Non-traumatic small intestinal perforation (SIP) is a common surgical emergency, especially in low- and middle-income countries, where there is a prevalence of tuberculosis and typhoid is common. Delayed presentation and limited diagnostic resources are the common constraints in these countries [1]. Traumatic perforations are quite easy to detect because of the etiology, whereas the non-traumatic SIP often occurs because of a pathological process from infectious conditions such as typhoid fever or tuberculosis. The other conditions that can cause non-traumatic SIPs are Crohn's disease, ischemic insult, and rarely neoplastic processes [2, 3]. Because of its heterogeneity in etiology, the diagnosis and timely intervention are critical for favourable outcomes. Common clinical presentation of cases of non-traumatic SIP is with symptoms of acute abdomen, including severe abdominal pain, fever, vomiting, and signs of peritonitis. Although these symptoms vary in frequency in the initial stages, especially in older patients and immunocompromised individuals, the diagnosis may be delayed. [4] The imaging modalities, especially abdominal radiography and contrast-enhanced computed tomography (CT), are very important in the diagnosis of free intraperitoneal air or the determination of the precise site of perforation, but CT is the gold standard because of its higher sensitivity and specificity [5,6]. Although imaging and perioperative care have improved recently, Surgical management is the modality of treatment required in all such cases. The type of surgical intervention is largely determined by the cause, size, and quantity of perforations, the extent of contamination, as well as patient stability upon presentation. Simple primary closure, segmental resection with primary anastomosis, or sometimes the stoma is created in more complex or unstable cases, are all common methods of surgery [7]. Laparoscopic approaches have also been discussed in recent years, but their usability is usually limited by widespread contamination and late presentation in most services [8]. The postoperative outcome in case of non-traumatic SIP depends on several factors such as time lapse in presentation, extent of contamination, nutritional status, and pre-existing comorbidities in cases such as diabetes [9]. Early identification of sepsis, fluid imbalance, and electrolyte imbalance with aggressive management is important for decreasing the number of postoperative complications. Nevertheless, the level of mortality is high in most areas, and has been above 20% especially where there is a delay in diagnosis and management [10]. Since the clinical significance of surgical outcome and post-operative recovery optimization is vital, continuous assessment of surgical decision-making and recovery after surgery is a necessity. Studies in this field have shown diverse etiologies of SIP; only a few of them have actually compared the surgical strategies and prognosis. With this background, to address the gap, we undertook this study to evaluate both management patterns and outcome patterns in non-traumatic SIP.

This prospective study was conducted in the Department of General Surgery, Dr Patnam Mahendar Reddy Institute of Medical Sciences, Hyderabad, Telangana. Institutional Ethical approval was obtained for the study. Written consent was obtained from all the participants of the study after explaining the nature of the study in the vernacular language. Inclusion criteria 1. Patients with signs and symptoms of an acute abdomen 2. Diagnosed as a non-traumatic small intestinal perforation intraoperatively 3. Aged 18 and above 4. Males and females Exclusion criteria 1. Traumatic small intestinal perforations 2. Perforations secondary to malignancies 3. Patients with gastric or colon perforations 4. Those patients are unfit to undergo surgery due to comorbidities. A total of 40 consecutive patients were included in the study based on the inclusion and exclusion criteria. Consecutive sampling was used to reach the sample size. All the included patients were analyzed in detail, including demographic profile, history, physical examination, and baseline investigations. Laboratory tests included CBC, renal function tests, liver function tests, electrolytes, serum lactate, and blood sugar estimation. Radiological evaluation included an erect abdominal radiograph and ultrasonography in all cases. Contrast-enhanced computed tomography (CT) of the abdomen was performed in the required case in order to localize the perforation and assess the extent of contamination. Surgical Management: The final diagnosis of small intestinal perforation was confirmed intraoperatively. The type of surgical procedure to be performed was determined by the surgeon based on the number and size of perforations, location, degree of peritoneal contamination, and hemodynamic stability of the patient. The commonly done procedure was simple primary closure. Resection and anastomosis were done in some cases, and creation of a temporary stoma was done in a few cases. A thorough peritoneal lavage was done in all cases using warm saline, followed by placement of abdominal drains if indicated. Postoperative Management and Follow-up: The postoperative management was done by administration of spectrum intravenous antibiotics, fluid and electrolyte management, analgesia, and early mobilization as per the case. Incidence of complications such as wound infection, intra-abdominal abscess, sepsis, anastomotic leak, and paralytic ileus was noted and managed accordingly. The duration of hospital stays, time to resume oral feeding, and need for ICU care were recorded. Patients were followed up for one month postoperatively. Mortality within the postoperative period was also recorded. Statistical Analysis: All the available data were segregated, refined, and uploaded to an MS Excel spreadsheet and analyzed by SPSS version 26 in Windows format. The continuous variables were denoted as mean, standard deviation, frequency, and percentage. Categorical variables were calculated by the Chi-square test for categorical variables, and values of p (<0.05) were considered significant.

The baseline demographic profile of the cohort (N=40) is given in Table 1. The analysis of the table showed that the mean age of the cohort was 48.2 ± 14.5 years, ranging from 22 to 75 years. This shows that non-traumatic small intestinal perforation is common in middle-aged and older adults. There was overall male predominance, with 70% of cases being male patients. Pre-existing comorbidities were present in 55% of cases, which included hypertension and diabetes mellitus. About 7.5% of people had chronic kidney disease. The mean duration of symptoms was more than 48.5 ± 24.2 hours, which shows a significant delay in presenting to the hospital, which could be an important potential risk factor for complications. Clinical symptoms frequently present were abdominal guarding/rigidity in 90% cases, fever in 80% of cases, and abdominal distension in 70% (Figure 1). Intraoperatively, we found 87.5% of cases had a single perforation and 12.5% had multiple perforations (Figure 2). Peritoneal contamination was moderate to severe in 70% of cases, showing late presentation and extensive intra-abdominal sepsis. Table 1: Baseline Demographic and Clinical Characteristics of the Study Population (N =40) Characteristic Category Number (n) Percentage (%) Age (Years) Mean ± SD (Range) 48.2 ± 14.5 (22-75) 18 – 40 14 35.0 41 – 60 18 45.0 >60 8 20.0 Sex Male 28 70.0 Female 12 30.0 Comorbidities Present Yes 22 55.0 Diabetes Mellitus 10 25.0 Hypertension 12 30.0 Chronic Kidney Disease 3 7.5 Duration of Symptoms (Hours) Mean ± SD 48.5 ± 24.2 24 8 20.0 24 – 72 24 60.0 >72 8 20.0 Grade of Peritoneal Contamination Mild (Localized) 12 30.0 Moderate 18 45.0 Severe (Generalized) 10 25.0 Figure 1: Showing the various clinical signs and symptoms of cases in the study Figure 2: Showing the frequency of perforations The description of the etiology of perforation in the cases of the study, along with the anatomical location, is given in Table 2. The common etiology of perforation was typhoid in 45% of cases, with tubercular perforation in 25% of cases. Other non-specific inflammatory causes were present in 20% of cases with Crohn's disease, and Meckel's diverticulum was present in 5% of cases each. Perforations were found more commonly in the ileum, 65% of cases, followed by the jejunum in 25% and the duodenum in 10% cases. This is a common pattern of involvement because ileal lymphoid tissue is particularly vulnerable to perforations. Table 3 shows the surgical procedures adopted in the cases of the study. Most patients were managed by primary closure 50% followed by resection and anastomosis in 40% cases, and in 10% cases, resection with stoma formation was done. Primary closure was done for ileal, duodenal, and smaller jejunal perforations. Resection and anastomosis were performed for larger and multiple perforations. Stoma formation was done in complicated cases with gross contamination and unstable physiology. Placement of drains was required in 95% of cases because of widespread peritoneal contamination. Table 2: Etiology of operative findings of small intestinal perforation Characteristic Category Frequency Percentage Presumed etiology Typhoid 18 45 Tubercular 10 25 Non-specific inflammatory 8 20 Crohn’s Disease 2 5 Meckel’s Diverticulum 2 5 Sites of perforation Duodenum 4 10 Jejunum 10 25 Ileum 26 65 Table 3: Surgical procedures performed (n=40) Surgical procedure By the perforation site Total (N=26) Duodenum (n=4) Jejunum (n=10) Ileum (n=26) Primary closure 4 6 10 20 (50%) Resection and anastomosis 0 4 12 16 (40%) Resection with diversion (Stoma) 0 0 4 4 (10%) Abdominal drain placement 4 10 24 38 (95%) The incidence of postoperative complications and outcomes is given in Table 4. The overall rate of complication was 45% the most frequently encountered complication was superficial SSI in 25% of cases, and intra-abdominal abscess in 10% of cases. Anastomotic leak occurred in 7.5% of patients, and stoma complications in 5% respectively. The rate of systemic complications was sepsis 20%, respiratory issues (12.5%), and paralytic ileus (15%). This indicates that the systemic inflammatory response is associated with perforation and contamination. Median time to oral feeding was 5 days (IQR 4–7), while 30% cases required ICU management. The mean hospital stay was 11.4 ± 6.2 days. The 30-day mortality rate was 10%, consistent with the severity of illness in this population. High morbidity and significant ICU requirement reflect the advanced disease state upon presentation. Table 4: Postoperative outcomes and complications (N=40) Outcomes/Complications Number Percentage Overall Morbidity 18 45 Infective complications Superficial surgical site infection 10 25 Intra-abdominal Abscess 4 10 Anastomotic/Stoma-related Anastomotic leak 3 7.5 Stroma-related complications 2 5.0 Systemic complications Sepsis 8 20 Respiratory complications 5 12.5 Paralytic ileas 6 15 Median time to oral feed (days) 5 IQR (4-7) Need for postoperative ICU care 12 30 Mean Hospital stay (days) 11.4 ± 6.2 30-day mortality rate 4 10 The comparative analysis of surgical outcomes by procedures is given in Table 5. A critical analysis of the table showed that the primary closure with resection and anastomosis; those undergoing resection were older in age, with a mean age of (51.8 vs. 45.3 years), although the differences were not statistically significant. Morbidity was higher in the resection group (9 cases vs. 7 cases), but not statistically significant. However, anastomotic leak was significantly higher in the resection group (p = 0.041), reflecting the complexity and risk associated with resection procedures. Hospital stay was longer in the resection group (13.1 vs. 9.8 days), though not significant. Mortality was also higher in the resection group (18.8% vs. 5%), suggesting greater physiological burden in these patients. Time to oral feeding was significantly delayed in the resection group (p = 0.012). The results indicate that the Primary closure was associated with better postoperative recovery and fewer postoperative complications. Table 5: Comparative analysis of outcomes by surgical methods Parameter Primary closure (n=20) Resection and anastomosis (n=16) P value Age (mean ± SD) 45.3 ± 13.2 51.8 ± 15.1 0.165 Morbidity Rate n(%) 7 9 0.197 Anastomotic leak 0 3 0.041* Mean Hospital Days (±SD) 9.8 ± 4.1 13.1± 7.5 0.087 Mortality rate 1 (5.0%) 3(18.8%) 0.202 Time to oral Feed (Median Days IQR) 4 (3-5) 6 (5-8) 0.012*

Non-traumatic small intestinal perforation (SIP) is a surgical emergency; however, the etiology is different based on the geographic locations. In low- and middle-income countries, infectious etiologies are common, such as typhoid and tuberculosis. In the current study, we observed that the mean age of the cohort was 48.2 years, which is in agreement with results from other studies that have shown that middle-aged adults are commonly affected, probably due to active lifestyles, increased consumption of foods from various sources, leading to increased risk of enteric infections [1, 2]. The male dominance in this study shows 70% of the involved cases were males. This observation is consistent with findings of previous studies in this field, which have reported that males are more prone to occupational exposure, lifestyle factors, and differences in health-seeking behaviour [3, 11]. Delayed presentation is a common feature in our study, and most patients presented after 24 hours of symptom onset. It could be due to the fact that abdominal pain is quite common and, in the initial stages, may be considered as simple gastrointestinal upset and ignored until symptoms aggravate. Such delayed presentation contributes to peritoneal contamination, risk of systemic sepsis, and postoperative morbidity [12]. A similar pattern of hospital presentation was also reported from previous studies in developing countries where there is limited access to early diagnosis and health care, leading to prolonged duration and possible adverse outcomes [4, 9]. Our study showed that the etiological profile was characterized by typhoid (45%) and tubercular perforations (25%). This indicates the persistence of these infections in endemic regions. The common region of perforation was ileal perforation due to necrosis of Peyer’s patches [2, 13]. Similarly, transmural inflammation and caseation result in tubercular perforation, which is mostly located in the ileocecal region [3, 14]. This pathophysiological pattern is observed in our study because the ileum is involved in 65% of cases, which is consistent with the previous studies [7,15]. The choice of procedure, SIP, the type of surgery to be performed in the given case, will depend on a number of factors, such as the quantity and size of perforations, tissue viability, patient stability, and contamination level. The most commonly used technique was primary closure (50%), especially in the case of small isolated perforations. More comprehensive disease, multiple perforations, or unhealthy bowel segments were left to resection and anastomosis (40%). The selective method is in line with the findings in previous studies that lay stress on an individualized decision-making process that is determined by the intraoperative findings [7, 11, 16]. In this study, there was a morbidity of 45% postoperatively, and the range (30-60%) was in similar series [10,12]. The most frequent ones were infectious complications, especially surgical site infections. The anastomotic leak rate of 7.5% correlates with the 6-12% rates of anastomotic leakage in the emergency bowel surgery [16,17]. It is also important to note that the leak rates and oral intake time of the patients who underwent resection and anastomosis were significantly higher than those of the patients who were subjected to primary closure. This confirms the fact that the resection processes are riskier because of bowel damage and intense contamination [11,15]. The overall mortality rate of this study was 10% which is in the range of mortality as reported by various global studies, where the reported rate of mortality was between 5 – 20% [10, 12]. It was also found that the mortality rates were higher in the resection group, indicating the more advanced disease of the cases. Sepsis and multiorgan dysfunctions were the major contributors to mortality in these cases. A similar pattern has been reported by other studies, and this shows the importance of early resection and sepsis control [9, 14]. In the end, our findings show that non-traumatic small intestinal perforations were common in middle-aged and older men, with a significant impact of delayed presentation on the outcomes. Therefore, early recognition and timely intervention can improve outcomes and survival in these cases.

Non-traumatic small intestinal perforation continues to be an important surgical emergency with significant morbidity and mortality. The present study showed that most of the causes of SIP in our cohort were of infectious etiologies. Typhoid and tubercular perforations were the frequent causes, with the ileum being the most commonly affected site. Primary closure was performed in 50% of cases and resulted in better postoperative outcomes, and resection was associated with higher complication rates and prolonged recovery. Therefore, early diagnosis as well as prompt surgical intervention and optimized perioperative care remain crucial for improving patient survival.

1. Singh R, Kumar N, Gupta P. Clinical profile and outcome of small intestinal perforations in emergency surgery. J Clin Diagn Res. 2018;12(5): PC01-PC04. 2. Chalya PL, Mabula JB, Koy M, Kataraihya JB, Jaka H, Mshana SE, et al. Typhoid intestinal perforations at a university teaching hospital in Northwestern Tanzania: A surgical experience of 104 cases in a resource-limited setting. World J Emerg Surg. 2012 Mar 8; 7:4. 3. Alam S, Mustafa G. Non-traumatic small bowel perforation: etiology and management. Bangladesh Med J. 2016;45(2):85-90. 4. De Souza LJ. Acute abdomen in infectious diseases. Curr Opin Infect Dis. 2019;32(5):406-12. 5. Hsu Y, Chen L. Diagnostic value of CT in bowel perforations. Clin Radiol. 2015;70(6):661-67. 6. Wang J, Zhao Y. Imaging in gastrointestinal perforation. Radiol Clin North Am. 2020;58(1):29-47. 7. Gupta V, Singh D. Surgical management of ileal perforations. Indian J Surg. 2016;78(2):102-07. 8. Khalil M, Haseeb A. Laparoscopic repair in bowel perforation: feasibility and outcomes. Surg Endosc. 2017;31(3):1255-62. 9. Mazahir H, Khan M. Predictors of outcome in intestinal perforation. Pak J Med Sci. 2019;35(4):1061-65. 10. Patel S, Rohit R. Mortality determinants in small bowel perforation. Int Surg J. 2020;7(9):2991-96. 11. Adesunkanmi AR, Ajao OG. The prognostic factors in typhoid ileal perforation. Ann Coll Surg Engl. 1997; 79:414–18. 12. Beniwal US, Jindal D, Sharma J. Comparative study of operative procedures in typhoid perforation. Trop Gastroenterol. 2003; 24:67–68. 13. Mock CN, Amaral J, Visser L. Typhoid perforation: management and outcome. J Trop Med Hyg. 1992; 95:207–15. 14. Kapoor VK. Abdominal tuberculosis. Postgrad Med J. 1998; 74:459–67. 15. Wani I, Parray F. Non-traumatic ileal perforation. World J Emerg Surg. 2006; 1:7. 16. Gupta S, Kaushik R. Peritonitis—overview and therapy. J Gastrointest Surg. 2006; 10:1260–1266. 17. Søreide K, Thorsen K, Søreide JA. Strategies in peritonitis management. Scand J Surg. 2014; 103:60–69.