College of Medicine and Health Sciences

School of Medicine and Pharmacy

EPIDEMIOLOGICAL STUDY OF PERITONITIS IN PEDIATRIC

POPULATION AND FACTORS PREDICTING MORTALITY.
CASE OF CHUK.

Submitted in partial fulfillment of the

requirements for the award of the Degree of
Master of Medicine in General Surgery at
University of Rwanda.

By Dr MUTABAZI Emmanuel

Supervisors: Dr Alex Bonane.

Dr Ndibanje Alain Jules.

Kigali, June 2016

 DECLARATION

Researcher:

I hereby declare that this dissertation: “Epidemiological study of peritonitis in pediatric population and
factors predicting mortality. Case of CHUK” is my own work and has not been submitted to any
university in Rwanda for the award of any degree.

Signed Date …03th August 2016

Dr MUTABAZI Emmanuel

Supervisor:

I hereby declare that this dissertation has been submitted with my approval as the supervisor.

Signed Date 03th August 2016

Dr Alex BONANE

i
 ACKNOWLEDGEMENTS
My gratitude goes first to my supervisor, Dr Alex BONANE for his continuous support and meticulous
guidance from the initial steps of this work.

My second thanks go to Dr Alain Jules NDIBANJE for his scientific enthusiasm from the time he accepted
to co-supervise this dissertation. His encouragements, availability and guidance express a high level of
teaching skills and mentorship.

Special thanks go to Dr Georges NTAKIYIRUTA, the academic head of surgical department, who judged
me to be fit for Surgery. His deep knowledge of general surgery and his willingness to strengthen the UR
postgraduate program in surgery improved it from far to where it is now.

To you Drs Robinson SSEBUUFU, Ahmed KISWEZI, Rashna GINWALLA, Michael KURCI with your
advices, encouragements and push I succeeded to decide my destiny.

I take this opportunity to thank the whole team of the department of surgery at CHUK through Dr Faustin
NTIRENGANYA the head of department and general surgery program coordinator, your effort to guide and
help us day to day has been a great experience and has made our dreams a reality.

A particular note of thanks goes to Dr Innocent NZEYIMANA and Dr KARENZI Irene David for their help
throughout the different steps of this work. Without your help, this work would not have been completed.

To you, members of my family, my wife Dr Marie Grace UWIMANA, our daughters Ange Henriette
IRADUKUNDA and Louange Ghisrraine ISHIMWE. Your love supported me, and stimulated my progress
to success.

Last but not least, thanks to you, parents, brothers and sisters, friends and good wishers, we have got
blessings to come over this hard way.

For all of you, cited or not cited herewith, find true recognition of your love and commitment.

Dr Emmanuel MUTABAZI

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 DEDICATION

To the memory of my brother USHIZIMPUMU Fidele, even though you couldn’t be there with
me through my surgical training or walk down the way I have chosen, you were always my
inspiration and my guide in striving for excellence.

To you Mother for your love patience and hard work.

To you my brother Desire NKURUNZIZA, sisters and friends for your help and
encouragements.

To you my beloved wife Dr Marie Grace UWIMANA and our daughters: Ange Henriette
IRADUKUNDA and Louange Ghisrraine ISHIMWE.

This work is dedicated.

iii
 ABSTRACT

Background: Peritonitis in children is a life threatening surgical condition requiring prompt

and adequate surgical management. The knowledge of its common causes and factors linked
with its morbidity and mortality may contribute to early recognition of patients in need of
special care.

Objectives: This study aims at identifying common causes of peritonitis in children and factors
affecting morbidity and mortality.

Methods: A prospective observational study was done on 63 patients operated for peritonitis
from 1st September 2015 to 28th February 2016 at CHUK.

Results: Of 63 patents, 35 were male and 28 female, sex ratio (M: F) was 1.25:1. The age
ranged from 4 months to 15 years, the mean was 8.8 years. 73% of patients presented within
the first week of symptom onset. 14 of 63 died (22.2%); 2 died on table; 6 died of sepsis in
ICU settings and 6 of post operative respiratory problems. 4 of 6 patients (66.7%) who had
traumatic small bowel perforation died.

Appendicular perforation (25.4%) and gangrenous intussusceptions (23.8%) were the common
causes of peritonitis. 60.3% were operated after 24 hours of admission. 74.6% of morbidity and
22.2% mortality were registered. The principal operator; symptom duration; post operative
ICU admission and septic shock were potential predictors of mortality. (p<0.05)

Conclusion: Peritonitis in children is a life threatening surgical emergency at CHUK, bearing

a significant morbidity and mortality. A wide variety of factors are linked significantly with the
overall outcome. Efforts need to be put in reducing the delayed presentation, improving
survival of trauma related peritonitis by providing care providers at different levels with
regular training in terms of trauma management and ICU inputs to improve recovery for this
particular group of patients.

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 LIST OF ABBREVIATIONS
BP: Blood pressure

CD4: Cluster of differentiation 4

CHUK : centre hospitalier universitaire de Kigali

CMHS: College of medicine and health sciences

CRP: C-reactive protein

CT: Computed tomography

ESR: Erythrocyte sedimentation rate

FBC: Full blood count

GI: Gastro intestinal

GIT: Gastrointestinal tract

Hb: Hemoglobin

Hg: Mercury

HID/AIDS: Human immunodeficiency disease/ Acquired immune deficiency syndrome

IRB: Institutional review board

IO: Intestinal obstruction

LOS: Length of stay

MOH: Ministry of Health

ºC: Degree centigrade

PaCO2: Partial arterial pressure of carbon dioxyde

v
PID: Pelvic inflammatory diseases

PMNL: Polymorpho nucleic leucocytes

Rwf: Rwandan francs

SBP: Spontaneous bacterial peritonitis.

SIRS: Systemic inflammatory response syndrome

TB: Tuberculosis

UR: University of Rwanda

WBC: White blood count

vi
 LIST OF TABLES.
Table 1 Distribution according to age ......................................................................................................13

Table 2: Distribution according to symptom duration .............................................................................14

Table 3 : Distribution according to the cause of peritonitis .....................................................................16

Table 4 : Distribution according to time elapsed between admission and surgery ..................................16

Table 5: Distribution according to the time of surgery ............................................................................16

Table 6 : Distribution according to the operator ......................................................................................16

Table 7: Distribution according to post operative antibiotic use .............................................................17

Table 8: Distribution of mortality according to the cause of peritonitis .................................................18

Table 9 : Distribution according to LOS ..................................................................................................19

Table 10: Correlation of age and cause of peritonitis ..............................................................................19

Table 11: Variables associated with mortality (bivariate analysis). .........................................................19

Table 12: Principal operator and complication occurrence (p=0.023) .....................................................20

Table 13: Correlation of the cause of peritonitis and length of stay (p=0.030). ......................................20

Table 14: Pulse rate status and Complication occurrence (p=0.002) .......................................................21

Table 15: Postoperative ICU admission and complication occurrence (p=000) ......................................21

Table 16: Symptom duration and complication occurrence (p=0.009) ....................................................21

Table 17: Cause of peritonitis and complication occurrence (p=0.046) ..................................................22

Table 18: Nausea/vomiting and complication occurrence (p=0.041) ......................................................22

Table 19: LOS and antibiotic use (p=0.018) ............................................................................................22

Table 20: Province and LOS (p=0.046) ...................................................................................................23

Table 21: Economic status and LOS (p=0.014) .......................................................................................23

Table 22: Pretransfer symptom duration and LOS (p=0.035)..................................................................23

Table 23: Fascia dehiscence and LOS (p=0.019).....................................................................................24

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Table 24: Intraabdominal abscess and LOS(p=0.011) .............................................................................24

Table 25: Denutrition/electrolyte imbalance and LOS(p=0.003).............................................................24

Table 26: Post operative ICU admission and outcome (p=0.001) ...........................................................24

Table 27 Symptoms duration and outcome (p=0.012) .............................................................................25

Table 28: Nausea/vomiting and outcome (p=0.017) ................................................................................25

Table 29: Principal operator and outcome (p=0.013) ..............................................................................25

Table 30: Sepsis and outcome (p=0.000) .................................................................................................25

LIST OF FIGURES
Figure 1: Distribution according to sex ....................................................................................................13

Figure 2: Distribution according to the Province of residence.................................................................13

Figure 3: Distribution according to the economic status..........................................................................14

Figure 4: Distribution according to symptoms at admission....................................................................14

Figure 5: Temperature at admission .........................................................................................................15

Figure 6: Distribution according to complications occurred ....................................................................17

Figure 7: Distribution according to mortality...........................................................................................18

viii
 TABLE OF CONTENTS
DECLARATION ........................................................................................................................................ i

ACKNOWLEDGEMENTS ....................................................................................................................... ii

DEDICATION .......................................................................................................................................... iii

ABSTRACT .............................................................................................................................................. iv

LIST OF ABBREVIATIONS .................................................................................................................... v

LIST OF TABLES. .................................................................................................................................. vii

LIST OF FIGURES ................................................................................................................................ viii

TABLE OF CONTENTS .......................................................................................................................... ix

I. INTRODUCTION .................................................................................................................................. 1

I.1. Background ...................................................................................................................................... 1

I.2 . General considerations of peritonitis. ............................................................................................. 2

I.2.1. Definition .................................................................................................................................. 2

I.2.2. Etiologies .................................................................................................................................. 2

I.2.3. Pathophysiology ....................................................................................................................... 2

I.2.4. Diagnosis .................................................................................................................................. 4

I.2.5 Classification ............................................................................................................................. 4

I.2.6. Management ............................................................................................................................. 5

I.3. Problem statement ........................................................................................................................... 6

I.4. Research question ............................................................................................................................ 6

I.5. Study objectives ............................................................................................................................... 6

I.5.1. General objective ...................................................................................................................... 6

I.5.2. Specific objectives .................................................................................................................... 6

I.6. Significance of the study. ................................................................................................................ 7

ix
II. LITERATURE REVIEW ...................................................................................................................... 8

II.1. Causes of peritonitis ....................................................................................................................... 8

II.2. Morbidity and mortality due to peritonitis ..................................................................................... 9

III. METHODOLOGY.............................................................................................................................10

III.1. Study design and setting .............................................................................................................10

III.2. Study population .........................................................................................................................10

III.3. Selection criteria .........................................................................................................................10

III.4. Sampling and sample size calculation.........................................................................................10

III.5. Data collection and analysis ........................................................................................................11

III.6. Study limitations .........................................................................................................................12

III.7. Ethical considerations .................................................................................................................12

IV. RESULTS ..........................................................................................................................................13

IV.1. Demographic characteristics .......................................................................................................13

IV.2. Clinical presentation ...................................................................................................................14

IV.2.1. Symptoms ............................................................................................................................14

IV.2.2. Vital signs ............................................................................................................................15

IV.2.3. Laboratory findings ..............................................................................................................15

IV.2.4. Diagnosis .............................................................................................................................15

IV.2.5. Management.........................................................................................................................16

IV.2.6. Complication ........................................................................................................................17

IV.2.7. Length of stay ......................................................................................................................18

IV.3. Analysis ......................................................................................................................................19

IV.3.1. Relationship between age and cause of peritonitis ..............................................................19

IV.3.2. Bivariate analysis .................................................................................................................19

V. DISCUSSION .....................................................................................................................................26

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VI. CONCLUSION AND RECOMMENDATIONS ..............................................................................28

VI.1. Conclusion ..................................................................................................................................28

VI.2. Recommendations .......................................................................................................................28

VIII. REFERENCES ................................................................................................................................29

VIII. APPENDICES.................................................................................................................................32

xi
I. INTRODUCTION

I.1. Background
Despite a better understanding of pathophysiology, as well as advances in diagnosis, surgery,
antimicrobial therapy and intensive care support, peritonitis remains a potentially fatal
condition. Severe bacterial peritonitis following gastrointestinal tract (GIT) perforation carries
high morbidity and mortality. [1]

Contamination of the peritoneal cavity can lead to a cascade of infection, sepsis, multisystem
organ failure and death if not treated timely and efficiently [3, 4]. The diagnosis is often
delayed or even missed, so that many patients deteriorate and develop septic shock and organ
failure. Successful management of peritonitis is aimed at timely surgical intervention to control
or to eliminate the source of the intra-abdominal infection and to decrease the contamination of
the peritoneal cavity, along with appropriate antimicrobial therapy. Various surgical
interventions may be performed, depending on the source of the infection, the severity of
peritoneal contamination and inflammation, the degree of septic deterioration, and the patient’s
previous state of health [2].

Even with ideal treatment there is high morbidity and mortality (ranging from 10 to 20%)
resulting from peritonitis. [6, 7]

The etiology of peritonitis in adults in developing countries tends to be different from that in
western countries. Whereas in high-resource settings peritonitis most commonly occurs due to
lower gastrointestinal (GI) perforations such as diverticulitis, in low-resource areas upper GI
perforations, especially peptic ulcer perforations, are more common[14].On the other hand, less
is known about whether the causes of peritonitis in the paediatric population differ in high
versus low-resource settings.

1
For example, although certain clinical conditions, such as primary peritonitis and appendicitis,
are found to be more common in children [5] it is unclear whether this is true throughout the
world. In Rwanda specifically there is a paucity of data regarding the etiology of peritonitis in
children.

I.2 . General considerations of peritonitis.

I.2.1. Definition

Peritonitis is referred to as inflammation of the peritoneum, the serosal lining of the abdominal
cavity and its contained viscera, commonly due to generalized or localized infection.

I.2.2. Etiologies

The most common cause of peritonitis in the general population are:

 Perforated appendicitis

 Perforated duodenal ulcer

 Typhoid ileal perforations.

 Complications of pelvic inflammatory disease (PID) for women.

 Abdominal trauma resulting in intestinal injury.

 Perforated bowel obstruction.

With HIV/AIDS emergence tuberculous and primary (SBP) are known but are rarely found in
the general population, the later being more prevalent in patients undergoing chronic peritoneal
dialysis and with liver failure.

I.2.3. Pathophysiology

Injury results in an influx of protein rich fluid, activation of the complement cascade, up-
regulation of peritoneal mesothelial cell activity and invasion of the peritoneum with
polymorphonuclear neutrophils and macrophages. [12].

2
There is stimulation of cytokine and chemokine production. Bacteria are opsonized and killed
by white blood cells and cleared through the lymphatics. The local consequences of this
activation are the translocation of granulocytes from peritoneal capillaries to the mesothelial
surface and a dilatation of peritoneal blood vessels resulting in enhanced permeability,
peritoneal edema and lastly the formation of protein-rich peritoneal exudate. [13]

The first line of host defense is clearance of noxious agents via the lymphatics of the parietal
peritoneum, diaphragm and omentum. The formation of fibrin acts to wall of the infection, it is
associated with abscess formation. [15] The response to intra-abdominal infection depends on
5 key elements: inoculum size; virulence of the contaminating organisms; the presences of
adjuvants within the peritoneal cavity; adequacy of local, regional, and systemic host defenses;
and the adequacy of initial management. [16]

Inflammation within the peritoneal cavity induces a sequence of secondary changes that
produce the clinical syndrome of peritonitis. These features are part of the Systemic
Inflammatory Response Syndrome (SIRS), whose characteristics include two or more of the
following: Temperature >38° C or <36° C; Heart rate >90 beats/min; Respiratory rate >20
breaths/min or Paco2 <32 mm Hg; WBC >12,000 cells/mm3 or <4000 cells/mm3. Severe
sepsis denotes organ dysfunction distant from the site of infection [renal, cardiac, respiratory or
brain] or hypotension [systolic < 90mm Hg or mean BP < 70 mm Hg]. Septic shock is sepsis
with hypotension unresponsive to fluid administration and requiring vasopressors.

The acute inflammatory process within the abdomen results in sympathetic activation, and
suppression of intestinal peristalsis, or ileus. Fluid absorption through the wall of the bowel is
impaired, and significant amounts of tissue fluid may be sequestered within the lumen of the
gut, resulting in systemic hypovolemia.

3
Moreover reduced intestinal peristalsis promotes microbial overgrowth, leading to
translocation of bacteria and their products from the gut lumen into regional nodes, the
peritoneal cavity, and the portal circulation. [17]

I.2.4. Diagnosis

I.2.4.1. Clinical features

The diagnosis of peritonitis remains mainly clinical. Appropriate information on past, medical,
surgical, gynecological and familial history, as well as the history of the presenting complaint
is paramount for accurate diagnosis. Physical examination is crucial and must include
inspection, auscultation, percussion and palpation, in that order. Rectal, genital and, in women,
pelvic examination should always be performed as well as that of extra-abdominal systems.

The first sign of peritoneal irritation is localized tenderness on deep palpation. With increasing
severity the signs progress to voluntary guarding, involuntary guarding or rigidity. Rebound
tenderness is a useful sign for localized peritoneal irritation. Generalized tenderness and board
like rigidity are pathognomonic of generalized peritonitis.

I.2.4.2. Laboratory

Tests including Hb, WBC, urinalysis and, if available, basic biochemistry including
electrolytes, amylase and liver function tests will be helpful.

I.2.4.3. Imaging

Routine 2 view examination of the supine and upright abdomen or chest x-rays are effective in
diagnosing pneumoperitoneum. CT scan has no additional advantage on standard x rays as
imaging in peritonitis.

I.2.5 Classification
Based on the mechanism, peritonitis is classified in 3 categories: primary, secondary and
tertiary peritonitis.

I.2.5.1. Primary peritonitis or spontaneous bacterial peritonitis (SBP)

Results from spontaneous bacterial infection in the peritoneum, rarely requires any surgical
treatment.
4
I.2.5.2. Secondary peritonitis
Secondary to GIT perforation resulting in contamination of the peritoneal cavity and bacterial
colonization depending on the site of perforation.

I.2.5.3. Tertiary peritonitis

Characterized by a class of very ill patients in whom secondary peritonitis fails to resolve
despite appropriate management and is associated with multi-organ failure.

I.2.6. Management
Adequate resuscitation, early antibiotics, source control and peritoneal lavage, are cornerstones
of appropriate management of peritonitis.

Ressuscitation aiming at restoration of cardiac and pulmonary function recognized by

normalization of blood pressure, urinary output and oxygen saturation through the prompt
administration of supplemental oxygen and intravenous fluids, is critical to survival. These
measures should be instituted immediately on initial assessment of the patient and continued
throughout the operative and post-operative period.

I.2.6.1 Antibiotics
Even if antibiotics are necessary in the treatment of peritonitis, there is paucity of evidence to
recommend one antibiotic regime over another. [25] Primary peritonitis is often mono-
microbial while secondary peritonitis is usually polymicrobial with both gram-negative aerobes
and anaerobes predominating. Antibiotics with adequate spectra to cover these organisms are
recommended.

I.2.6.2. Peritoneal lavage

Some studies in the last 3 decades have questioned the use of peritoneal lavage post
laparotomy for peritonitis, but most of them were lacking strong evidence. Thus, intra-
operative lavage remains standard therapy. All fluid should be aspirated at the closure of the
abdomen as there is evidence that the ongoing presence of fluid decreases macrophage
efficiency. [24]

5
I.3. Problem statement
Peritonitis is one of the most serious surgical conditions commonly received at Accident and
Emergency in developing countries and more especially in paediatric patients where the
common causes are not well known, nor are the factors that can delay the prompt diagnosis and
management plan [24]

This often delays the prompt diagnosis and management plan, resulting into increased
morbidity and mortality associated with the condition in this fragile population.

We conducted a study which was intended to identify different causes of peritonitis in children,
as well as the factors related to mortality and morbidity in this population in order to contribute
to better diagnosis and management of peritonitis in this group of patients.

I.4. Research question

What are the etiologies of peritonitis in the Rwandese paediatric population, and what are the
factors that are associated with an increased risk of mortality?

I.5. Study objectives

I.5.1. General objective

To study the causes, treatment, and outcome of pediatric patients with peritonitis in Rwanda,
in order to identify key ways in which management and survival can be improved.

I.5.2. Specific objectives

1 .To identify different causes of peritonitis in children at CHUK.

2. To identify the treatments received by these children.

3. To assess the patients’ in-hospital outcomes.

4. To demonstrate the association of mortality and its various predictors.

6
I.6. Significance of the study.
A wide variety of disease states give rise to intra-abdominal infection. While varying according
to age, gender and geography, the three most common causes of generalized peritonitis in low-
income countries in general population are probably appendicitis, perforated duodenal ulcer
and typhoid perforations, in no particular order. [8] Similarly, a study of Nigerian children with
peritonitis found that 50% of patients had typhoid perforation [9]

While in Rwanda one study showed peptic ulcer perforation and ileal typhoid perforation as
the main causes of peritonitis in the general population [33]. However, the causes of peritonitis
in Rwandan children have not been studied.

By reviewing the surgical database of the year 2014 ( January to December) we found that
among a total 695 abdominal surgeries done the whole year including emergencies and elective
surgeries only 30 were done for peritonitis in children, representing 4.3%.[32]

The understanding of the main causes of peritonitis may assist in the early diagnosis in
children, particularly because their history and clinical exam may have a little value compared
to the counterpart adult population.

This may reduce the range of diagnostic investigations and the timeframe between admission
and treatment initiation, hopefully reducing the associated morbidity and mortality and
contributing to cost-effective health service delivery to our population.

Similarly, understanding the factors that are associated with poor outcomes following
peritonitis may allow for earlier and more aggressive interventions in those patients who are at
the highest risk, particularly for death.

7
II. LITERATURE REVIEW
The generalized surgical acute abdomen is a significant cause of morbidity and mortality
among children. [9] The three most common causes of generalized peritonitis in low-income
countries are probably appendicitis, perforated duodenal ulcer and typhoid perforations in
general population, but still differences exist from country to country. [10] However, little
evidence concerning causes of peritonitis in children is available.

Most studies discussing the etiologies and outcome of peritonitis were done for the general
population, few of them with children consideration in Africa were found mainly from West
Africa. [2, 9, 14, 33, 34, 35, 36]

II.1. Causes of peritonitis

There is a lot of controversies throughout the available literature concerning the common
causes of peritonitis. The causes tend to differ from region to region or country to country.

Jeteender et al in India found the most common cause of peritonitis to be peptic perforation [9],
the same as Sajid in Pakistan [2] while Ntirenganya in Rwanda found ileal perforation to be the
most common cause of peritonitis[33] in the general population. These findings differ from
results of Jonathan in Malawi in 190 patients operated for peritonitis in Kamzu referral hospital
who found appendicular perforation to be the most common cause in the general population
[36].

Controversies still exist in few studies done on peritonitis in children; Adesunkanmi [9] in
Nigeria working on 69 children in Obafemi Owolowo teaching hospital from 1993 to 1997
found typhoid intestinal perforation the common cause of peritonitis in Nigeria. Similar results
were found by Abantanga in Ghana in a study done in Komfo Anokye teaching hospital in
Kumasi. However Osarumwense, even if in the same region and working on children, found
appendicular perforation to be the most common cause [34].

8
II.2. Morbidity and mortality due to peritonitis
The generalized surgical acute abdomen is a significant cause of morbidity and mortality
among children, ranging from 10 to more than 50% in some studies [9].

Many factors have been described as responsible for surgical morbidity and mortality of
children who underwent laparotomy for peritonitis. These comprise delayed presentation,
nature of operation, delayed diagnosis and management. [2, 37, 35,14] Age was generally not
likely to influence significantly mortality[14,34], but Nuhu in Nigeria found children aged less
than 11 years to be significantly vulnerable from peritonitis as compared to other age
groups.[35]

The leading cause of death in paediatric peritonitis differs from site to site and from study to
study, however, typhoid intestinal perforation has been found to be more lethal. [35, 37]

Our peritonitis paediatric patients may have the similar characteristics possibly associated with
morbidity and mortality, however no data is available.

9
III. METHODOLOGY

III.1. Study design and setting

This study was a prospective descriptive observational study from 1st September, 2015 to 28th
February, 2016.

The research was conducted in the Surgical Department at CHUK, one of the three major
referral hospitals, with 170 surgical beds, six operative rooms and an emergency department
receiving the majority of the surgical emergencies of the capital city of Kigali and from all
over the country. For that high demand, the department has 9 general surgeons, 1 plastic
surgeon and 1 urologist, combining both clinical and academic activities. The hospital has a
varying number of foreign surgeons coming for teaching purposes and a varying number of
medical officers. As any other teaching hospital, CHUK has a number of junior and senior
residents in different surgical disciplines as well as medical and nursing students.

III.2. Study population

All pediatric surgical patients admitted and operated on with a pre or post-operative diagnosis
of peritonitis at CHUK during the period of the study.

III.3. Selection criteria

Inclusion criteria:

All pediatric patients aged from 1 month to 15 years surgically managed for peritonitis.

Exclusion criteria:

Patients transferred in after undergoing laparotomies for peritonitis or other conditions outside
CHUK or patients transferred to continue treatment related to peritonitis in other hospitals after
surgery.

III.4. Sampling and sample size calculation.

Patients meeting the inclusion criteria were consecutively enrolled in the study until the sample
size was achieved.
The sample size was calculated using the Fischer’s formula considering the prevalence of
peritonitis in CHUK at 4.3%.
10
N= [α²*p*q]/ e²
Where N: Sample size
p: Estimated peritonitis prevalence in children estimated at 4.3% at CHUK
q:1-p
e: Precision, if confidence interval = 95%, e = 0.05
: Relative error risk corresponding to 95% confidence interval.
Generally equals 1.96 for clinical studies.
Then, N= [(1.96)²*0.043*0.957]/(0.05)²= 63 patients.

III.5. Data collection and analysis

Data collection was done using a coded data sheet/questionnaire of variables under
investigation (see Appendix). Data were recorded by the investigator himself. The investigator
didn’t influence in any case the treating surgeon in the management or discharge plan and
didn’t play a role in discussion of the management to anyone.

Patients were primarily admitted to CHUK either from pediatric emergency side or through the
main accident and emergency unit of the hospital. From there initial assessment was always
done, laboratory and imaging investigations were done as needed, and then the surgical team
on day or night call was consulted for review and management.
If the diagnosis of peritonitis was established upon arrival of the surgical team, patients were
optimized and brought to theatre for surgery. Patients were recruited in the study after
postoperative diagnosis of peritonitis.
Data were initially extracted from the file of the patient and interview to the parents/guardians
within the first 24 hours after surgery after identifying the operated patient’s name in the
surgical register.
Patients operated in absence of the researcher were traced using surgical register within the
first 24 hours post operative.
At the initial visit, relevant data on history of symptoms, investigations done and results, pre
and post-operative diagnosis, intraoperative findings, and definitive surgical procedure as per
case notes were noted.

11
Variables recorded at this time included: age, sex, presenting symptoms and their duration,
presenting vital signs, diagnosis on admission, preoperative diagnosis, investigations done and
results (full blood count, urea, creatinine, electrolytes), post-operative diagnosis, and surgical
procedure performed. For analysis, age groups were stratified basing on FDA(Food and Drug
Administration guidelines). Patients were followed throughout their hospital stay in order to
ascertain whether any complications occurred, and whether the patient survived to discharge.
Data were recorded using EpiData software and analyzed using Statistical Package of Social
Sciences software, version 16.0.
Pearson’s chi square was calculated to compare variables and a p value < 0.05 was considered
statistically significant. A bivariate analysis was done to determine variables associated with an
increased risk of morbidity and mortality. Variables with significant link were crossed with
outcome variables including mortality and complications to draw their correlation with
mortality and morbidity. Descriptive demographic data tables and cross tabulations were
directly extracted from SPSS; charts and figures were obtained using SPSS or MS Office Excel
2007.

III.6. Study limitations

Being an observational study, we assumed that patients received adequate care in accordance
with the diagnosis. However system related problems may have led to inadequate management
thus contributing negatively to the outcome while these were not part of the study.
The constraints of study period compelled the researcher to be limited to short term outcome.
Long term outcome may be a subject for another study in the future.

III.7. Ethical considerations

The research protocol obtained approval, respectively from the department of Surgery, research
commission of the School of Medicine at the University of Rwanda and the ethical committee
of CHUK. All the participants were required to sign an informed consent through their parents/
guardians. Participation in the study was voluntary, and wouldn’t, in any case, affect the
patients’ management. The information obtained was treated confidentially, and only used for
research purposes by the researcher.

12
IV. RESULTS

IV.1. Demographic characteristics

In total 64 patients meeting the admission criteria were found during the period of study. 1 of
them was excluded as he was not yet discharged at the end of the study period, thus we had in
total 63 patients corresponding to the sample size. The patients’ age was ranging between 4
months and 15 years with a mean of 8.83±5.18 years and the mode was 15 years.
35 of them (55.6%) were male while 28 (44.4%) were female with a sex ratio M: F of 1.25:1.
Table 1 Distribution according to age

Age groups Frequency %

>1month to 2 years 10 15.9
>2 to 12 years 33 52.4
>12 to 15 years 20 31.7
Total 63 100.0
Most patients (52.4%) were in children age range (2 to 12years). The minimum age was 4 months, maximum 15 years with a mean of
8.83±5.18 years; the median age was 10 years, while the mode was 15 years.

Figure 1: Distribution according to sex

35 of 63(55.5%) of the sample were male while female were 28(45.5%)

Figure 2: Distribution according to the Province of residence

24 patients (38.1%) came from East, 19(30.2%) from North, 9(14.3%) from West and Kigali city each, only 2 (3.2%) came from South.
Patients were coming from 22 of 30 districts in all 5 provinces of the country: Nyagatare (in East) and Gakenke (in North) had 8 (12.7%) each,
Rubavu District in West had 6 (9.5%).
13
Figure 3: Distribution according to the economic status

40 patients (63.5%) were from middle income families, 21 (33.3 %) from low income and 2 (2.2 %) from better income families respectively.

IV.2. Clinical presentation

IV.2.1. Symptoms
Figure 4: Distribution according to symptoms at admission

Abdominal pain/tenderness in 59(93.7%); nausea and vomiting reported in 44(69.8%); fever was present in 40 patients (63.5%); constipation
in 24(38.1%); abdominal distension in only 23(36.5%).

Table 2: Distribution according to symptom duration

Symptoms duration Frequency %

1 to 7 days 46 73.0
> 7 days 17 27.0
Total 63 100.0
The pretransfer symptom duration ranged from 1 to 28 days with a mean of 7.38±6.45 days. 73% of patients presented at CHUK within the
first week of symptoms onset and 27% after 1 week.

14
IV.2.2. Vital signs
Figure 5: Temperature at admission

45 patients (71.4%) presented with abnormal temperature (fever or hypothermia) whilst 18(28.6%) exhibited normal temperature. Grouped in
ranges hypothermia (<36ºC) was found in 3 patients (4.8%); 36.1 to 37.4ºC found in10 (15.9%); 37.5 to 38.5ºC found in 33 (33%) 38.6 to
39.5ºC found in 11% and 6 patients (9.5%) had > 39.5ºC.

Blood pressure and heart rate: Only 36.5% presented with hypotension while considering the
systolic blood pressure at different age groups, 81% presented with tachycardia.

IV.2.3. Laboratory findings

Leucocytosis/leucopenia was found in 79.4% of cases; 44% were found to have anemia; 14.3%
with hemoconcentration probably secondary to dehydration; 41.3% had normal hemoglobin.
No case of renal failure found with reference to creatinine level, platelets were all in normal
range.
25.4% had low Na level, 41.3% had low K level and 36.5% had low chloride level. HIV
serology was negative in 57.1% of our sample, in 42.9% the serology was unknown due to the
fact that the test is not systematically done preoperatively in CHUK.

IV.2.4. Diagnosis
The right diagnosis of peritonitis was done preoperatively in only 60.3% of cases whereas it
was done post operatively in 40% of cases.

15
Appendicitis was the disease most commonly complicated by bacterial peritonitis(25.4%),
followed by perforated intussusceptions in 15 patients(23.8%) and typhoid ileal perforation and
perforated traumatic or obstructed ileum with 11(17.5%) and 6(9.5%) respectively, whereas the
least common cause of peritonitis was the liver or biliary origin(3.2%).
Table 3 : Distribution according to the cause of peritonitis

Causes of peritonitis Frequency %

Appendix perforation 16 25.4
Perforation of gangrenous ileal obstruction 6 9.5
Gangrenous intussusceptions 15 23.8
Traumatic ileal perforation 6 9.5
Liver/biliary empyema 2 3.2
PID 3 4.8
Primary peritonitis 4 6.3
Typhoid ileal perforation 11 17.5
Total 63 100.0
Appendicular perforation(25,4%), Gangrenous intussusceptions(23.8%) and Typhoid ileal perforation(17.5%) were the first on the list to cause
peritonitis, while trauma and primary peritonitis were responsible for 9.5% and 6.3% respectively.

IV.2.5. Management
Patient waiting period to be operated ranged from 1 to 120 hours of admission to CHUK with a
mean of 23.29±20.24 hours. 60.3% were operated after 24 hours post admission in CHUK.
Table 4 : Distribution according to time elapsed between admission and surgery

Surgery delay Frequency %

Surgery performed before 24 hours 25 39.7
Surgery performed after 24 hours 38 60.3
Total 63 100.0
Most patients (60.3%) got operated after 24 hours of admission to CHUK. 63.5% of operations were done during night calls, performed by
senior residents in 76.2%, general or pediatric surgeon in 20.6% and by a junior resident in 3.2% of cases respectively.

Table 5: Distribution according to the time of surgery

Time of surgery Frequency %

Day time 23 36.5
Night duty 40 63.5
Total 63 100.0
63.5% of patients were operated during the night call.

Table 6 : Distribution according to the operator

Principal operator Frequency %

General/pediatric surgeon 13 20.6
Senior resident 48 76.2
Junior resident 2 3.2
Total 63 100.0
In 76.2% the principal operator was a senior resident either PGY III or PGY IV. 74.6% of surgery done consisted either of laparotomy/perforation repair and lavage or resection/anastomosis
and lavage. Stomas were done in 9.5% of cases. Post operatively antibiotics were prescribed for therapeutic purpose in 81% and 29% as prophylaxis.

16
Table 7: Distribution according to post operative antibiotic use

Post operative antibiotic use Frequency %

Antibioprophylaxis 12 19.0
Antibiotherapy 51 81.0
Total 63 100.0
81% of patients got antibiotics in terms of antibiotherapy postoperatively.

IV.2.6. Complication
Complications occurred in 74.6% of cases with 29.8% of denutrition and electrolyte
imbalance; 27.6% of sepsis and septic shock; 10.6% of surgical site infection; 8.5% of
respiratory complications and fascia dehiscence as well. Re-laparotomy for compliactions was
performed in 8(12.7%) in the whole post operative course. 14/63 (22.2%) cases of deaths were
registered, 2 died on table, 6 died of sepsis in ICU settings and 6 died of post operative
respiratory problems.
Figure 6: Distribution according to complications occurred

Denutrition and electrolyte imbalance was the most registered complication(29.8%) ; followed with sepsis and septic shock(27.6%); surgical
site infection(10.6%); then respiratory complications and fascia dehiscence(8.5%).

17
Figure 7: Distribution according to mortality

14 deaths (22.2%) were registered among whom 8(57.1%) have been admitted in ICU postoperatively. 2 of them died on table; 8 died of sepsis
in ICU settings and for the remaining 4 the cause of deaths was due to respiratory infections postoperatively.

Table 8: Distribution of mortality according to the cause of peritonitis

Cause of peritonitis Deaths registered %

Traumatic ileal perforation 4 28.6
Perforated gangrenous ileal obstruction 3 21.4
Gangrenous intussusception 3 21.4
Appendix perforation 2 14.3
Typhoid ileal perforation 2 14.3
Liver/biliary empyema 0 0
Primary peritonitis 0 0
PID 0 0
Total 14 100
Trauma caused more mortality than other causes of peritonitis: 4 of 6 patients died representing 28.6% of overall mortality and 66.7% of
mortality within trauma patients.

IV.2.7. Length of stay

The length of stay varied between 1 and 28 days with a mean of 12.14±5.736 days. 44.4% were
hospitalized for 8 to 14 days; 34.9% for > 15 days while 20.6% stayed between 1 and 7 days.

18
 Table 9 : Distribution according to LOS

Length of stay Frequency %

1 to 7 days 13 20.6
8 to 14 days 28 44.4
>15 days 22 34.9
Total 63 100.0
44.4% had a LOS of 8-14 days 34.9% the LOS of >15 days and 20.6% a LOS of 1 week or less.

IV.3. Analysis

IV.3.1. Relationship between age and cause of peritonitis

Table 10: Correlation of age and cause of peritonitis

Cause of peritonitis Age groups Total

>1month to 2 >2 to 12 >12 to 15
Appendix perforation 1years 9years 6years 16
6.2% 56.2% 37.5% 100.0%
Perforation of gangrenous obstructed SB 1 3 2 6
16.7% 50.0% 33.3% 100.0%
Gangrenous intussusception 8 7 0 15
53.3% 46.7% .0% 100.0%
Traumatic hollow viscus perforation 0 6 0 6
.0% 100.0% .0% 100.0%
Liver/biliary empyema 0 0 2 2
.0% .0% 100.0% 100.0%
PID 0 1 2 3
.0% 33.3% 66.7% 100.0%
Primary peritonitis 0 3 1 4
.0% 75.0% 25.0% 100.0%
Typhoid ileal perforation 0 4 7 11
.0% 36.4% 63.6% 100.0%
Total 10 33 20 63
15.9% 52.4% 31.7% 100.0%
Age was found to be significantly associated with the cause of peritonitis with most intussusceptions below the age of 2 years and most TIP
and PID at above 10 years of age.(p=0.001)

IV.3.2. Bivariate analysis

Bivariate analysis was done to identify factors significantly linked with an increased risk of
morbidity (post operative complications) and mortality and found the following:
Table 11: Variables associated with mortality (bivariate analysis).

Score df Sig.
SYMPTOM DURATION 5.699 1 .012
PRINCIPLE OPERATOR 5.248 1 .013
PRESENCE OF NAUSEA AND VOMITING 6.222 1 .012
SEPSIS AS COMPLICATION 20.942 1 .000
POST OP ICU ADMISSION 14.649 1 .000

19
Table 12: Principal operator and complication occurrence (p=0.023)

Principal surgeon Complication occurrence Total

Yes None
General/pediatric surgeon 2 11 13
6.5% 34.4% 20.6%
Senior resident 28 20 48
90.3% 62.5% 76.2%
Junior resident 1 1 2
3.2% 3.1% 3.2%
Total 31 32 63
100.0% 100.0% 100.0%
90.3% of patients who got complications were operated by senior residents; only 6.5% were operated by a general or pediatric surgeon.
(p<0.05)

Table 13: Correlation of the cause of peritonitis and length of stay (p=0.030).

Cause of peritonitis Length of stay Total

1 to 7 days 8 to 14 days >15 days
Appendix perforation 2 8 6 16
12.5% 50.0% 37.5% 100.0%
Perforation of gangrenous obstructed 2 4 0 6
small bowel 33.3% 66.7% .0% 100.0%
Gangrenous intussusception 5 5 5 15
33.3% 33.3% 33.3% 100.0%
Traumatic hollow viscus perforation 3 2 1 6
50.0% 33.3% 16.7% 100.0%
Liver/biliary empyema 0 1 1 2
.0% 50.0% 50.0% 100.0%
PID 0 2 1 3
.0% 66.7% 33.3% 100.0%
Primary peritonitis 0 4 0 4
.0% 100.0% .0% 100.0%
Typhoid ileal perforation 1 2 8 11
9.1% 18.2% 72.7% 100.0%
Total 13 28 22 63
20.6% 44.4% 34.9% 100.0%
Peritonitis secondary to typhoid ileal perforation was found to be more associated with the longer length of stay 72.75 as compared to other
causes of peritonitis in pediatric population (p=0.030)

20
Table 14: Pulse rate status and Complication occurrence (p=0.002)

Pulse rate status Complication occurrence Total

Yes None
Normal 1 11 12
3.2% 34.4% 19.0%
Tachycardia 30 21 51
96.8% 65.6% 81.0%
Total 31 32 63
96.8% of patients who got complications post operatively had tachycardia at admission. (p<0.05)

Table 15: Postoperative ICU admission and complication occurrence (p=000)

Post operative ICU admission Complication occurrence Total

Yes None
Yes 12(38.7%) 1(3.1%) 13(20.6%)
No 19(61.3%) 31(96.9%) 50(79.4%)
Total 31(100.0%) 32(100.0%) 63(100.0%)
96.9% of patients who had no post operative complications have had post operative recovery without ICU requirement.
p<0.05)

Table 16: Symptom duration and complication occurrence (p=0.009)

Pretransfer symptoms duration

groups Complication occurrence

Yes None Total

1 to 7 days duration 18 28 46

39.1% 60.9% 100.0%

> 7 days duration 13 4 17

76.5% 23.5% 100.0%

Total 31 32 63

49.2% 50.8% 100.0%

76.5% of patients who had postoperative complications were admitted after 7 days of symptoms onset. (p<0.05)

21
Table 17: Cause of peritonitis and complication occurrence (p=0.046)

Per operative diagnosis Complication occurrence Total

Yes None
Appendix perforation 5(31.2%) 11(68.8%) 16(100.0%)
Gangrenous obstructed SB perforation 2(33.3%) 4(66.7%) 6(100.0%)
Gangrenous intussusception 8(53.3%) 7(46.7%) 15(100.0%)
Traumatic hollow viscus perforation 4(66.7%) 2(33.3%) 6(100.0%)
Liver/biliary empyema 0(.0%) 2(100.0%) 2(100.0%)
PID 1(33.3%) 2(66.7%) 3(100.0%)
Primary peritonitis 1(25.0%) 3(75.0%) 4(100.0%)
Typhoid ileal perforation 10(90.9%) 1(9.1%) 11(100.0%)
Total 31(49.2%) 32(50.8%) 63(100.0%)
Patients with peritonitis post TIP were the most to develop post operative complications (90.9%) followed by traumatic intestinal perforation
(66.7%) (p<0.05)

Table 18: Nausea/vomiting and complication occurrence (p=0.041)

Nausea and/or vomiting Complication occurrence Total

Yes None
Yes 18 26 44
58.1% 81.2% 69.8%
No 13 6 19
41.9% 18.8% 30.2%
Total 31 32 63
100.0% 100.0% 100.0%
Patients who had nausea and vomiting as symptoms at admission were the most to develop post operative complications (58.1%) (p<0.05)

Table 19: LOS and antibiotic use (p=0.018)

Antibiotic use Length of stay Total

1 to 7 days 8 to 14 days >15 days
Antibioprophylaxis 6 4 2 12
46.2% 14.3% 9.1% 19.0%
Antibiotherapy 7 24 20 51
53.8% 85.7% 90.9% 81.0%
Total 13 28 22 63
100.0% 100.0% 100.0% 100.0%
Patients treated with antibiotherapy were the ones to have a longer LOS as compared to their antibioprophyaxis counterparts. (p<0.05)

22
Table 20: Province and LOS (p=0.046)

Province Length of stay Total

1 to 7 days 8 to 14 days >15 days
North 8 8 3 19
61.5% 28.6% 13.6% 30.2%
West 0 4 5 9
.0% 14.3% 22.7% 14.3%
South 0 2 0 2
.0% 7.1% .0% 3.2%
Est 4 10 10 24
30.8% 35.7% 45.5% 38.1%
Kigali City 1 4 4 9
7.7% 14.3% 18.2% 14.3%
Total 13 28 22 63
100.0% 100.0% 100.0% 100.0%
Patients from Eastern province were the most to stay longer in hospital than others (p<0.05). Most of typhoid fever patients 35.3% were from
the Eastern province and typhoid fever patients were the ones who stayed longer(>15 days) as compared to others (72.7%).

Table 21: Economic status and LOS (p=0.014)

Economic status Length of stay Total

1 to 7 days 8 to 14 days >15 days
Good 0 2 0 2
.0% 100.0% .0% 100.0%
Moderate 7 13 20 40
17.5% 32.5% 50.0% 100.0%
Poor 6 13 2 21
28.6% 61.9% 9.5% 100.0%
Total 13 28 22 63
20.6% 44.4% 34.9% 100.0%
Patients in poor economic condition were the most to have a longer LOS (61.9%) as compared to others. (p<0.05)

Table 22: Pretransfer symptom duration and LOS (p=0.035)

Pretransfer symptoms duration Length of stay Total

1 to 7 days 8 to 14 days >15 days
1 to 7 days duration 12 22 12 46
92.3% 78.6% 54.5% 73.0%
> 7 days duration 1 6 10 17
7.7% 21.4% 45.5% 27.0%
Total 13 28 22 63
100.0% 100.0% 100.0% 100.0%
Patients admitted within the first 7 days of symptoms onset were the ones to stay shorter in hospital post operatively(92.3%), this making early
admission a factor of quick recovery.(p<0.05)

23
Table 23: Fascia dehiscence and LOS (p=0.019)

Fascia dehiscence Length of stay Total

1 to 7 days 8 to 14 days >15 days
Yes 0 0 4 4
.0% .0% 100.0% 100.0%
No 13 28 18 59
22.0% 47.5% 30.5% 100.0%
Total 13 28 22 63
20.6% 44.4% 34.9% 100.0%
All patients (100%) who had fascia dehiscence as complication had a prolonged LOS (>15 days) as compared to their counterparts. (p<0.05)

Table 24: Intraabdominal abscess and LOS(p=0.011)

Intaraabdominal abscesses Length of stay Total

1 to 7 days 8 to 14 days >15 days
Yes 0 1 6 7
.0% 14.3% 85.7% 100.0%
No 13 27 16 56
23.2% 48.2% 28.6% 100.0%
Total 13 28 22 63
20.6% 44.4% 34.9% 100.0%
85.7% of patients who had intraabdominal absce as complication had a long LOS, making this a factor of poor prognosis for recovery in post
operative course. (p<0.05)

Table 25: Denutrition/electrolyte imbalance and LOS(p=0.003)

Denutrition and electrolyte imbalance Length of stay Total

1 to 7 days 8 to 14 days >15 days
Yes 0 4 10 14
.0% 28.6% 71.4% 100.0%
No 13 24 12 49
26.5% 49.0% 24.5% 100.0%
Total 13 28 22 63
20.6% 44.4% 34.9% 100.0%
71.4% of patients with denutrition and electrolyte imbalance as post operative complication stayed > 15 days in hospital. (p<0.05)

Table 26: Post operative ICU admission and outcome (p=0.001)

Post operative ICU admission Treatment outcome Total

Cure Death
Yes 5 8 13
10.2% 57.1% 20.6%
No 44 6 50
89.8% 42.9% 79.4%
Total 49 14 63
100.0% 100.0% 100.0%
89.8% of cured patients recovered from anesthesia without ICU requirement and 57.1% of deaths have been admitted in ICU postoperatively.
ICU requirement post operatively predicts poor prognosis, while safe post anesthesia recovery was found to be a factor of good prognosis.
(p<0.05)

24
Table 27 Symptoms duration and outcome (p=0.012)

Pre transfer symptoms duration Treatment outcome Total

Cure Death
1 to 7 days duration 38 8 46
82.6% 17.4% 100.0%
> 7 days duration 11 6 17
64.7% 35.3% 100.0%
Total 49 14 63
77.8% 22.2% 100.0%
There were more cure in patients admitted within the first week of symptoms onset (82.6%) and more deaths in the ones admitted after 7 days
of symptoms onset(35.3%); this makes the longer pretransfer symptom duration a good predictor of the outcome.(p<0.05)

Table 28: Nausea/vomiting and outcome (p=0.017)

Nausea and/or vomiting Treatment outcome Total

Cure Death
Yes 38 6 44
77.6% 42.9% 69.8%
No 11 8 19
22.4% 57.1% 30.2%
Total 49 14 63
100.0% 100.0% 100.0%
Most cured patients had nausea and vomiting symptom at admission (77.6%) (p<0.05) Nausea and vomiting was found in intestinal
obstruction and intussusceptions causing peritonitis without massive fecal peritoneal spillage.

Table 29: Principal operator and outcome (p=0.013)

Principal surgeon Treatment outcome Total

Cure Death
General/pediatric surgeon 13 0 13
26.5% .0% 20.6%
Senior resident 35 13 48
71.4% 92.9% 76.2%
Junior resident 1 1 2
2.0% 7.1% 3.2%
Total 49 14 63
100.0% 100.0% 100.0%
100% of death cases (14/14) were operated by residents while all patients operated by a general or pediatric surgeon survived. This makes low
operative skills a factor associated with an increased risk of mortality. (p<0.05)

Table 30: Sepsis and outcome (p=0.000)

Sepsis Treatment outcome Total

Cure Death
Yes 4 9 13
8.2% 64.3% 20.6%
No 45 5 50
91.8% 35.7% 79.4%
Total 49 14 63
100.0% 100.0% 100.0%
64.3% of deaths cases (9/14) had sepsis as postoperative complication, while 91.8% of cured patients (45/49) didn’t have
sepsis as complication. (p<0.05)
25
V. DISCUSSION
Peritonitis is a commonly encountered surgical pediatric emergency in Rwanda like in other
developing countries. [9]
In most of cases patients with well established peritonitis present tardy to the hospital. Thus
purulent/faecal contamination leads to varying degree of abdominal sepsis with typical signs
and symptoms making it possible to make a clinical diagnosis of peritonitis for almost all
patients.
In our study the main causes of peritonitis in pediatric population were appendicular
perforation (25.4%), gangrenous intussusceptions(23.8%), typhoid ileal perforations (17.5%).
These results are similar to findings in the study done in Pakistan [2] where typhoid ileal
perforation was found to cause peritonitis in 17% of cases. Surgical management, which
included bowel resection and anastomosis, stoma creation, and closure of perforations, was
dependent on the intraoperative findings and to the surgeon’s judgment, and the options
adopted were similar to those reported in other studies.[9, 34]
Mortality found in our study, (22.2%), was comparable to results found in other studies in
Africa [34, 35]. However, this is high compared to the one found in studies done in Pakistan
(9%) [2] and West Africa: Nigeria (11.6%) [9]. In contrary to results of studies done in
children [34, 35] lower age was not found to be a predicting factor of mortality in our sample
(p=0.133). In keeping with other studies [14, 2] tachycardia and sepsis were found to be
associated with an increased risk of mortality. Correlation of nausea and vomiting and the high
risk of mortality was a new finding not similar to results in available data [2,14,9].In contrary
with findings elsewhere in literature, surgery delay was not found to be associated with
increased risk of mortality(p=0.277) nor with the risk of morbidity(p=0.459).[1,2,4,9]
4 of 6 patients with peritonitis due to traumatic intestinal perforation died, representing 66.7%
p=NS (0.277), other studies in developing countries found lower figures ranging from 10 to
20% [9, 14].

26
Peritonitis in pediatric population in CHUK has been found to be associated with a low length
of stay (12.14 days) as compared to finding in adults in the same hospital (15.3 days).[33]
Nevertheless, this LOS is greater than the mean overall surgical LOS in CHUK which was 8
days in January 2016 (CHUK monthly report; January 2016).
Peritonitis related complications occurred in 49.2% of our population the most frequent was
denutrition with electrolyte imbalance and sepsis representing 22.2% and 20.6% respectively.
The resident as principal operator was significantly correlated with mortality: 100% of death
cases (14/14) were operated by residents while all patients operated by a general or pediatric
surgeon survived. This demonstrates how low expertise and operative skills contribute
negatively to the outcome and thus, the need of close senior supervision of surgeries performed
by surgical trainees on children.
Post operative ICU admission, presence of nausea and vomiting at admission and sepsis as
complication were correlated with mortality (p<0.05). This may be due to severe illness,
dehydration with electrolyte disorders contributing to mortality. [14]
Some variables like the post operative antibiotic use; poor economic status of the family;
delayed presentation to hospital and the eastern province origin were associated with high risk
of morbidity; even if not associated significantly with mortality, they influence the overall
outcome.

Patients operated by residents stayed longer and had more complications compared to ones
operated by specialists. Like for mortality, low technical skills may be the explanation.
Patients who needed antibiotherapy post operatively were already very sick with abdominal
purulent/fecal contamination exposing them to the higher risk of morbidity and mortality, but
data are still not conclusive.

27
 VI. CONCLUSION AND RECOMMENDATIONS

VI.1. Conclusion
Our study has achieved its objectives. Peritonitis in pediatric population in CHUK was found
to be among the common causes of admission in the surgical department. It bears the
significant morbidity and mortality. The challenges found and mostly correlated with an
increased risk of morbidity and mortality were the delayed transfer of patients from the District
hospitals; the delayed surgery; skills of operators; the postoperative sepsis and severe illness
requiring ICU post operatively.
Other factors like pulse rate (tachycardia), cause of peritonitis, nausea and vomiting, economic
status, denutrition were found to be significantly linked with an increased morbidity and
prolonged LOS; these could be regarded as influencing also the overall outcome. However, a
multi institutional study covering the other surgical centers of the country with a larger number
of patients is needed for further validation of our findings.
Other studies focusing trauma related peritonitis in children as well as the causes of mortality
in peritonitis patients, especially children, in ICU settings could be considered in the future.

VI.2. Recommendations
In the light of these results we recommend the following:
 To CHUK surgical department, to ensure close supervision by consultants to laparotomies for
peritonitis in children performed by surgical trainees.
 To CHUK, to conduct regular training to clinicians from peripheral health facilities under its
catchment zone, on trauma care and common abdominal surgical emergencies with emphasis
to children, to improve early recognition and management of peritonitis.
 To CHUK in collaboration with MOH, to increase CHUK ICU admission capacity.

28
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5. Thompson AE, Marshall JC, Opal SM. Intraabdominal infections in infants and children:
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29
15. Riquelme A, Calvo M, Salech F, Valderrama S, Pattillo A, Arellano M et al. Value of adenosine
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[Review] [34 refs]. Journal of Clinical Gastroenterology 40[8]:705-10, 2006.
16. Malangoni MA. Contributions to the management of intraabdominal infections. [Review] [30
refs]. American Journal of Surgery 2005; 190[2]:255-259.
17. Marshall JC. Intra-abdominal infections. [Review] [66 refs]. Microbes & Infection 6[11]:1015-
25, 2004.
18. Lee MJ. Non-traumatic abdominal emergencies: imaging and intervention in sepsis. [Review]
[33 refs]. European Radiology 12[9]:2172-9, 2002.
19. Marshall JC, Innes M. Intensive care unit management of intra-abdominal infection. [Review]
[110 refs]. Critical Care Medicine 31[8]:2228-37, 2003.
20. Streat SJ, Plank LD, Hill GL. Overview of modern management of patients with critical injury
and severe sepsis. [Review] [68 refs]. World Journal of Surgery 24[6]:655-63, 2000.
21. Weigelt JA. Empiric treatment options in the management of complicated intra-abdominal
infections. [Review] [59 refs]. Cleveland Clinic Journal of Medicine 74 Suppl 4:S29-37, 2007.
22. Schein M, Gecelter G, Freinkel W, Gerding H, Becker PJ. Peritoneal lavage in abdominal
sepsis. A controlled clinical study. Archives of Surgery 125[9]:1132-5, 1990.
23. Schein M. Surgical management of intra-abdominal infection: is there any evidence?. [Review]
[30 refs]. Langenbecks Archives of Surgery 387[1]:1-7, 2002.
24. Dorairajan LN, Gupta S, Deo SVS, Chumber L: Peritonitis in india –A decades experience.
Tropical Gastroentrology 1995, 16(1): 33-38.
25. Koulaouzidis A, Bhat S, Karagiannidis A, Tan WC, Linaker BD. Spontaneous bacterial
peritonitis. [Review] [91 refs]. Postgraduate Medical Journal 83[980]:379-83, 2007.
26. Mowat C, Stanley AJ. Review article: spontaneous bacterial peritonitis--diagnosis, treatment
and prevention. [Review] [70 refs]. Alimentary Pharmacology & Therapeutics 15[12]:1851-9,
2001.
27. Wiggins KJ, Johnson DW, Craig JC, Strippoli GF. Treatment of peritoneal dialysis-associated
peritonitis: a systematic review of randomized controlled trials. [Review] [76 refs]. American
Journal of Kidney Diseases 50[6]:967-88, 2007.
28. Bosscha K, van Vroonhoven TJ, van der WC. Surgical management of severe secondary
peritonitis.[see comment]. [Review] [85 refs]. British Journal of Surgery 86[11]:1371-7, 1999.
29. Hunter JD, Damani Z. Intra-abdominal hypertension and the abdominal compartment syndrome.
[Review] [64 refs]. Anaesthesia 59[9]:899-907, 2004.
30. Malangoni MA. Evaluation and management of tertiary peritonitis. [Review] [25 refs].
American Surgeon 66[2]:157-61, 2000.

30
31. Evans HL, Raymond DP, Pelletier SJ, Crabtree TD, Pruett TL, Sawyer RG. Diagnosis of intra-
abdominal infection in the critically ill patient. [Review] [36 refs]. Current Opinion in Critical
Care 7[2]:117-21, 2001.
32. CHUK Surgical database.2015
33. F. Ntirenganya, G. Ntakiyiruta, I. Kakande. Prediction of Outcome Using the Mannheim
peritonitis Index in Patients with Peritonitis at Kigali University Teaching Hospital. East and
Central African Journal of Surgery. July/August 2012 Volume 17.
34. Osarumwense D. Osifo and Scott O. Ogiemwonyi. Peritonitis in Children: Our Experience in
Benin City, Nigeria. SURGICAL INFECTIONS. Vol. 12, Number 2, 2011.
35. Nuhu Ali and Bata Mtaku Gali. Causes and treatment outcome of perforation peritonitis in north
eastern Nigeria.Surgical Practice. (2010) 14, 92–96.
36. Jonathan C SamuelJaveria S Qureshi, Gift Mulima,Carol G Shores. An Observational Study of
the Etiology, clinical presentation and outcomes associated with peritonitis in Lilongwe,
Malawi. World Journal of Emergency Surgery20116:37
37. F.A Abatanga, B. Nimako, M.Amoah.The range of abdominal surgical emergencies in children
older than 1 year at Komfo Onokye Teaching Hospital, Kumasi,Ghana.Annals of African
medicine.Vol 8,No 4;2009: 236-242.

31
VIII. APPENDICES

32
 1. Data collection form
1.Study number: ……………….
2.Date of admission: ………./……../20…….
3.Date of discharge: ………./……../20……..
4.Length of stay in days:……………
5.Hospital ID: ……………………………………..
6.Age in years:………………..
7.Sex: Male: 1 Female: 2
8.Address(District/Province): ………………………………/…..……………………
9.Socio economic status: Good: 1; Moderate: 2; Poor: 3
10.Presenting symptoms: 1. Fever; 2. Nausea and/or vomiting; 3.Abd. pain; 4.Abd. distension; 5.
Stool & gas arrest; 6. Diarrhea. Others(specify):………………….……..
11. Period between symptoms onset to transfer (days): ……………………….
12. Period between the admission and surgery(hours/days):….…………
13. Laboratory investigations results:
Leucocytes(10ˆ6/mL) :………………….
Platelets( 10ˆ3/mL):………………………
Hemoglobin level (g/dL):…………..
Creatinine(micromol/L) :…………..
Na(mmol/L):………. K(mmol/L):……….. Cl(mmol/L):…………..
HIV serology: Positive Negative Unknown
CD4 count (if HIV positive):……………
14.Vital signs
Temperature in centigrades:………. BP(mmHg):……… Pulse(bt/min):…….
SpO2(%):………
15.Diagnosis at admission: App perforation , gastric perf , Gangrenous IO
Intussusception Trauma , Others(mention):………..
16.Operation time: Daytime: 1, During the night: 2
17.Principal operator: General surgeon: 1, Senior resident: 2, Junior resident: 3, Medical
officer: 4, others(specify)……………………………………
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18.Operation done:………………………………………………………………………
19.Perioperative cause of peritonitis: 1.App perforation; 2.Gastric perf.; 3.Gangrenous IO;
4.Intussusception; 5.Trauma; 6.Others[mention]:………..
20. Medical treatment: 1.Prophylactic antibiotics; 2.Therapeutic antibiotherapy; 3. None; 4.
Others (specify):……………………..
21.Complications: 1.Burst abdomen; 2.Sepsis ;3.Others: ………………..…
22. Required ICU? Yes: 1, No: 2
23. Status at discharge: Improved: 1, Non improved: 2, Dead: 3

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 2. Consent form( English)
Patient’s number:………………………..
I am Dr MUTABAZI Emmanuel a postgraduate student at University of Rwanda in the department of
Surgery who is carrying out a study on “Epidemiological study of peritonitis in pediatric population and
predictors of mortality. Case of CHUK”. I am doing it in partial fulfillment for the award of the degree of
MMed (General Surgery).
You will be required to understand its purpose, risks and benefits before you agree to participate in it.
Aim: To identify the common causes of peritonitis in children and assess their correlation with the treatment
outcome in CHUK.
Risks to the participants
There are no major risks in this study.
Benefits
The information from the study will provide useful input for early recognition/ diagnosis and thus treatment
of peritonitis in children.
Results of the study will help in improving the management of peritonitis in children. There are no financial
benefits to be provided to the participants in the study.
Confidentiality:
All informations will be kept confidential by the principal investigator for purposes of the study strictly.
Questions
Participants of the study are free to ask questions or seek any clarifications about the study when they so
wish. My phone number: 0788550617.
Rights to withdraw from the study
You are free to withdraw from the study at any time you wish to without any consequence.
Statement of consent
I have read the information above and understood the contents. I have had a full explanation of the nature and
purpose of the study, risks and benefits in a language I understand. I have understood that I have right to
withdraw from the study at anytime I wish to.
By signing this consent form, I understand that I am accepting (my child) to be enrolled in this study.
I hereby sign for myself……………………………………as a proof to participate in the study.
Names :………………………………………………………..Date :………………………
I have explained the purpose of the study to the participant to the best of my knowledge and he has fully
understood the purpose, benefits and risks to him or her.
Signature:……………………………………Date :………………………………

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 3.Consent form (Kinyarwanda)

URUPAPURO RWO KWEMERA KUGIRA URUHARE MU BUSHAKASHATSI

Nitwa Dr MUTABAZI Emmanuel, umuganga w’umunyeshuri wiga kubaga muri Kaminuza y’u Rwanda
nkaba ndi gukora ubushakashatsi ku ndwara ya peritonite mu bana n’impamvu z’ingenzi zifitanye isano
n’impfu za bamwe muri abo bana barwaye iyi ndwara.
Urasabwa kubanza gusobanukirwa intego y’ubu bushakashatsi, inyungu n’ingaruka zishobora kubaho igihe
wemeye ko bukorerwa ku mwana urwaje/ubereye umubyeyi.
Intego: Kugaragaza inkomoko y’uburwayi bwa peritonite mu bana ndetse n’impamvu z’ingenzi zifitanye
isano n’impfu z’abo bana barwaye ubu burwayi.
Ingaruka:
Nta ngaruka ugize uruhare muri ubu bushakashatsi azagira.
Inyungu:
Ibizava muri ubu bushakashatsi bizafasha mu kwihutisha kumenya no kuvura ubu burwayi mu bana.
Ibizava muri ubu bushakashatsi bizafasha kandi kuvura neza abana barwaye indwara ya peritonite. Nta
nyungu y’amafaranga uwagize uruhare muri ubu bushakashatsi azabukuramo.
Ibanga:
Amakuru yose kuri buri muntu azajya abikwa n’umushakashatsi kugira ngo akoreshwe mu bushakashatsi
gusa.
Ibibazo:
Umuntu wese wemeye kugira uruhare muri ubu bushakashatsi yemerewe kubaza ibibazo byose igihe cyose
yifuza ubundi busobanuro. Nimero ya telefoni yanjye ni: 0788550617.
Uburenganzira bwo kwivana mu bushakashatsi
Ufite uburenganzira bwo kwivana mu mubare w’abakorerwaho ubushakashatsi igihe ubishakiye kandi nta
ngaruka ugize.
Amasezerano yo kwemera gukorerwaho ubushakashatsi
Maze gusoma ibyanditse hejuru kandi nabisobanukiwe. Nasobanuriwe birambuye mu rurimi numva intego,
inyungu n’ingaruka muri ubu bushakashatsi. Nasobanuriwe n’uko nemerewe kwivana mu mubare
w’abakorerwaho ubushakashatsi igihe mbishakiye nta ngaruka ngize.
Nshyize umukono kuri aya masezerano nsobanukiwe kandi nemera ko umurwayi wanjye akorerwaho
ubushakashatsi.
Umukono wanjye:…………………………………itariki:………………………………
Nasobanuriye umurwayi/umurwaza mu buryo burambuye intego, inyungu n’ingaruka by’ubu bushakashatsi.
Umushakashatsi:……………………………….itariki:……………………………….

36
 4. Informed assent form for children above 7 years
Patient ID:…………………
I am Dr MUTABAZI Emmanuel a postgraduate student in Surgery at University of Rwanda, conducting a
study entitled “Epidemiological study of peritonitis in pediatric population and factors predicting mortality.
Case of CHUK”. I am doing it in partial fulfillment for the award of the degree of MMed (General Surgery).
You will be required to understand its purpose, risks and benefits before your agreement to participate in it
without which you will not take part in the study.
Purpose of the Study: To identify the common causes of peritonitis in children and formulate their
correlation with the treatment outcome in CHUK.
Choice of participants: We are asking you to take part in the study because you have been diagnosed with
this disease and you are a child.
Participation is voluntary: You can accept yourself to us to be part of the study or if you wish ask your
parent/guardian to take the decision.
Procedures: If you accept we will take information regarding your disease since its beginning till now and
take data on your evolution during your hospitalization course to be used in the study. No particular
procedure will be done to you by us.
Risks: There is no expected risk to the participants in this study and no hurt nor physical discomfort.
Benefits: Results of the study will help in improving the management of peritonitis in children. There are no
financial benefits to be provided to the participants in the study.
Confidentiality: Information provided on your person during the study will be kept confidential by the
principal investigator and will only be used for research purpose. What will be published are only general
results from the study. Your parent/guardian also has been given more information.
Right to Refuse or Withdraw: As participation in this study is voluntary you have also the right to withdraw
from the study at any point you wish.
Who to Contact: You are allowed to ask any question to the researcher any time you wish to or ask your
parent/guardian to do it for you using my number: 0788550617.You can also talk to anyone they want to
about this (your doctor, your friend, your teacher,…)
Statement of Assent
I know that I can choose to be in the research study or choose not to be in the research study. I know that I
can stop whenever I want. I had this information read to me and I understand it.
I hereby sign for myself……………………………………as a proof to participate in the study.
Names :………………………………………………………..Date :………………………
Witness: Names and signature:………………………………………………………………..

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 5. Informed assent form (Kinyarwanda)
Urupapuro rwo kwemera kugira uruhare mu bushakashatsi ku bana(barengeje imyaka irindwi)

Nimero y’umurwayi:…………………

Nitwa MUTABAZI Emmanuel, umuganga w’umunyeshuri wiga kubaga muri Kaminuza y’u Rwanda nkaba ndi gukora ubushakashatsi ku
ndwara ya peritonite mu bana n’impamvu z’ingenzi zifitanye isano n’impfu za bamwe muri abo bana barwaye iyi ndwara.

Intego: Kugaragaza inkomoko y’uburwayi bwa peritonite mu bana ndetse n’impamvu z’ingenzi zifitanye isano n’impfu z’abo bana barwaye
ubu burwayi mu bitaro bya CHUK.

Impamvu twaguhisemo: Twahisemo kugusaba ko wagira uruhare muri ubu bushakashatsi kubera ko abaganga basanze urwaye ubu burwayi
kandi ukaba uri umwana.

Kugira uruhare muri ubu bushakashatsi ni ubushake: Ushobora kutwemerera ku bushake bwawe kugira uruhare muri ubu bushakashatsi
cyangwa ugasaba umubyeyi/umurwaza wawe kubifataho icyemezo.

Ibizagukorerwaho: Ni ubyemera tuzafata amakuru ajyanye n’uburwayi bwawe guhera butangiye kugeza ubu. Tuzanafata kandi amakuru
ajyanye n’uburyo uburwayi bwawe buzzagenda buhinduka mu gihe cyose uzaba uri mu bitaro kugira ngo yose azakoreshwe mu bushakashatsi.
Uretse ibyo nta kindi gikorwa duteganya kuzagukoreraho.

Ingaruka: Nta ngaruka ubushakashatsi buzatera abazagira uruhare muri ubu bushakashatsi kandi nta gikorwa kibabaza kizakorerwa ku mubiri
wawe.

Inyungu : Ibizava muri ubu bushakashatsi bizafasha kandi kuvura neza abana barwaye indwara ya peritonite. Nta nyungu y’amafaranga
uwagize uruhare muri ubu bushakashatsi azabukuramo.

Ibanga: Amakuru yose kuri buri muntu azajya abikwa n’umushakashatsi kugira ngo akoreshwe mu bushakashatsi gusa. Hazatangazwa gusa
ibyavuye mu bushakashatsi muri rusange ubushakashatsi burangiye. Umubyeyi/umurwaza wawe nawe yahawe amakuru ahagije kuri ibyo.

Uburenganzira bwo kwivana mu bushakashatsi

Ufite uburenganzira bwo kwivana mu mubare w’abakorerwaho ubushakashatsi igihe ubishakiye.

Uwo wasobanuza: Wemerewe kubaza umushakashatsi ibibazo byose wifuza bifitanye isano n’ubu bushakashatsi igihe ubishakiye cyangwa
ugasaba umubyeyi/umurwaza wawe kubigukorera hakoreshejwe nimero yanjye ya telefoni ariyo: 0788550617.Wemerewe kandi kuganiriza
uwo wifuza wese ibijyanye nabwo(inshuti yawe, umwarimu wawe,…)

Amasezerano yo kwemera kugira uruhare mu bushakashatsi

Nzi neza ko nshobora kwemera cyangwa kwanga kugira uruhare muri ubu bushakashatsi. Nzi neza ko nshobora guhagarika kugira uruhare
muri ubu bushakashatsi igihe mbishakiye. Ibi byose nabisobanuriwe kandi nabyumvise neza.Nshyize umukono kuri aya masezerano
nk’ikimenyetso cy’uko nemeye kugira uruhare mu bushakashatsi.

Umukono…………………………………………………...

Amazina :………………………………………………………..Itariki :………………………

Umuhamya: Amazina n’umukono:………………………………………………………………..

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6. CMHS IRB ETHICAL CLEARANCE

39
7. CHUK ETHICAL CLEARANCE

40