Looking for global standards of care in patients with acute peritonitis


The world’s burden of emergency surgery diseases is significant and appears to be increasing. Emergency services and acute surgical care constitute a major gap in the focus of the health sector worldwide, and several issues need to be addressed in order to promote a global dialogue on what is the most appropriate way to configure acute care surgery worldwide. Although variations in the spectrum of surgical diseases are observed among and within countries, “essential” surgery and anaesthesia in emergency should be viewed as a core group of services that can be delivered within the context of universal access. Particularly for the rural populations in low- and middle-income countries (LMICs), there are enormous gaps in access to life-saving and disability-preventing surgical services. Furthermore, many hospitals continue to have logistic barriers associated with the application of evidence-based practice. This may lead to an overall poorer adherence to international guidelines, making them impractical to a large part of the world’s population.

In many countries worldwide, a large proportion of patients with diffuse peritonitis still present to the hospital with unacceptable delay. This event reduces the percentage of surviving at the lowest rates in the world. In emergency departments of limited-resource hospitals, the diagnosis of acute peritonitis is mainly clinical; supported by basic laboratory tests like full blood count (complete blood count). Ultrasonography is sometimes done to aid diagnosis, if available. Therefore, the clinician has to improve clinical diagnosis by looking carefully for those signs and symptoms. In rural and remote areas of LMICs, diagnostic imaging is often insufficient, and in some instances, completely lacking. In recent years, ultrasound use has increased worldwide, facilitated by ultrasound machines becoming smaller, more reliable, and less expensive. Ultrasound is reproducible and can be easily repeated, but remains highly user-dependent, and thus, experience should be taken into account for diagnostic accuracy and reliability. CT may be very useful especially when the diagnosis is uncertain. In high-income countries, it has become the gold standard, however it is inaccessible to many people worldwide.

Though all surgeons worldwide now share the concerns of the increasing incidence of injury-related surgical conditions, the challenges of surgical infections are not of the same nature in various regions of the world. Surgeons working in some areas of the world will most likely face the difficult problem of nosocomial infections in the context of increasing antibiotics resistance and its estimated 10 million yearly deaths. Meanwhile surgeons working in other areas of the world will often manage peptic ulcer or typhoid fever related bowel perforations (two conditions which are now considered surgical curiosity in the north). To manage these cases, he will likely still use a major open abdominal incision, in the absence of an intensive care unit, without basic imaging tools and laparoscopic facilities. His choice of antibiotics will probably be narrow.

Our aim is to promote global standards of care