Gastrointestinal (GI) perforation peritonitis is a severe abdominal emergency characterized by full-thickness breach of the gastrointestinal tract, resulting in peritoneal contamination and systemic sepsis. ^[1] It constitutes a significant portion of emergency surgical admissions, particularly in developing nations where delayed presentation and limited resources pose additional challenges. ^[2]

While the general population has been extensively studied, limited data exist specifically analyzing the elderly subset. ^[3] The geriatric population—defined as individuals aged 60 years and above—is particularly susceptible to perforation peritonitis due to multiple physiological and anatomical changes. ^[4] These include reduced mucosal defense, decreased visceral pain perception, impaired immune responses, and poor cardiopulmonary reserve. ^[5] Additionally, polypharmacy and comorbidities such as diabetes mellitus, hypertension, ischemic heart disease, and chronic kidney disease further complicate management and outcomes in the elderly. ^[6]

Previous studies have primarily focused on young and middle-aged patients, where typhoid and acid peptic disease are common etiologies. ^[7] However, with increasing life expectancy and improved access to healthcare, elderly patients are forming a growing proportion of emergency surgical cases. ^[8] These patients often present atypically and late in the disease course, increasing the risk of systemic sepsis, multiorgan dysfunction, and mortality. ^[9]

The present study aims to provide a comprehensive analysis of the clinical profile, intraoperative findings, postoperative course, and surgical outcomes in elderly patients with gastrointestinal perforation peritonitis, based on prospective observational data from a tertiary care teaching hospital in South India. 

This was a prospective observational study conducted in the Department of General Surgery at Meenakshi Medical College and Research Institute, Kanchipuram, Tamil Nadu, India. The study spanned 12 months from July 2024 to June 2025.

Sample Size and Population

A total of 280 patients who underwent emergency exploratory laparotomy for gastrointestinal perforation were included. Among them, 65 patients aged 60 years and above were identified as the elderly subgroup and analyzed separately.

Inclusion Criteria

• Patients of all genders aged ≥18 years undergoing emergency surgery for GI perforation.
• Patients aged ≥60 years were classified as elderly.
• Radiological confirmation (X-ray, USG, or CT) and/or intraoperative identification of GI perforation.

Exclusion Criteria

• Patients with primary peritonitis (e.g., spontaneous bacterial peritonitis).
• Peritonitis from non-GI sources (e.g., pancreatitis, biliary or genitourinary perforations).
• Patients who succumbed before surgical intervention.

Data Collection

Baseline demographics, presenting symptoms, comorbidities, vital signs, laboratory investigations, imaging findings, site and cause of perforation, type of surgery, complications, ICU need, duration of hospital stay, and mortality were recorded. Intraoperative decisions such as resection, repair, or stoma creation were documented.

Statistical Analysis

Data were analyzed using SPSS software. Continuous variables were expressed as mean ± standard deviation, and categorical variables as percentages. Chi-square and Student’s t-test were applied for comparison between elderly and non-elderly groups. A p-value <0.05 was considered statistically significant.

Of the 280 patients, 234 (76.79%) were under 60 years of age and 65 (23.21%) were 60 years or older. The male-to-female ratio among elderly was 5:1, indicating a higher incidence in males. The average time from symptom onset to hospital presentation was 30–36 hours in elderly patients, suggesting significant diagnostic delay.

Table 1: Age-wise Distribution of Patients with GI Perforation (n = 280)

Table 2: Site of Gastrointestinal Perforation in Elderly Patients (n = 65)

In table 2, the most common sites of perforation in the elderly were Duodenum: 32.3% followed by Ileum: 29.2%, Colon: 16.9% and Jejunum and stomach are less frequent

Table 3: Etiological Factors in Elderly Patients (n = 65)

In table 3, the leading causes included Acid peptic disease (duodenal/stomach) 43% followed by Typhoid ileitis 27% and Ischemic colitis and malignancy-related perforations 10%

Table 4: Comorbidities in Elderly Patients with Perforation (n = 65)

In table 4, Comorbidities in Elderly Patients were Diabetes Mellitus 43%, followed by Hypertension 38.5%, ischemic heart disease 15.4%, Chronic Kidney Disease 9.2% and COPD 6.1%.

Table 5: Postoperative Complications in Elderly Patients (n = 65)

Table 6: Comparison of Outcomes: Elderly vs. Non-Elderly Patients

In table 6, Postoperative Complications were Respiratory complications (including pneumonia, ARDS) 40%, followed by Surgical site infection 35.38%, Electrolyte disturbances 20%, Wound dehiscence 12.3%, Sepsis and multiorgan dysfunction 10.7%, ICU admission required in 26.1% and Average hospital stay 13.8 ± 4.1 days.

Gastrointestinal perforation peritonitis remains a critical abdominal emergency with substantial morbidity and mortality, particularly in the elderly. ^[10] This study sheds light on the clinical nuances, perioperative challenges, and surgical outcomes in elderly patients undergoing emergency laparotomy for GI perforations in a tertiary care center in South India. Our findings confirm that elderly patients (≥60 years) represent a distinct subgroup with unique characteristics that demand targeted clinical attention.

In our cohort, elderly patients comprised approximately 23% of all cases, reflecting a notable shift in the age distribution traditionally dominated by younger adults in developing countries. This may be attributed to increasing life expectancy, improved access to healthcare, and changing disease patterns. ^[11] The male preponderance (male-to-female ratio of 5:1) is consistent with earlier Indian studies, such as those by Jhobta et al., suggesting lifestyle and occupational exposure differences may play a role in disease incidence. ^[12]

Duodenal and ileal perforations were the most common in elderly patients, accounting for over 60% of cases. Acid peptic disease emerged as the leading etiology, reinforcing data from both Western and Eastern experiences of peritonitis. Gupta and Kaushik (2006) and Ramakrishnan et al. (2007) previously highlighted the predominance of peptic ulcer-related perforations in India, which remains relevant despite advances in medical management. ^[13,14] The ileal perforations—frequently linked to typhoid—highlight that enteric infections still pose significant risks, especially in immunocompromised or older populations.

One of the most striking observations in our study was the high burden of comorbidities in the elderly, with over 86% having at least one chronic illness. Diabetes mellitus and hypertension were the most prevalent, often compounding perioperative risk and postoperative recovery. These comorbid conditions likely contributed to the elevated rates of complications, prolonged hospital stays, and increased ICU admissions observed in this group.

Postoperative complications were significantly more common in the elderly. Respiratory complications (40%) were the leading cause, emphasizing the vulnerability of this age group to pulmonary decompensation due to poor respiratory reserve, prolonged bed rest, and sepsis-related systemic inflammation. Wound infections (35.38%) and electrolyte imbalances (20%) further underscore the need for meticulous perioperative care and monitoring. Our findings align with the work of Schein and Gecelter (1990), who identified age, comorbidities, and delayed presentation as independent predictors of postoperative morbidity and mortality in elderly patients with abdominal sepsis. ^[15]

Surgical strategy in elderly patients is often dictated by the extent of contamination, patient physiology, and intraoperative findings. In our setting, damage control principles were frequently applied, including limited resections and temporary stoma creation in hemodynamically unstable or frail individuals. This approach aims to minimize surgical trauma while controlling sepsis, in line with the principles described in damage control laparotomy for high-risk patients.

Mortality in the elderly cohort was 13.84%, nearly 2.5 times higher than in the non-elderly (5.55%). This significant difference reiterates that age is a critical determinant of outcome in peritonitis, not merely due to chronological aging but because of the compounded effect of physiological decline, comorbidity, and delayed systemic response. Studies by Chalya et al. (2011) and Dorairajan et al. (1995) also reported higher mortality among older adults, further substantiating our findings. ^[16,17]

It is essential to recognize that elderly patients often present with atypical or muted symptoms, leading to diagnostic delays. Abdominal pain may be less intense, fever may be absent, and leukocytosis may be blunted, resulting in late recognition of peritonitis. Clinicians must maintain a high index of suspicion and expedite diagnostic imaging when elderly patients present with vague abdominal complaints or systemic deterioration.

Our study underscores the importance of multidisciplinary management, incorporating surgical, anesthetic, geriatric, and intensive care expertise. Early and aggressive fluid resuscitation, optimization of comorbid conditions, timely surgical intervention, and vigilant postoperative care are vital components in improving outcomes.

Limitations of our study include its single-center design and the relatively limited sample size of elderly patients, which may affect the generalizability of results. Additionally, long-term functional outcomes and quality-of-life assessments were not included, which could provide deeper insights into recovery trajectories in this population.

Gastrointestinal perforation peritonitis in the elderly is associated with a significantly higher rate of postoperative complications, ICU requirements, prolonged hospitalization, and mortality. This highlights the importance of a multidisciplinary approach involving geriatric care principles, preoperative optimization, careful intraoperative decision-making, and vigilant postoperative monitoring.

Enhancing awareness, promoting early healthcare-seeking behavior among elderly populations, and implementing targeted clinical pathways are crucial for improving outcomes in this vulnerable demographic.

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