A cohort study of patterns, treatment outcomes and predictors of mortality in patients with secondary generalized peritonitis in two referral hospitals in Addis Ababa, Ethiopia.

A total of 235 patients were enrolled in to the study, 69 patients were from TASH and the remaining 166 patients were from ZMH, 21.7% whom were female and 78.3% male. Figure 1 shows the etiology of patients who underwent surgery for generalized peritonitis. Perforated PUD was the most common cause accounting for approximately 53.6% of cases and among these cases, duodenal perforation accounted for 87.3% of the total cases of perforated PUD the remaining cases being perforated stomach ulcer. It was followed by perforated appendicitis accounting for 25.5% of the cases. Tumor perforation accounted for 5.1% of the total cases succeeded by Gangrenous Small Bowel Obstruction secondary to Adhesions. The remaining etiologies accounted for 12% of the cases, with ileo-sigmoid knotting being the least common. Table  1 shows the frequency of procedures performed for each etiology of secondary generalized peritonitis. Laparotomy and omental patch repair and laparotomy and appendectomy were performed for 78.8% of the total patients. Laparotomy and resection with anastomosis were subsequently performed on 5.5% of the patients. Fig. 1 Pie chart showing the intra-operative findings of patients with generalized peritonitis. Perforated PUD is largest at 53.6 % of cases followed by perforated appendicitis accounting for 25.5 % of cases. Tumor perforation accounts for 5.1 % of the total cases followed by gangrenous small bowel obstruction secondary to adhesions and gangrenous sigmoid volvulus each accounting 3.8%  Table 1 Table showing the frequency of death from each etiology of GP Procedure Frequency Percent Laparotomy + Patch repair 126 53.6 Laparotomy + Appendectomy 59 25.1 Laparotomy + Resection and anastomosis 18 7.7 Laparotomy + Resection + colostomy 13 5.5 Laparotomy + cholecystectomy 5 2.1 Laparotomy + colostomy only 2 0.9 Laparotomy only 2 0.9 Laparotomy + Abscess drainage 1 0.4 Laparotomy + Bypass of Jejunal mass 1 0.4 Laparotomy + Diverting colostomy + rectal repair 1 0.4 Laparotomy + ileostomy 1 0.4 Laparotomy + lavage 1 0.4 Laparotomy + Resection and ileostomy 3 1.3 Laparotomy + wedge resection of the stomach 2 0.9 Total 235 100.0 Pie chart showing the intra-operative findings of patients with generalized peritonitis. Perforated PUD is largest at 53.6 % of cases followed by perforated appendicitis accounting for 25.5 % of cases. Tumor perforation accounts for 5.1 % of the total cases followed by gangrenous small bowel obstruction secondary to adhesions and gangrenous sigmoid volvulus each accounting 3.8% Table showing the frequency of death from each etiology of GP At presentation 97.9% of patients’ main complaint was abdominal pain and 17.4% of patients complained of abdominal distension. A total of 78.7% of patients had vomiting of ingested matter and 8.1% had vomiting of bilious matter. A total of 39% of patients had failure to pass feces and flatus with only 3% had failure to pass only for feces. On examining the patients, 94.5% had direct tenderness and 93% had rebound tenderness where as 87.7% of them had involuntary guarding. Post-operative complications occurred in 21.7% of the total patients. Figure  2 shows a pie chart demonstrating the proportion of post-operative complications. The most common complication was post operative abdominal collection which occurred in 5.6% of patients followed by pneumonia which occurred around 5.2% of patients. A total of 4.2% of patients developed superficial surgical site infection where as 2.5% of them developed deep surgical site infection. A new diagnosis of septic shock after surgery was made in 3% of patients. A total of 1.7% of patients developed acute kidney injury. Fig. 2 Pie chart showing the proportion of post-operative complications; AKI, acute kidney injury; post op abdominal collection is the largest followed by pneumonia. superficial surgical site infection and deep surgical site infection follows Pie chart showing the proportion of post-operative complications; AKI, acute kidney injury; post op abdominal collection is the largest followed by pneumonia. superficial surgical site infection and deep surgical site infection follows Among the total patients, 6.8% which equates to 16 patients had undergone re-laparotomies. Six patients were diagnosed with perforated PUD of whom two of them had patch failure and the remaining had solely post op collection with an intact patch. The second most common patient group to have re-laparotomy was 4 patients with generalized peritonitis secondary to perforated appendicitis followed by 3 patients with tumor perforation. The indications for re-laparotomies were with l post op intra-abdominal collection for 13 patients, deep SSI with complete wound dehiscence for 2 patients and colostomy necrosis for a single patient. Among from the above patient groups, two patients died because of multi-organ failure secondary to refractory septic shock. All patients had prolonged hospital stay the longest being 41 days. The mean duration of hospital stay for the patients was 7.76 days with the maximum of 78 days. A total of 25.1% of patients had prolonged hospital stay i.e. greater than 8 days of hospital stay before discharge. It’s interesting to see that 30% of patients with generalized peritonitis secondary to perforated appendicitis had prolonged stay because of wound infection. A total of 11.1% of patients were admitted to the ICU post operatively. Initial Systolic blood pressure < 90 mmHg and diastolic blood pressure < 60 mm Hg were significantly associated with ICU admission with P value of 0.025 and 0.043 respectively. The total mortality recorded was 16 patients accounting for 6.8% of the total cases. The most common cause of death was refractory septic shock of the GI focus with associated multi-organ failure which was responsible for demise of 13 patients. Cardiogenic shock was responsible for the death of a single patient who was a known cardiac patient on follow up. Massive aspiration and massive PTE each caused one patient to die. The chi square test revealed that post operative complications were significantly associated with the death of a patient (P value = 0.001, 95% CI). Table  2 shows the total number of cases and the frequency of deaths from each etiology of GP. Most patients who died had perforated PUD and tumor perforation as etiology. Two patients with gangrenous SBO with primary volvulus and typhoid ileal perforation were each operated and one of the patient died from each group. Table 2 Table showing the frequency of death from each etiology of GP Total Cases Death Gangrenous Primary small bowel volvulus 2 1 Gangrenous sigmoid volvulus 9 3 Perforated PUD 126 6 Tumor Perforation 12 5 Typhoid Small bowel perforation 2 1 Total 16 Small bowel volvulus, torsion of small bowel along its mesentery, Tumor Perforation, perforation of the gastrointestinal tract due to erosion of cancer of the tract PUD Peptic Ulcer Disease Table showing the frequency of death from each etiology of GP Small bowel volvulus, torsion of small bowel along its mesentery, Tumor Perforation, perforation of the gastrointestinal tract due to erosion of cancer of the tract PUD Peptic Ulcer Disease Table  3 shows the results of the multivariate binary logistic regression analysis of the independent variables to determine their association with mortality of the patients. Table 3 Table showing binary logistic regression of clinical factors to determine association with mortality of patients Independent Variables df Sig. Exp(B) 95% C.I.for EXP(B) Lower Upper Presence of dehydration 1 0.933 1.072 0.213 5.386 Duration of illness in hours 1 0.201 1.005 0.997 1.013 Time gap from triaging to operation 1 0.630 1.022 0.936 1.115 Systolic BP 90–140 mmHg 2 0.719 Systolic_BP  140 mmHg 1 0.813 1.390 0.091 21.149 Amount of intraoperative fluid 1 0.217 1.558 0.770 3.152 Duration of surgery in hours 1 0.005 3.270 1.441 7.423 Intraoperative Vasopressor requirement 1 0.001 28.039 4.428 177.562 WBC count between 4,000–11,000 cells per micro liter 2 0.281 WBC count less than 4000 cells per micro liter 1 0.224 4.555 0.396 52.439 WBC count greater than 11,000 cells/micro liter 1 0.741 0.702 0.086 5.726 Initial hemoglobin greater than 13 gm/dl 3 0.730 Initial hemoglobin less than 8 gm/dl 1 0.290 10.134 0.139 738.695 Initial hemoglobin between 8 and 10.9 gm/dl 1 0.881 0.832 0.075 9.214 Initial hemoglobin between 11 and 12.9gm/dl 1 0.998 0.000 0.000 . Constant 1 0.000 0.001 All variables with P-value of < 0.1 in the bivariate model were taken forward to the multivariate model to determine association with mortality. Those with P value of < 0.05 were taken to be significant; mm Hg: millimeter of mercury; gm/dl,:gram per deciliter Table showing binary logistic regression of clinical factors to determine association with mortality of patients All variables with P-value of < 0.1 in the bivariate model were taken forward to the multivariate model to determine association with mortality. Those with P value of < 0.05 were taken to be significant; mm Hg: millimeter of mercury; gm/dl,:gram per deciliter the multivariate logistic regression revealed that the duration of surgery was significantly related to mortality of patients. An hourly increase in the time of surgery was associated with an increase in mortality by a factor of 3.2 (P value of 0.005 95%CI, OR = 3.2). A total of 7.7% of patients became hypotensive intraoperatively and required vasopressor support for correction.. It was found out to be significantly related and very strong indicator for mortality of patients in that those who required vasopressor had increased mortality by a factor of 28 (P value = 0.001 CI = 95%, OR = 28). The minimum age was 14 years and the maximum age was 96 years old with a mean age of 32.4 yrs. Most of the patients operated were those less than 30 years of age accounting for about 60% of the total patients. In this research increment in age of a patient was not associated with mortality of the patients. By using World Health Organization age classification, most mortalities were found in the age group 25 to 44 years and 75 to 90 years. A total of 71.3% of the total patients were males the remaining being females accounting only for 12.5% of mortalities and 24.1% of morbidities. However, there was no significant relationship between sex and the mortality or the morbidity of patients. Most patients came from the urban areas i.e. major cities of the country, with 9.4% from rural areas and the remaining 3.8% from semi-urban areas. Patients residency was not significantly related to patients mortality. A total of 56.3% of patients presented after 24 h of onset of illness. The analysis revealed that more females presented after 24 h of symptom onset. There was no statistically significant relation between duration of illness and mortality. The mean time from triaging of patients with generalized peritonitis to surgery is 8 h. The time gap from triaging to operation of a patient was not associated with mortality of patients. The mean pulse rate of the patients was 105 bpm with a range of 84 bpm. It was not significantly related to the mortality or morbidity of the patient. A total of 8.1%patients were hypotensive on presentation with initial systolic blood pressure of less than 90 mm of mercury where as 12.8% were hypotensive with an initial diastolic pressure of less than 60 mm of mercury. In the bivariate analysis, an initial systolic blood pressure measurement less than 90 mm Hg was associated with mortality of the patient but the same didn’t occur in the multivariate analysis. On the other hand, derangements in diastolic pressures were not associated with mortality but diastolic pressure hypotension less than 60 mm Hg was significantly associated with increased rate of wound infection. The mean respiratory rate of patients was 22.41 with a range of 22. There was no statistically significant relationship with the final patient outcome. In the present study 14.9% of the total patients were febrile with a temperature > 37.3 °C. The mean temperature of the patients was 36.19º C. There was no correlation between the temperature of the adult patients to their outcome. Through clinical assessment 44.7% of patients were dehydrated when they presented to the emergency department which was assessed clinically. There was a significant association between the presence of dehydration and adverse outcome i.e. mortality as assessed through bivariate logistic regression but not in multivariate logistic regression. From the collected data 5.5% of the total patients had comorbidities which were documented in medical records. Cardiac illnesses and hypertension accounted for most cases of comorbidities of patients operated. The Presence of comorbidities was related to mortality of patients by using Chi-square analysis (P value is 0.017). But bivariate logistic regression failed to show significant association. Most patients in this study were in ASA class I and II accounting for 82.6% of the total patients where as 2.1% were ASA class V. ASA physical status classification was not significantly related to mortality of patients. A total of 5.1% of the total patients had an initial WBC count of less than 4,000 cells per microliter and 59.6% had leukocytosis of greater than 11,000 cells per microliter. With bivariate logistic regression analysis along with other laboratory values, patients with WBC count < 4000 cells per microliter had no increased risk of death. 14.1% of patients had haemoglobin level of less than 13 g per deciliter and 1.3% of the total patients had haemoglobin level of less than 8 gram per deciliter. Patients who were anemic had no increased mortality with p value > 0.05. Retroviral infection status, neutrophil percentage in complete blood count, serum creatinine and urea levels and serum electrolyte levels has missing values. The values were filled with multiple imputation multiple times and they didn’t have significant relation with mortality. Abscess was the most common intraperitoneal fluid followed by bile. Only 7.2% of patients had hemorrhagic intraperitoneal fluid. There was no correlation between the nature of intraperitoneal fluid and patient outcome. The mean amount of intraperitoneal fluid was 0.76 L. There was no correlation between the nature or amount of intraperitoneal fluid with mortality. The etiology of generalized peritonitis was not significantly related to patient mortality. A total of 3.8% of total patients developed superficial surgical site Infections where as 2.9% of them developed deep surgical site infections during their admission. In this study there was no patient who developed enterocutaneous fistula post operatively. There were three patients who developed anastomotic leak. One patient had Generalized peritonitis secondary to ileo-sigmoid knotting and the other typhoid small bowel perforation and the third had gangrenous small bowel obstruction secondary to adhesions. All three patients survived and were discharged from the hospital. A total of 25.1% of patients had prolonged hospital stay that greater than 75th percentile of the total patients. A total of 11.1% of patients were admitted to ICU and 75% of those admitted died after admission. Relaparotomy surgery had no statistically significant relation with patients’ mortality. However, binary logistic regression diastolic blood pressure less than 60 mm of mercury and ASA class IV and V patients were also at increased risk of relaparotomy. An increased duration of surgery was also associated with relaparotomy. A total of 6.4% of the total patients developed post-operative pneumonia and were treated for it.

Generalized peritonitis is among the most common surgical reason for patients’ emergency visits. In addition in the training of General Surgery it is the commonly encountered illness by residents and general surgeons. The condition has high mortality and morbidity and is exacerbated by treatment delays. Thus early detection of patients who are likely to deteriorate and proper timely support greatly helps to improve their outcome. In this study perforated PUD was the most common etiology accounting for about 53.6% of the total cases operated followed by Generalized Peritonitis secondary to perforated appendicitis accounting for 25.5% of cases. A research done in a hospital in Eastern Ethiopia reported a similar finding that the most common etiology being PUD followed by perforated appendicitis [ 6 ]. The trend is slightly different in other African states that one research done in Tanzania where commonest cause was perforated appendicitis followed perforated PUD [ 21 ]. Another study performed in Nigeria revealed the most common etiology to be typhoid perforation succeeded by perforated PUD [ 14 ]. This is clearly different from the developed countries in which the most common cause is perforated appendicitis and lower GI perforation secondary to complicated diverticulitis [ 2 ]. In this study the mortality of patients was 6.8% which is comparable to that reported in Eastern Ethiopia which was 7.7% significantly lower than that of Tanzania which was about 15% [ 6 , 21 ]. Another study performed in Nigeria which enrolled 153 patients revealed a mortality of 26.1% [ 14 ]. In contrast to African studies an Indian study which involved 504 patients reported a mortality rate of 10% [ 34 ] Another Indian study which enrolled 350 patients reported a mortality rate of 6% [ 8 ]. The low mortality rate in this study was likely due to the young age of the patients with no comorbidities as compared with their European counterparts whose majority have a worse prognosis. Post op Complications occurred in 21.7% of thetotal patients. The most common complication was post op abdominal collection followed by pneumonia. Where as in another study Eden et al. found post op complications in 29.8% of patients. The commonest being pneumonia followed by post op complications [ 6 ]. This trend goes along with other African studies. Patients age was not significantly associated with mortality of patients. This could be due to the fact that most patients were from the same age group. The time interval from arriving at the hospital until beginning of surgery and the duration of surgery were not associated with patient mortality. The duration of surgery was directly associated with patient mortality. This could be partly explained by prolonged stress due to the surgery itself and exposure to anesthesia leading to further physiologic deterioration. This could be explained by intraoperative difficulties increasing the duration of the surgery. Intraoperative vasopressor requirement is mostly due to cardiovascular organ failure due to sepsis which can’t cope up with the surgical stress. Because of the aforementioned reason vasopressor requirement was strongly associated with mortality of patients. The Pulse rate doesn’t have direct correlation with the patients’ mortality. Increased pulse rate can be secondary to various factors in addition to systemic inflammatory response syndrome. Dehydration is also one of the common cause because patients usually present late to the hospital and also most patients had vomiting. Initial systolic pressure hypotension was not significantly related to patient mortality. This could be due to most patients respond to this hypovolemia with fluid resuscitation and the physiology is restored. Diastolic pressure hypotension was associated with patient morbidity especially with relaparotomies and wound infection. This could be explained by the fact low diastolic blood pressure affects the wound healing process leading to the aforementioned complications. Thus this group of patients deserve a close follow up. Postoperative complications tend to occur in patients with high amount of intraperitoneal fluid collection. Because of increased peritoneal contamination the intraperitoneal fluid and it might not be completely drained and the initial lavage might not be adequate for the patient. Finally, the retrospective nature of the study is the main limitation of the study. There were also missing variables. The missing laboratory values were analyzed and they were found to be missing completely at random. Multiple imputation is performed and the missing values didn’t affect the validity of the model. In the future, analyzing large datasets from national data bank can be used to find the exact statistical figures, extent of the disease and the outcome at a country or continent level. It will also aid to integrate and recognize various innovative procedures done in various areas of the country in resource limited setup. Prospective studies involving basic and advanced laboratory tests with cutting edge intensive patient care and surgery can revolutionize the care given to patients with generalized peritonitis. This will have a huge public health impact. GP is one of the most common disease treated by general surgeons and is at a core of general surgery training for residents. In the study areas of this research, it was the most common reason for emergency visits, and it carries significant morbidity and mortality for the patients. The human and material resources invested in the management of these patients is considerable, thus appropriate use of resources and early identification and support of patients likely to have complicated course are mandatory for a better outcome. In this study perforated PUD accounted for most cases of GP. Thus appropriate testing for Helicobacter Pylori i.e. which is commonest etiologic agent for PUD perforation, should be eradicated in patients with dyspepsia. Other risk factors for PUD such as smoking and chewing Khat, which is a local stimulant drug, should be discouraged among the younger generations. Proper triaging and appropriate fluid resuscitation and correction of hemodynamic instability are lifesaving interventions for patients with GP. Patient hemodynamic status should be optimized prior to surgery otherwise worse outcomes will follow. Vasopressors should be started if no adequate response. These patients are in need of intensive organ support thus should be transferred to ICU or other units with specialized care. The care should also continue post operatively. This study has clearly revealed that having anemia is associated with worse outcome in these patients underscoring transfusing patients preoperatively necessary for a better outcome. Intensive care should be given for patients who present with comorbidities, have a long duration of illness, are hypotensive and have leukopenia on presentation. This also holds true for patients with high ASA score. Increased surgery time was also significantly associated with worse outcomes. It is prudent to practice damage control surgery and have an effort to minimize intraoperative time of the patient. A second surgery can be considered after the patient is stabilized and in a better condition and the surgeon being prepared. Patients who have extensive peritoneal contamination have worse outcomes and increased mortality. This group of patients needs close follow up and its prudent to consider early relaparotomy and other supportive care to avoid sepsis. The results of this study suggest that responsible administrative bodies should consider training surgical residents and allocating medical resources in a manner that reduces the morbidity and mortality of the disease. The national surgical database should be utilized to study the disease and its outcome nationwide and in general its precise health impact.

Secondary generalized peritonitis is still a common surgical illness encountered in an emergency setting. This disease is associated with high morbidity and mortality especially in sub-Saharan Africa. Generalized peritonitis secondary to perforated peptic ulcer disease and perforated appendicitis accounted for most cases. The occurrence of complications and mortalities were associated with various epidemiological, clinical, laboratory and intraoperative factors and their interactions. Postoperative abdominal collection followed by pneumonia accounted for most of the patients’ morbidity. An Increased duration of illness and duration of surgery lead to increased mortality. The same held true for systolic pressure hypotension and intraoperative vasopressor requirements. Laboratory parameters such as leucopenia and anemia were also greatly associated with mortality of patients. Emergent Surgical therapy with Intensive care for those in need should be delivered for the best outcome in treating the illness. PUD, Peptic Ulcer Disease; Small bowel volvulus, torsion of small bowel along its mesentery, Tumor Perforation, perforation of the gastrointestinal tract due to erosion of cancer of the tract.

Institutional based retrospective cohort study. The outcome of each patient is measured in the same admission at which the surgery was performed . The study was conducted at Tikur Anbessa Specialized Hospital and Zewditu Memorial Hospital. Tikur Anbessa Specialized Hospital is the first tertiary treatment center of the country and patients are referred from every corner of the country for treatment. The surgical department is one of the oldest department currently organized in sub-specialty. Zewditu Memorial Hospital is also one of the largest referral hospital in the country located in the heart of the city. It is a hospital accepting and treating quite significant number of patients from the city. The hospital is affiliated with Addis Ababa university school of medicine and surgical residents are the primary physicians responsible for diagnosing and managing emergency surgical cases. The surgical department is composed of general surgeons and also subspecialists. Patients presenting to the surgical emergency department in the specified time period. Patients who were treated for secondary Generalized peritonitis presented in the time period between Jan 1, 2020 to May 30, 2024 GC. Sample size was calculated by using P value of 17% [ 23 ]. The sample size is calculated to be 217 using Daniel’s formula. Z= 1.96 P= 0.17 d= 0.05 n  = 217 and adjusting for 10% non response rate it becomes 241 patients. \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$n\;\mathit=\mathit\;\frac{Z^{\mathit2}\mathit\;P\mathit\;\left(\mathit1\mathit-P\right)}{d^{\mathit2}}$$\end{document} - all patients of age 14 and and greater and treated for secondary peritonitis in the study period. primary peritonitis. traumatic peritonitis, localized peritonitis. pancreatitis. peritonitis secondary to Mycobacterium Tuberculosis. Complicated Pelvic Inflammatory Disease. Mesenteric Ischemia. primary peritonitis. traumatic peritonitis, localized peritonitis. pancreatitis. peritonitis secondary to Mycobacterium Tuberculosis. Complicated Pelvic Inflammatory Disease. Mesenteric Ischemia. Age. Sex. Residence : Urban, Semirural or Rural area. Age. Sex. Residence : Urban, Semirural or Rural area. Duration of illness. Duration from triage to Surgery. Pulse rate at presentation. Systolic Blood pressure. Diastolic blood pressure. Respiratory rate. Presence and absence of dehydration. Presence and absence of comorbidities. American Society of Anesthesiologists class of the patient. Duration of illness. Duration from triage to Surgery. Pulse rate at presentation. Systolic Blood pressure. Diastolic blood pressure. Respiratory rate. Presence and absence of dehydration. Presence and absence of comorbidities. American Society of Anesthesiologists class of the patient. Total white blood cell count with neutrophil percentage. Haemoglobin Level. Serum creatininelevel`. Total white blood cell count with neutrophil percentage. Haemoglobin Level. Serum creatininelevel`. Nature of the peritoneal fluid : Serous, hemorrhagic, pus, bile, Fecal matter. Etiology of the Generalized Peritonitis. Intraoperative vasopressor Requirement. Nature of the peritoneal fluid : Serous, hemorrhagic, pus, bile, Fecal matter. Etiology of the Generalized Peritonitis. Intraoperative vasopressor Requirement. Acute Kidney Injury : is an abrupt decrease in renal function. It is defined as an increase in serum creatinine by ≥ 0.3 with in 48 hrs or increase in serum creatinine to ≥ 1.5 times baseline or urine volume is less than 0.5 milliliters per kilogram per hour for 6 h [ 24 ]. Sepsis: is a life threatening organ dysfunction caused by a dysregulated host response to surgery [ 25 ]. Septic shock: defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with greater risk of mortality than with sepsis alone. It can be clinically defined as a vasopressor requirement to maintain mean arterial pressure of 65 mm of mercury or greater and serum lactate level greater than 2 millimole per liter [ 25 ]. Mean Arterial Pressure :- the average arterial pressure throughout one cardiac cycle [ 26 ]. Intensive Care Unit (ICU) Admission: admitting critical patients for intensive care and organ support [ 26 ]. traumatic peritonitis: peritonitis caused by contamination from after GI tract secondary to traumatic injury [ 26 ]. localized peritonitis: peritoneal inflammation and contamination localized to specific area and not generalized [ 26 ]. Acute pancreatitis: Acute pancreatitis is an inflammatory disorder of the pancreas. that is characterized by edema and, when severe necrosis of the pancreas [ 26 ]. Acute appendicitis: a disorder characterized by acute inflammation to the vermiform appendix caused by a pathogenic agent [ 26 ]. TB peritonitis: peritoneal inflammation and contamination due to Mycobacterium Tuberculosis which is treated medically [ 26 ]. Tumor Perforation: perforation of the gastrointestinal tract due to erosion of cancer of the tract [ 26 ]. Perforated Peptic Ulcer Disease (Perforated PUD) : indicate an acute peptic ulcer, site unspecified, with perforation. The perforation can of either duodenal or stomach ulcer [ 26 ]. Intussusception: a form of intestinal obstruction caused by the prolapse of part of the intestine in to the adjoining intestinal lumen [ 26 ]. Small or large bowel volvulus: is twisting of section of the intestine around its mesentery potentially leading to obstruction and other complications [ 26 ]. Gangrenous small bowel obstruction: small bowel necrosis caused by interruption of blood supply secondary to the obstruction. The obstruction can be due to post-operative adhesions or volvulus [ 26 ]. Ileo-sigmoid Knotting : type of volvulus where ileum and sigmoid colon creates a knot and obstruction [ 26 ]. Cholecystitis: an acute or chronic inflammation of the gall bladder wall [ 26 ]. Gangrenous cholecystitis: severe complication of cholecystitis where the wall of gall bladder dies due to lack of blood supply and necrosis [ 26 ]. Complicated Pelvic Inflammatory Disease : Pelvic inflammatory disease. (PID) is an inflammatory disorder of the upper female genital tract, including any combination of endometritis, salphingitis, tubo-ovarian abscess, and pelvic peritonitis [ 26 ]. ASA class of the patient: American Society of Anesthesiologists classification of preoperative physical status. Further divided to five class [ 27 ]. ASA I A normal healthy patient. ASA II A patient with mild systemic disease. ASA III A patient with severe systemic disease. ASA IV A patient with severe systemic disease that is a constant threat to life. ASA V A moribund patient who is not expected to survive without the operation. Acute Kidney Injury : is an abrupt decrease in renal function. It is defined as an increase in serum creatinine by ≥ 0.3 with in 48 hrs or increase in serum creatinine to ≥ 1.5 times baseline or urine volume is less than 0.5 milliliters per kilogram per hour for 6 h [ 24 ]. Sepsis: is a life threatening organ dysfunction caused by a dysregulated host response to surgery [ 25 ]. Septic shock: defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with greater risk of mortality than with sepsis alone. It can be clinically defined as a vasopressor requirement to maintain mean arterial pressure of 65 mm of mercury or greater and serum lactate level greater than 2 millimole per liter [ 25 ]. Mean Arterial Pressure :- the average arterial pressure throughout one cardiac cycle [ 26 ]. Intensive Care Unit (ICU) Admission: admitting critical patients for intensive care and organ support [ 26 ]. traumatic peritonitis: peritonitis caused by contamination from after GI tract secondary to traumatic injury [ 26 ]. localized peritonitis: peritoneal inflammation and contamination localized to specific area and not generalized [ 26 ]. Acute pancreatitis: Acute pancreatitis is an inflammatory disorder of the pancreas. that is characterized by edema and, when severe necrosis of the pancreas [ 26 ]. Acute appendicitis: a disorder characterized by acute inflammation to the vermiform appendix caused by a pathogenic agent [ 26 ]. TB peritonitis: peritoneal inflammation and contamination due to Mycobacterium Tuberculosis which is treated medically [ 26 ]. Tumor Perforation: perforation of the gastrointestinal tract due to erosion of cancer of the tract [ 26 ]. Perforated Peptic Ulcer Disease (Perforated PUD) : indicate an acute peptic ulcer, site unspecified, with perforation. The perforation can of either duodenal or stomach ulcer [ 26 ]. Intussusception: a form of intestinal obstruction caused by the prolapse of part of the intestine in to the adjoining intestinal lumen [ 26 ]. Small or large bowel volvulus: is twisting of section of the intestine around its mesentery potentially leading to obstruction and other complications [ 26 ]. Gangrenous small bowel obstruction: small bowel necrosis caused by interruption of blood supply secondary to the obstruction. The obstruction can be due to post-operative adhesions or volvulus [ 26 ]. Ileo-sigmoid Knotting : type of volvulus where ileum and sigmoid colon creates a knot and obstruction [ 26 ]. Cholecystitis: an acute or chronic inflammation of the gall bladder wall [ 26 ]. Gangrenous cholecystitis: severe complication of cholecystitis where the wall of gall bladder dies due to lack of blood supply and necrosis [ 26 ]. Complicated Pelvic Inflammatory Disease : Pelvic inflammatory disease. (PID) is an inflammatory disorder of the upper female genital tract, including any combination of endometritis, salphingitis, tubo-ovarian abscess, and pelvic peritonitis [ 26 ]. ASA class of the patient: American Society of Anesthesiologists classification of preoperative physical status. Further divided to five class [ 27 ]. ASA I A normal healthy patient. ASA II A patient with mild systemic disease. ASA III A patient with severe systemic disease. ASA IV A patient with severe systemic disease that is a constant threat to life. ASA V A moribund patient who is not expected to survive without the operation. ASA I A normal healthy patient. ASA II A patient with mild systemic disease. ASA III A patient with severe systemic disease. ASA IV A patient with severe systemic disease that is a constant threat to life. ASA V A moribund patient who is not expected to survive without the operation. Surgical site infection: Surgical site infections (SSIs) are infections of the tissues, organs, or spaces exposed by surgeons during performance of an. invasive procedure [ 28 ]. Superficial Surgical Site Infection: infection of surgical wounds limited to skin and subcutaneous tissue [ 28 ]. Deep Surgical Site Infection = Infection of surgical wounds deeper to subcutaneous tissue [ 28 ]. Entero-cutaneous fistula formation: are the abnormal communication of bowel. to an adjacent skin epithelial layer and are associated with. extensive morbidity and mortality [ 28 ]. Post op pneumonia: infection and inflammation of the lung parenchyma in the post-operative period [ 26 ]. anastomotic leak: defect of intestinal wall at anastomotic site leading to a communication between intra and extra luminal compartments [ 26 ]. new onset of organ failure: organ dysfunction to such degree that normal homeostasis cannot be maintained without clinical intervention or life support [ 26 ]. Prolonged hospital stays: staying greater than 75th Percentile from admission to discharge or death [ 29 ]. Re-laparotomies: is a planned or an unplanned re-operation carried out with in 60 days after laparotomy for reasons related to first operation [ 30 , 31 ]. Morbidity: complications that are associated and arises with a particular illness [ 26 ]. Mortality: demise of a patient [ 26 ]. Abscess drainage: procedure aimed at removing pus from an abscess cavity [ 32 ]. Open Appendectomy: is a surgical removal of appendix accomplished opening abdomen layer by layer and ligating the meso-appendix with absorbable or nonabsorbable sutures suture and applying sutures over appendiceal stump to obliterate the lumen [ 33 ]. Open Cholecystectomy: is a surgical removal of the Gall bladder accomplished by opening abdomen layer by layer and involving ligating the cystic duct and artery by abraoded 2/0 sutures. Subsequently removal from the gall bladder fossa with sharp dissection [ 33 ]. Colostomy: surgically created passage between the colon and abdominal wall resulting in an opening called stoma. The damaged and diseased part of the colon is removed and stoma is created with abdominal wall with reabsorbable sutures [ 28 ]. Ileostomy : surgically created passage between the ileum and abdominal wall resulting in an opening called ileostomy. The damaged and diseased part of the ilium is removed and stoma is created with abdominal wall with reabsorbable sutures [ 28 ]. Resection and Hand Sewn anastomosis: removal of the diseased segment of the bowel and joining the two ends of the bowel with absorbable or permanent sutures in one or two layers. The anastomosis is done in two layers the first layers being through and through sutures and the second layer being sero-muscular sutures [ 28 ]. Resection and colostomy: removal of the diseased segment of the large bowel and creating a surgically created passage by anastomosing the colon with anterior abdominal wall [ 28 ]. Resection and ileostomy: removal of the diseased segment of the ileum and creating an artificial opening by anastomosing the colon with anterior abdominal wall [ 28 ]. Hand Sewn Wedge resection of the stomach: removal of wedge shaped part of the stomach and repairing the stomach in two layers of sutures. The first suture is through and through the whole layers and the second suture is sero-muscular [ 33 ]. Graham’s patch repair: 3–4 bites of 2/0 sutures are taken from the perforation sites and Omentum is applied over the duodenal perforation and approximated [ 33 ]. Modified Graham’s omental Patch repair: perforation is approximated with 3–4 bites of 2/0 sutures and then the repair is reinforced with omentum [ 33 ]. Bypass of a mass: diverting a colon and doing colostomy due to distal colonic cancer perforation or obstruction [ 33 ]. Rectal repair: repairing rectal perforation with 3/0 stiches in an interrupted or continuous fashion [ 33 ]. Surgical site infection: Surgical site infections (SSIs) are infections of the tissues, organs, or spaces exposed by surgeons during performance of an. invasive procedure [ 28 ]. Superficial Surgical Site Infection: infection of surgical wounds limited to skin and subcutaneous tissue [ 28 ]. Deep Surgical Site Infection = Infection of surgical wounds deeper to subcutaneous tissue [ 28 ]. Entero-cutaneous fistula formation: are the abnormal communication of bowel. to an adjacent skin epithelial layer and are associated with. extensive morbidity and mortality [ 28 ]. Post op pneumonia: infection and inflammation of the lung parenchyma in the post-operative period [ 26 ]. anastomotic leak: defect of intestinal wall at anastomotic site leading to a communication between intra and extra luminal compartments [ 26 ]. new onset of organ failure: organ dysfunction to such degree that normal homeostasis cannot be maintained without clinical intervention or life support [ 26 ]. Prolonged hospital stays: staying greater than 75th Percentile from admission to discharge or death [ 29 ]. Re-laparotomies: is a planned or an unplanned re-operation carried out with in 60 days after laparotomy for reasons related to first operation [ 30 , 31 ]. Morbidity: complications that are associated and arises with a particular illness [ 26 ]. Mortality: demise of a patient [ 26 ]. Abscess drainage: procedure aimed at removing pus from an abscess cavity [ 32 ]. Open Appendectomy: is a surgical removal of appendix accomplished opening abdomen layer by layer and ligating the meso-appendix with absorbable or nonabsorbable sutures suture and applying sutures over appendiceal stump to obliterate the lumen [ 33 ]. Open Cholecystectomy: is a surgical removal of the Gall bladder accomplished by opening abdomen layer by layer and involving ligating the cystic duct and artery by abraoded 2/0 sutures. Subsequently removal from the gall bladder fossa with sharp dissection [ 33 ]. Colostomy: surgically created passage between the colon and abdominal wall resulting in an opening called stoma. The damaged and diseased part of the colon is removed and stoma is created with abdominal wall with reabsorbable sutures [ 28 ]. Ileostomy : surgically created passage between the ileum and abdominal wall resulting in an opening called ileostomy. The damaged and diseased part of the ilium is removed and stoma is created with abdominal wall with reabsorbable sutures [ 28 ]. Resection and Hand Sewn anastomosis: removal of the diseased segment of the bowel and joining the two ends of the bowel with absorbable or permanent sutures in one or two layers. The anastomosis is done in two layers the first layers being through and through sutures and the second layer being sero-muscular sutures [ 28 ]. Resection and colostomy: removal of the diseased segment of the large bowel and creating a surgically created passage by anastomosing the colon with anterior abdominal wall [ 28 ]. Resection and ileostomy: removal of the diseased segment of the ileum and creating an artificial opening by anastomosing the colon with anterior abdominal wall [ 28 ]. Hand Sewn Wedge resection of the stomach: removal of wedge shaped part of the stomach and repairing the stomach in two layers of sutures. The first suture is through and through the whole layers and the second suture is sero-muscular [ 33 ]. Graham’s patch repair: 3–4 bites of 2/0 sutures are taken from the perforation sites and Omentum is applied over the duodenal perforation and approximated [ 33 ]. Modified Graham’s omental Patch repair: perforation is approximated with 3–4 bites of 2/0 sutures and then the repair is reinforced with omentum [ 33 ]. Bypass of a mass: diverting a colon and doing colostomy due to distal colonic cancer perforation or obstruction [ 33 ]. Rectal repair: repairing rectal perforation with 3/0 stiches in an interrupted or continuous fashion [ 33 ]. Study variables were listed out. A standardized google form was developed based on the variables. Most questions were a type in which Principal investigator entered data by choosing. The answer portion of the form contained all the possible scenarios and involved blank space for writing additional information. The google form was tested with some patient charts for completeness then the whole were collected. The Log book of patients who were operated for Secondary Generalized peritonitis from Jan 1, 2020 to May 30, 2024 GC was obtained from emergency operating room and their medical record number was recorded. All patients who were treated for Secondary Generalized Peritonitis were enrolled to the study. The patients’ charts were obtained from the Medical record department and online electronic record system. The developed Google form was used to extract the data and was stored online. After the Google form was developed and it was tried on 50 medical records to validate and check for comprehensiveness. The patients’ medical records were immediately returned to the department. All data was collected and accessed only by the principal investigator. The entered data were extracted from Google forms to Microsoft Excel 2016 then finally to SPSS v 26. The collected data were entered into SPSS version 26, and analyzed. Descriptive statistics such as mean, mode, median and percentiles and standard deviation were calculated. Initially missing data were identified and those variables were retroviral infection status, neutrophil percentage in complete blood count, serum creatinine and urea levels and serum electrolyte levels. Little’s test was done to check for the pattern of missing data and CHI square was calculated to be 50.5, with a significance level of 0.300. The final result suggested that the variables were missing completely at random. Multiple imputation was performed for the missing values and there was no significant change in P values, adjusted odds ratios and confidence intervals. Initially all the independent variables listed were analyzed individually through bivariate logistic regression to determine their relationships with the mortality. The variables were checked for mulitcollinearity and there was none. Those who hada P value of < 0.1 were reanalyzed via multivariate analysis. The model fitness was checked with an Omnibus test and the P value was  0.05 and Nagelkerke Pseudo R square is around 0.6 which is well above 0 all suggesting good model fitness. A Receiver Operator Curve was plotted and Area Under Curve was 0.93 suggesting the model was robust. The sensitivity of the model was 56.3% and specificity of 99.1%. Positive predictive value is 81.8% and Negative predictive value is 96.9%. The P values were reanalyzed with Benjamini-Hochberg’s test to control false discovery rate and only two variables were found to be statistically significant.

Peritonitis is defined as irritation and inflammation of the peritoneum covering the abdominal wall. This usually occurs due to microbial contamination of the peritoneum. It is one of the most common encountered cases and admissions in the practice of general surgery [ 1 – 3 ] It is diagnosed clinically patients having diffuse tenderness and rebound tenderness with guarding and rigidity. This is lethal illness with extremely high mortality and morbidity in untreated cases. Etiologically it is further classified as primary, secondary, or potentially tertiary [ 4 , 5 ]. S econdary peritonitis occurs due to direct contamination through perforation or severe inflammation of intra-abdominal organs. Complicated appendicitis, perforated peptic ulcer disease, typhoid perforation and colonic perforation due to various reason are common etiologies of secondary peritonitis [ 6 – 10 ]. It occurs most commonly from a physical disruption of gastrointestinal tract integrity and is typically polymicrobial [ 3 , 11 ]. Patients with secondary generalized peritonitis can present late with signs and symptoms of multi organ failure. Hypotension can ensue despite fluid resuscitation. Respiratory failure with altered and depressed mentation indicating CNS failure is also common. Decreased Urine output may herald acute kidney injury. It’s unethical and dreadful to delay surgery for such patients by investigating them. Emergent laparotomy should be done without delay. Secondary generalized peritonitis accounts for most cases of surgical emergency visits. A study done in one state of United States found that generalized peritonitis accounts for 9.3 of total 1000 admissions [ 12 ] whereas figures are higher in sub-Saharan Africa. A study done in Malawi showed that patients with generalized peritonitis accounted for 21.9% of patients presenting to surgical emergency department [ 13 ]. The disease is also associated with greater cost of treatment since most patients require preoperative preparation, surgery and intensive specialized care after they are operated. The economic burden and the expense on the health care system is huge by itself. Worldwide the mortality of secondary generalized peritonitis ranges between 6% and 30% [ 5 , 8 , 14 , 15 ]. Multicenter prospective study involving 2,152 patients suffering from intra-abdominal infections from 68 medical institutions throughout Europe has found the cumulative mortality to be 7.5% [ 3 ] A French study which involved 841patients from 66 hospitals showed that the mortality based on etiology was 1.5% for patients with appendicitis, 23% for colonic and 27% for small bowel peritonitis [ 2 ]. Another French study reported mortality of 19% which increased to 35% for those who had septic shock where as in Canada it was 38% [ 16 , 17 ]. In Ethiopia, Debele et al. studied these patients and reported mortality of 7.7% [ 6 ]. There are many predictors of both mortality and morbidity for the patients with secondary generalized peritonitis. Azuhata et al. studied 154 patients with Gastrointestinal perforation and Sequential Organ Function Assessment score and time to surgery were found to be significantly related to 60 day survival [ 18 , 19 ]. Age greater than 50 years, delayed surgery of patients and intraoperative finding of fecal contamination, Presence of comorbid illness, high ASA class and post-operative complications were also associated with adverse outcome [ 20 – 22 ]. In a developing country such as Ethiopia, this area is not well studied and there are limited number of researches done on the topic making it difficult to determine the exact etiologies and mortality in the Ethiopian context. By studying the general pattern and the factors that predict patient outcome, the morbidity and mortality can be significantly reduced. This can also help to properly utilize health resources for the best outcome. This study will be helpful for developing countries especially for sub-Saharan countries for the aforementioned reasons.