutive children with peritonitis managed over six years (2004–2009) at the University of Benin Teaching Hospital, Nigeria, were included in this prospective experience after approval by the local Ethics Committee.

Results:

Of the 721 children aged between one day and 18 years (mean 5 ± 4.2 years), comprising 415 males and 306 females (male/female ratio 1.4:1) who were managed for gastrointestinal disease, 182 (25.2%) developed peritonitis, 179 (98.4%) preoperatively and three (1.6%) postoperatively. Secondary bacterial peritonitis most often followed complicated appendicitis (120; 65.9%), intussusception (13; 7.1%), volvulus (5; 2.7%), and intestinal atresia (4; 2.2%). Peritonitis was generalized in all children younger than 11 years but less so after that age, and the outcome was poorest in neonatal infants, who accounted for 14 (63.6%) of the 18 peritonitis-related deaths (p < 0.0001). All the children had thorough peritoneal irrigation and lavage that included the insertion of drains in cases of localized peritonitis. The choice of antibiotics and additional surgical options that included bowel resection and anastomosis, stoma creation, and closure of perforation depended on the primary pathology and bacteriology findings. The duration of hospitalization was increased to between seven days in older children with localized peritonitis and 25 days in neonatal infants with generalized peritonitis compared with 3–5 days in children with similar pathology who did not have peritonitis (p < 0.0001).

Conclusion:

Peritonitis was severe and generalized in younger children, especially neonatal infants, who accounted for the majority of the deaths recorded. Early referral of children, particularly neonatal infants, having gastrointestinal complaints for surgical consultation and prompt surgical management is recommended to prevent peritonitis and to improve the outcome of children with the disease.

Peritonitis, inflammation or infection of the peritoneum, is a serious, even life-threatening, pathology that may be generalized or localized to an abdominal quadrant [1,2]. It has been classified as primary (spontaneous) or secondary to complications of other gastrointestinal disease and is caused usually by chemical irritation or bacterial invasion of the peritoneal cavity [3,4]. The etiology and outcome differ among medical centers, with poorer outcomes recorded in generalized and bacterial peritonitis occurring at the extremes of age, especially in regions with poor hygiene and in cases of infections with virulent organisms [5 –7]. The rapid and massive loss of fluid and electrolytes secondary to increased insensible loss, vomiting, and sequestration into the third space and the systemic invasion and dissemination of virulent gut anaerobes/enterococci lead to rapid clinical deterioration and irreversible sequelae that are worse in children [6,8]. Moreover, the superimposition of peritonitis on the primary gastrointestinal pathology in secondary peritonitis aggravates the morbidity and increases the mortality rate, especially in neonatal infants, who have additional problems of adjusting to postnatal life and the stress of delivery [6,9].

It has been emphasized that knowledge of the vulnerable age groups and the patients with primary disease mostly at risk, the etiology, as well as the bacteriology of peritonitis in a center may influence the speed of diagnosis and institution of prophylactic or therapeutic measures [10,11]. This may be important in policy formulation, especially in developing countries with meager resources and where reported incidences of virulent bacterial peritonitis are high [6,12]. Not many publications are available on childhood peritonitis in this African subregion, even though it is a common and challenging problem for pediatricians and pediatric surgeons [1,3,6,9].

This paper reports our six-year experience with the epidemiology and outcome of childhood peritonitis in an African setting that may be useful to practitioners in similar settings.

Patients and Methods

This prospective experience with childhood peritonitis was accumulated at the University of Benin Teaching Hospital, Benin City, Nigeria, between January 2004 and December 2009. The hospital is multidepartmental and houses a pediatric surgery department that serves as a referral center for Edo and neighboring states. Children were admitted to the department via the surgical outpatient clinic and the emergency department of the hospital. Following approval by the hospital Ethics Committee, consecutive cases of children who were managed for peritonitis at the hospital were included in the study. A combination of clinical, radiologic, and laboratory evaluations were required to make the diagnosis of peritonitis, which was confirmed at laparotomy. The biodata, etiology/type of peritonitis, frequency, duration of symptoms before presentation, clinical state on arrival, bacteriology/sensitivity pattern, surgical options, complications, and outcome of each case were collated on a structured form. We included only those patients who had operative and microscopic confirmation of peritonitis and excluded children (n = 34) with peritonitis who required no surgical intervention and all those who died before surgery.

The data were analyzed using SPSS version 13 software (SPSS, Chicago, IL). Continuous data were expressed as mean ± standard deviation (SD), whereas categorical data were analyzed using the chi-square test, with a p value ≤0.05 regarded as statistically significant.

Results

Of a total 721 children aged between one day and 18 years (mean 5 ± 4.2 years), comprising 415 males and 306 females (male/female ratio 1.4:1) who were managed for gastrointestinal disease, 182 (25.2%) developed peritonitis, 179 (98.4%) preoperatively and 3 (1.6%) postoperatively. Primary (spontaneous) peritonitis was rare, being seen in only three girls aged between 11 and 18 years who had chronic nephritis. The bacteria isolated in these three cases were Escherichia coli and Bacteriodes spp., which occurred with equal frequency. The majority of cases, 179 (98.4%), were secondary to other gastrointestinal pathologies, including a case of tuberculous peritonitis. Overall, bacterial peritonitis accounted for 173 (95.1%) of cases, whereas chemical peritonitis following solid visceral injury occurred in 9 (4.9%). Appendicitis (120; 65.9%) was the disease most commonly complicated by bacterial peritonitis, followed by perforated intussusception in 13 children (7.1%), whereas the least common cause of peritonitis was Hirschsprung's disease with bowel perforation (two cases; 1.1%).

Table 1 shows the correlation between patient age and the frequency of gastrointestinal diseases complicated by peritonitis. These ranged from appendicitis in 120 children (65.9%) aged 6–18 years to perforated volvulus (5; 2.7%) and intestinal atresia (4; 2.2%), which occurred only in neonatal infants. Peritonitis was generalized in all 76 children aged less than 11 years (41.8%), whereas in the 106 (58.2%) aged greater than 12 years, it was localized in 69 (65.1%), mainly with appendicitis, and generalized in 37 (34.9%).

Table 1.

Correlation between Age of Children and Etiology of Peritonitis over Six Years in Benin City

	0–1 mo	2–6 mos	7 mos–1 y	2–5 y	6–11 y	12–18 y	Total (%)
Perforated appendicitis	–	–	–	3	26	91	120 (65.9)
Intussusception/perf	–	10	2	1	–	–	13 (7.1)
Volvulus/perf	5	1	–	–	–	–	6 (3.3)
Traumatic visceral perf	2	–	–	–	4	9	15 (8.2)
Bowels atresia/perf	4	–	–	–	–	–	4 (2.3)
Ruptured ovarian cyst	–	–	–	–	–	4	4 (2.3)
ARM/perf	3	–	–	–	–	–	3 (1.6)
Spontaneous bowel perf/NEC	3	–	–	–	–	–	3 (1.6)
Postoperative peritonitis	2	1	–	–	–	–	3 (1.6)
Primary peritonitis	–	–	–	–	1	2	3 (1.6)
Typhoid ileal perf	–	–	–	–	2	–	2 (1.1)
Congenital bands/perf	2	–	–	–	–	–	2 (1.1)
Adhesive bands/perf	–	–	–	1	1	–	2 (1.1)
Hirschsprung's Dx/perf	1	1	–	–	–	–	2 (1.1)
Total	22 (12.1)	13 (7.1)	2 (1.1)	5 (2.7)	34 (18.7)	106 (58.2)	182 (100)

ARM = anorectal malformation, Dx = disease; NEC = necrotizing enterocolitis; perf = perforation.

The duration of symptoms of primary gastrointestinal disease before the onset of peritonitis differed with the disease entity, but ranged overall from 12 h to four years, which allowed enough time for bowel gangrene/perforation and consequent peritonitis to set in. Excepting 69 children with localized peritonitis who were clinically stable on arrival, others, particularly the neonatal infants, were severely compromised, with nine (40.9%) of them in septic shock. They required aggressive resuscitation with physiologic saline (4 mL/kg/h), correction of electrolyte derangement, a 100% maintenance fluid therapy of 5% glucose in 1/5 saline, and broad-spectrum antibiotics. In addition, blood transfusion was required in 38 children (20.9%) who were anemic. Laparotomy confirmed the etiology of peritonitis, as depicted in Table 1. Surgical options that included thorough peritoneal lavage and drainage of localized abscess were based on intraoperative findings, and no child required re-laparotomy. Intraoperative peritoneal fluid collected for microscopy culture and sensitivity yielded mixed growth in the majority of cases, as shown in Table 2. There were no facilities to isolate anaerobes, but metronidazole was added empirically to the regimen. The gentamicin/cefuroxime/metronidazole combination, used in 81 children (44.5%), and a ceftriaxone/metronidazole combination, used in 58 (31.2%), were most common antibiotic regimens.

Table 2.

Frequency of Bacterial Isolates among 173 Children with Bacterial Peritonitis

	No. (%)
Escherichia coli	173 (100)
Neisseria meningitidis	151 (87.3)
Klebsiella pneumoniae	140 (80.9)
Staphylococcus aureus	87 (50.3)
Pseudomonas	80 (46.2)

Table 3 shows the correlation between the age bracket of the patients and the frequency of peritonitis and peritonitis-related deaths, which were very high among neonatal infants. Of 91 such infants treated for gastrointestinal disease during the period, 22 (24.2%) developed peritonitis, which resulted in 14 deaths (63.6%). Protracted postoperative ileus, electrolyte problems, overwhelming sepsis, wound infection, burst abdomen, pulmonary/renal complications, and inanition were the major causes of death. On the other hand, of 304 children aged greater than 12 years, 106 (34.9%) had peritonitis with no deaths recorded. There was a significant statistical difference when peritonitis-related deaths were compared in neonatal infants and older children (p < 0.0001). There was no serious postoperative morbidity or death recorded among children with localized and chemical peritonitis. No significant statistical difference was observed in the outcomes of upper and lower gastrointestinal disease complicated by peritonitis (p = 0.6712). Overall, peritonitis accounted for 18 deaths (2.5%) among all children with gastrointestinal surgical pathology and 10% of those, mainly neonatal infants, whose disease was complicated by peritonitis. Among children who survived, the duration of hospitalization ranged from seven days in older children with localized peritonitis to 25 days in neonatal infants with generalized peritonitis. On comparing children with similar gastrointestinal surgical disease, the postoperative morbidity, the duration of hospitalization, and the mortality rate were significantly higher in those whose disease was complicated by peritonitis (p < 0.0001).

Table 3.

Correlation between Age, Number with Peritonitis, and Peritonitis-Related Deaths

Age	No. of children	No. (%) with peritonitis	Peritonitis-related deaths (%)
0–1 mo	91	22 (24.2)	14 (63.6)
2–6 mos	114	13 (11.4)	2 (15.4)
7 mos–1 y	85	1 (1.2)	0
2–5 y	58	5 (8.6)	0
6–11 y	69	34 (49.3)	2 (5.9)
12–18 y	304	106 (34.9)	0
Total	721	182 (25.2)	18 (9.9)

Discussion

Secondary bacterial peritonitis was common and accounted for the majority of cases treated in this center during the period, which is similar to the experiences of others [1,6]. On the other hand, primary peritonitis was rare, unlike in other studies, in which primary peritonitis of cirrhotic liver was common [12,13]. This could be because liver cirrhosis is rare in children in this subregion, whereas bacterial peritonitis is common because of poor environmental hygiene [6,14]. Rapid development of secondary bacterial peritonitis before presentation complicated most of the pediatric gastrointestinal operations performed during the period. The three cases of primary peritonitis in chronic nephritis may have resulted from bacterial translocation from the gut or ascension from the vagina in these postpubertal girls. Chemical peritonitis caused by blood following traumatic solid visceral injury was similarly rare during the period. This could be a reflection of the low incidence of pediatric trauma in many developing countries. The incidence of tuberculous peritonitis was low despite the poor sanitary conditions in many residential areas, perhaps because of routine vaccination of children against tuberculosis that has been fully adopted. This result is unlike those in other reports [1,15,16] in similar settings, in which the disease is still common. Other authors [1,6,16] in this subregion also reported typhoid ileal perforation as the major cause of secondary bacterial peritonitis in their centers. This was contrary to findings in this series in which typhoid ileal perforation accounted for only 2 of the entire number of cases of peritonitis (1.1%) managed in six years [17].

Complicated appendicitis was the leading cause of secondary bacterial peritonitis in our experience; this complication was similarly common in earlier reports from this subregion [1,3,6]. The unspecific clinical features of acute appendicitis in children influenced late presentation, which allowed time for development of perforation or gangrene that progressed to peritonitis [2,15]. Generally, there was an alarming time lag between the onset of primary gut pathology and presentation of the children for surgical consultation. This resulted in challenging and poor surgical source control in the majority of children in the study cohort. Appropriately timed surgical management would have enhanced source control and averted many of the peritonitis cases recorded, as emphasized by earlier authors [1,6,16,18]. The rarity of secondary peritonitis in more developed countries because of early presentation confirms the poor medical attention-seeking attitudes of parents and caregivers for children in developing countries. Inappropriate treatment received before presentation altered the disease picture and compounded the clinical conditions of the affected children, which influenced the life-threatening morbidity and deaths recorded.

Peritonitis was generalized in children below 11 years but less so after that age. The poorly developed omentum, which is unable to curtail peritoneal invasion, and the poorly developed immune response in younger children were highlighted as factors predisposing patients at the extreme of age to generalized peritonitis [2,15,16]. This allows gut organisms, particularly enterococci, to invade the entire peritoneum and leads to systemic dissemination, which resulted in the fatal outcome [5,10,19,20]. As shown in this and other similar studies [1,6,12,13], generalized bacterial peritonitis was more devastating and produced more serious sequelae than localized peritonitis, even when caused by the same primary gut pathology and by the same species of bacteria. All the peritonitis cases in neonatal infants were generalized and had progressed to systemic invasion, with many of the affected infants already in septic shock on arrival. Although neonatal infants accounted for only 22 (12.1%) of the entire number of patients with peritonitis, they constituted 14 (63.6%) of the 18 peritonitis-related deaths recorded during the period, which is similar to what has been seen in other series [1,4 –7,9]. No serious postoperative morbidity, deaths, or significant increase in the length of hospitalization were recorded following peritonitis that complicated appendicitis after the age of 12 years [2,15]. This was because the majority of peritonitis was localized to the right lower quadrant by the well-developed omentum, unlike the situation in newborns and younger children.

Surgical management, which included bowel resection and anastomosis, stoma creation, and closure of perforations, was dependent on the primary cause of peritonitis, and the options adopted were similar to those reported in other studies [1,4,6,16,21,22]. All the children had thorough peritoneal irrigation and lavage that included the insertion of drains in cases of localized peritonitis [2,15]. Nonoperative management of peritonitis, as suggested by other authors [23], was not attempted in this series, as the surgical options were found adequate, and the incidence of postoperative peritonitis was low. The choice of antibiotic regimen, which included cephalosporin and metronidazole in many cases, was influenced by the bacteriology and sensitivity patterns of the peritoneal fluid and proved adequate.

In conclusion, bacterial peritonitis secondary to bowel gangrene and perforation was common, whereas primary, chemical, typhoid, and tuberculous peritonitis were rare in this African subregion. Peritonitis was more severe and generalized in younger children, especially in neonatal infants, who accounted for the majority of the deaths recorded. Early referral of children, particularly newborns, with gastrointestinal complaints for surgical consultation and prompt surgical management is recommended for prevention of disease and improvement of the outcome of children with peritonitis.

Footnotes

Author Disclosure Statement

No conflicting financial interests exist.

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