2016 November-December; 37(6): 243–249. ISSN: 1971-145X
Published online 2017 March 29. doi: 10.11138/gchir/2016.37.6.243.

Mannheim Peritonitis Index (MPI) and elderly population: prognostic evaluation in acute secondary peritonitis


General and Emergency Surgery, “Policlinico Universitario P. Giaccone”, University of Palermo, Palermo, Italy

Corresponding author: Giuseppe Salamone, e-mail: giuseppe.salamone@unipa.it


Acute Secondary Peritonitis due to abdominal visceral perforation is characterized by high mortality and morbidity risk. Risk stratification allows prognosis prediction to adopt the best surgical treatment and clinical care support therapy. In Western countries elderly people represent a significant percentage of population

Evaluation of Mannheim Peritonitis Index (MPI) and consideration upon old people.

Patients and methods
Retrospective study on 104 patients admitted and operated for “Acute Secondary Peritonitis due to visceral perforation”. MPI was scored. In our study we want to demonstrate efficacy of MPI and the possibility to consider older age an independent prognostic factor.

Mortality was 25.96%. Greatest sensitivity and specificity for the MPI score as a predictor of mortality was at the score of 20. MPI score of <16 had 0.15 times lower risk of mortality compared to patients with MPI score 17 – 21 and 0.61 lower than patients with MPI >22. Patients with MPI score 17–21 had 0.46 times lower risk of mortality compared to patients with MPI score >21. In the group of patients with MPI score of >20 the mortality rate was 48.5% for patients older than 80 years old and 12.1% for younger patients (p < 0.005); in the group with MPI score of < 20 mortality rate was respectively 8.4% and 1.4% (p < 0.005).

Discussion and conclusions
Data confirm the accuracy of the test. MPI score and age over 80 years old resulted independent predictors of mortality at multivariate analysis.

Keywords: Evaluation, Score systems, Prognosis, Acute Secondary Peritonitis, Perforative peritonitis, High mortality risk, Mannheim Peritonitis Index (MPI), Elderly, Mortality


Acute secondary peritonitis represents the common presentation of gastro-intestinal perforation and the classification, in chemical and bacterial, is well known (1). Perforative peritonitis is linked with Multiple Organ Dysfunction Syndrome (MOFS) up to 73% and mortality rates is reaching 30% (2, 3). It remains a life-threatening condition, even though considerable progresses are done in diagnostic techniques, antibiotic therapies and surgical management. The prognosis remains poor despite development in management strategies. It is useful an early identification of patients with severe peritonitis in order to select them for intensive management (4).

Nonetheless, Western and industrialized countries are populated by old people (individuals older than 65 years are about 10%), and this percentage is estimated to grow-up with decades (5).

Clinical management of old people is more challenging for a lot of reasons linked to physiologic alterations shown by elderly population as the well defined cellular-immunological reaction changing to environmental interaction, together with frequent associated comorbidities (6).

Grading the severity of the peritonitis improves the management of severely ill patients.

Several scores have been proposed to identify risk factors of predictiveness due to perforative peritonitis mortality; frequently they seem to be complex to calculate or difficult to use outside intensive care units.

Main score-systems reported are the Acute Physiology and Chronic Health Evaluation score (APACHE II), Simplified Acute Phisiology Score (SAPS), Sepsis Severity Score (WSES) (7), Ranson Score, Peritonitis Index Altona (PIA), Sepsis Score and Physiological and Operative severity Score for enumeration of Mortality and Morbidity (POSSUM), Mannheim Peritonitis Index (MPI) (8, 9).

APACHE score is considered the best score-system in prognostic evaluation. Widely used in emergency, it has good correlation with perforative peritonitis mortality. It does not evaluate type of peritonitis and cause of perforation. Its use is suggested in ICU in 24h from injury (1012). MPI instead achieves the best in reliability on risks’ evaluation, allowing the prediction of the individual prognosis of patients with peritonitis (13, 14).

It was elaborated in 1980s in a German retrospective study and then validated. It collects data from clinical examination and surgical evidence, and it is precious into predict when to perform “aggressive treatment” and intensive care monitoring.

In MPI are taken into account 8 variables: age, sex, organ failure, diagnosis of carcinoma, preoperative duration of peritonitis, origin of sepsis, peritonitis extension, characteristics of exudate (14, 15).

Each of them are evaluated and scored obtaining a global score (Table 1).

Table 1Table 1

MPI considers age score evaluating it in higher and lower than 50 years old but nothing is said about the prognostic impact of older age on mortality. The evidence that older age is linked with poor prognosis in surgical pathologies suggests that it could be considered an independent prognostic factor in global evaluation of MPI.

In our study we want to demonstrate efficacy of MPI and the possibility to consider older age an independent prognostic factor, analysing a perforative peritonitis population with high percentage of older patients (1618).

Patients and methods

Retrospective study was performed recruiting 104 patients that underwent surgical operation for “Acute Secondary Peritonitis” from 2013 to 2015 in “A.O.U Policlinico Paolo Giaccone” – Palermo, Italy, General and Emergency Surgery. Anastomotic leak or perforation in patients recently operated were not included. Standardized pre-operative work-up was represented by record of signs and symptoms, laboratory evaluation, CT scan of abdomen, i.v. fluids, antibiotics, nasogastric decompression when indicated. Site of peritonitis secondary to perforation was diagnosed during surgery, and appropriate operation performed. Peritoneal lavage was given in all the cases and description of exudate performed. Resuscitation and ICU care was given when necessary.

Required data in order to rate MPI were collected during chart retrospective analysis and then compared between survivor and non-survivor groups. Informed consent was collected on hospitalization. Old age was evaluated as an independent prognostic factor.

Patients were divided into 3 age-range-groups: younger than 50 years old (y.o.), 50–80 years old, older than 80 years old.

Statistical analysis
Statistical analysis was done using PRIMIT Package for Win. t-Student test was used for intergroup comparisons; statistical significance was evaluated by means of chi-squared test for categorical variables. Risk Ratio and 95% confidence interval calculated for each group. ROC curve performed to identify the threshold value of MPI with higher sensitivity and specificity. The level of significance was fixed at p-value <0.05.

Predictiveness of MPI was tested through ROC curve, and statistic significance of every single MPI inclusion criteria performed in order to verify the relevance on prognosis.

Factors independently related to an increased risk of mortality were identified through logistic regression model.


The population included 104 patients with “Acute Secondary Peritonitis” that underwent surgical operation with a median age of 61.9 years (range 16–94). 36.5% were female, 63.5% male.

Co-morbidities were recorded for each patient with cases in which more than one pathology co-existed.

The ASA score was II in 33 cases (31.7%), III in 47 cases (45.2%), IV in 24 cases (23.1%).

Perforation sites were: appendix (n=17), gallbladder (n=21), stomach (n=15), ileus (n=11), cecum (n=6), sigma-rectum (n=23), colon (n=9).

Mortality rate was higher in colonic localization (55.5%), than stomach (46.6%), sigma-rectum (43.5%), cecum (33.3%) and ileus (27.3%).

Mortality wasn’t associated with appendix and gallbladder perforation although the elevate number of cases (n=17, n=21 respectively) (Table 2).

Table 2Table 2

Death occurred in 27 patients, 10 patients died of renal failure; 5 patients died of respiratory failure; 12 died of MOF.

Pre-operative peritonitis duration was over 24 h in 31.7% of patients. Exudate was described in 100% of cases with different characteristics: 67% cloudy/purulent, 18% faecal, 15% clear.

MPI was easily scored and categorized into 3 groups: MPI<16 in 36.6%; 17<MPI<21 in 31.7%; MPI>22 in 31.7%

Each MPI class was further divided in survivor and non-survivor group.

It was useful calculate probability to survive, RR and OR. In order to test the hypothesis that prognosis is independent by MPI group, it was calculated RR in 3 groups and it was compared between them.

The comparison between 1st and 2nd group proves the independence of prognosis.

It isn’t the same in the comparison between 1st – 3rd group and 2nd – 3rd group – where the probability to survive is 2.68 and 2.25 major respectively.

MPI score was analysed with the mortality. With highest sensitivity of 78% and specificity of 89% MPI score of 20 was taken as a threshold value for dichotomous analysis using ROC curve; the AUC of the ROC curve was 0.89 (Table 3).

Table 3Table 3

Statistical significance of every single risk factor used for MPI calculation was rated through t-Student test. p-value < 0.05 was considered statistically significant. Table 4 shows the results obtained by univariate analysis.

Table 4Table 4

At univariate analysis, age older than 80 years, number of pathologies, malignancy, generalized peritonitis and MPI score resulted associated to increased risk of mortality.

Including MPI score and age over 80 years old in a logistic regression model, they resulted independent predictors of mortality at multivariate analysis.

ROC curve was further updated eliminating that factors with non significant p-value. The re-calculated ROC curve shows higher accuracy in evaluation of prognosis with MPI cut-off of 13 (AUC = 0.96) (Table 5).

Table 5Table 5

In the group of patients with MPI score of >20 the mortality rate was 48.5% for patients older than 80 years old and 12.1% for younger patients (p < 0.005); in the group with MPI score of < 20 mortality rate was respectively 8.4% and 1.4% (p < 0.005) (Tables 6, 7).

Table 6Table 6
Table 7Table 7

Discussion and conclusions

“Acute Secondary Peritonitis due to abdominal visceral perforation” is characterized by high mortality and morbidity risk that increases with sepsis and MOF. The early classification of seriousness and risk stratification allows prognosis prediction to be able to adopt the best surgical treatment and clinical care support therapy.

Mortality rate is estimated from 13 to 43%. Mortality rate in our series was 25.9% Prognosis depends on interaction of performance-status, etiology, diagnostic therapeutic strategies and use of immunomodulators. It is well known the correlations between pharmacological strategies, such as in Crohn’s disease, and the risk to develop rare tumors or complications such as bowel perforation. Bowel herniation also represents a risk factor of perforation (1937). Multiple Organ Failure (MOF) represents the fatal evolution of the peritonitis (4). In Western countries, the increasing number of older patients worsen the prognosis of surgical pathologies often also for relevant comorbidities presence (38).

In literature are reported numerous score-systems for prediction of peritonitis mortality risk in order to consider the efficacy of surgical options compared between them, or to identify possible post-operative complications (4, 5). According with the literature, MPI is an independent, objective and effective scoring system in predicting mortality evaluating single risk factors (1012).

It was tested the prognostic value of MPI; the data confirm the accuracy of the test as reported in international literature.

In our study patients with MPI scores of <16; 17 – 21; >22 had a mortality of 2.6%, 18% and 64% respectively. Greatest sensitivity and specificity for the MPI score as a predictor of mortality was at the score of 20. At this value we found a sensitivity of 78% and a specificity of 89%.

The risk of mortality based on MPI score was done comparing the 3 groups considered.

Patients with MPI score <16 had 0.15 times lower risk of mortality compared to patients with MPI score 17 – 21 and 0.61 lower than patients with MPI >22. Patients with MPI score 17–21 had 0.46 times lower risk of mortality compared to patients with MPI score >21.

This suggests increasing risk of mortality with increasing MPI score. The analysis of risk factors for MPI calculation shows the possibility to create a “short MPI”, evaluating the only variables with p<0.05 in our series. This allows to identify a new MPI value of 13 as score of best sensitivity and specificity.

The mortality for patients with MPI > 20 and over 80 years old was of 48.5% than 12.1% of younger patients. Patients with MPI < 20 and over 80 years old had a mortality risk of 8.4% than 1.4% of younger. MPI score and age over 80 years old resulted independent predictors of mortality at multivariate analysis.

The study confirmed the prognostic value of MPI index in Acute Secondary Peritonitis. Age older than 80 years old showed to be an independent risk factor of mortality evident both in low and high MPI score. Evaluation of Age and MPI should be taken into account in the choice of which surgical operation to perform and if to realize intensive post-operative care.


To Dr. Cacioppo Emanuele, University of Palermo, that provided statistical analysis help.

Sartelli M, Abu-Zidan FM, Ansaloni L, Bala M, Beltrán MA, Biffl WL, Catena F, Chiara O, Coccolini F, Coimbra R, Demetrashvili Z, Demetriades D, Diaz JJ, Di Saverio S, Fraga GP, Ghnnam W, Griffiths EA, Gupta S, Hecker A, Karamarkovic A, Kong VY, Kafka-Ritsch R, Kluger Y, Latifi R, Leppaniemi A, Lee JG, McFarlane M, Marwah S, Moore FA, Ordonez CA, Pereira GA, Plaudis H, Shelat VG, Ulrych J, Zachariah SK, Zielinski MD, Garcia MP, Moore EE. The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper. World J Emerg Surg. 2015 Aug 12;10:35. doi:10.1186/s13017-015-0032-7. eCollection 2015.
Barie PS, Hydo LJ, Fisher E. Development of multiple organ dysfunction syndrome in critically ill patients with perforated viscus. Predictive value of APACHE severity scoring. Arch Surg. 1996;131:37e43.
Bohnen JM, Mustard RA, Oxholm SE, Schouten BD. APACHE II score and abdominal sepsis. A prospective study. Arch Surg. 1988;123:225e229.
Srinivasarangan M, et al. Efficacy of Mannheim Peritonitis Index (MPI) Score in Patients with Secondary Peritonitis. J Clin Diagn Res. 2014 Dec;8(12):NC01–3. doi:10.7860/JCDR/2014/8609.5229. Epub 2014 Dec 5.
Crossley KB, Peterson PK. Infections in the elderly. Clin Infect Dis. 1996;22:209e215.
Podnos YD, Jimenez JJ, Wilson SE. Intra-abdominal sepsis in elderly persons. Clin Infect Dis. 2002;35:62e68.
Sartelli M, Abu-Zidan FM, Catena F, Griffiths EA, Di Saverio S, Coimbra R, Ordoñez CA, Leppaniemi A, Fraga GP, Coccolini F, Agresta F, Abbas A, Abdel Kader S, Agboola J, Amhed A, Ajibade A, Akkucuk S, Alharthi B, Anyfantakis D, Augustin G, Baiocchi G, Bala M, Baraket O, Bayrak S, Bellanova G, Beltràn MA, Bini R, Boal M, Borodach AV, Bouliaris K, Branger F, Brunelli D, Catani M, Che Jusoh A, Chichom-Mefire A, Cocorullo G, Colak E, Costa D, Costa S, Cui Y, Curca GL, Curry T, Das K, Delibegovic S, Demetrashvili Z, Di Carlo I, Drozdova N, El Zalabany T, Enani MA, Faro M, Gachabayov M, Giménez Maurel T, Gkiokas G, Gomes CA, Gonsaga RA, Guercioni G, Guner A, Gupta S, Gutierrez S, Hutan M, Ioannidis O, Isik A, Izawa Y, Jain SA, Jokubauskas M, Karamarkovic A, Kauhanen S, Kaushik R, Kenig J, Khokha V, Kim JI, Kong V, Koshy R, Krasniqi A, Kshirsagar A, Kuliesius Z, Lasithiotakis K, Leão P, Lee JG, Leon M, Lizarazu Pérez A, Lohsiriwat V, López-Tomassetti Fernandez E, Lostoridis E, Mn R, Major P, Marinis A, Marrelli D, Martinez-Perez A, Marwah S, McFarlane M, Melo RB, Mesina C, Michalopoulos N, Moldovanu R, Mouaqit O, Munyika A, Negoi I, Nikolopoulos I, Nita GE, Olaoye I, Omari A, Ossa PR, Ozkan Z, Padmakumar R, Pata F, Pereira GA Junior, Pereira J, Pintar T, Pouggouras K, Prabhu V, Rausei S, Rems M, Rios-Cruz D, Sakakushev B, Sánchez de Molina ML, Seretis C, Shelat V, Simões RL, Sinibaldi G, Skrovina M, Smirnov D, Spyropoulos C, Tepp J, Tezcaner T, Tolonen M, Torba M, Ulrych J, Uzunoglu MY, van Dellen D, van Ramshorst GH, Vasquez G, Venara A, Vereczkei A, Vettoretto N, Vlad N, Yadav SK, Yilmaz TU, Yuan KC, Zachariah SK, Zida M, Zilinskas J, Ansaloni L. Global validation of the WSES Sepsis Severity Score for patients with complicated intra-abdominal infections: a prospective multicentre study (WISS Study). World J Emerg Surg. 2015 Dec 16;10:61. doi:10.1186/s13017-015-0055-0. eCollection 2015.
Kologlu M, Elker D, Altun H, Sayek I. Validation of MPI and PIA II in two different groups of patients with secondary peritonitis. Hepatogastroenterology. 2001 Jan–Feb;48(37):147–51.
Bosscha K, Reijnders K, Hulstaert PF, Algra A, van der Werken C. Prognostic scoring systems to predict outcome in peritonitis and intra-abdominal sepsis. Br J Surg. 1997 Nov;84(11):1532–4.
Malik AA, Wani KA, Dar LA, Wani MA, Wani RA, Parray FQ. Mannheim Peritonitis Index and APACHE II-prediction of outcome in patients with peritonitis. Ulus Travma Acil Cerrahi Derg. 2010 Jan;16(1):27–32.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985 Oct;13(10):818–29.
Billing A, Fröhlich D, Schildberg FW. Prediction of outcome using the Mannheim peritonitis index in 2003 patients. Peritonitis Study Group. Br J Surg. 1994 Feb;81(2):209–13.
Wacha H, Linder MM, Feldman U, Wesch G, Gundlach E, Steifensand RA. Mannheim peritonitis index – prediction of risk of death from peritonitis: construction of a statistical and validation of an empirically based index. Theoretical Surg. 1987;1:169–77.
Notash AY, Salimi J, Rahimian H, Fesharaki Ms, Abbasi A. Evaluation of Mannheim peritonitis index and multiple organ failure score in patients with peritonitis. Indian J Gastroenterol. 2005 Sep–Oct;24(5):197–200.
Biondo S, Ramos E, Fraccalvieri D, Kreisler E, Ragué JM, Jaurrieta E. Comparative study of left colonic Peritonitis Severity Score and Mannheim Peritonitis Index. Br J Surg. 2006 May;93(5):616–22.
Tan KK, Bang SL, Sim R. Surgery for small bowel perforation in an Asian population: predictors of morbidity and mortality. J Gastrointest Surg. 2010;14:493e499.
Tan KK, Hong CC, Zhang J, Liu JZ, Sim R. Predictors of outcome following surgery in colonic perforation: an institution’s experience over 6 years. J Gastrointest Surg. 2011;15:277e284.
Makela JT, Kiviniemi H, Laitinen S. Prognostic factors of perforated sigmoid diverticulitis in the elderly. Dig Surg. 2005;22:100e106.
Di Carlo P, Di Vita G, Guadagnino G, Cocorullo G, D’Arpa F, Salamone G, Salvatore Buscemi, Gulotta G, Cabibi D. Surgical pathology and the diagnosis of invasive visceral yeast infection: two case reports and literature review. World Journal of Emergency Surgery. 2013;8:38.
Guercio G, Tutino R, Falco N, Cocorullo G, Salamone G, Licari L, Cabibi D, Bagarella N, Gulotta G. Solitary metastasis from melanoma causing bowel perforation. Ann Ital Chir. 2015 Nov;26:86. (ePub). pii: S2239253X15024287.
Cappello M, Randazzo C, Peralta S, Cocorullo G. Subcutaneous emphysema, pneumomediastinum and pneumoperitoneum after diagnostic colonoscopy for ulcerative colitis: a rare but possible complication in patients with multiple risk factors. Int J Colorectal Dis. 2011 Mar;26(3):393–4. doi:10.1007/s00384-010-1005-7. Epub 2010 Jul 9.
Salamone G, Falco N, Atzeni J, Tutino R, Licari L, Gulotta G. Colonic stenting in acutely obstructed left-sided colon cancer Clinical evaluation and cost analysis. Ann Ital Chir. 2014 Nov–Dec;85(6):556–62.
Cappello M, Bravatà I, Cocorullo G, Cacciatore M, Florena AM. Splenic Littoral Cell Hemangioendothelioma in a Patient With Crohn’s Disease Previously Treated With Immunomodulators and Anti-TNF Agents: A Rare Tumor Linked to Deep Immu-nosuppression. Am J Gastroenterol. 2011;106:1863–1865. doi:10.1038/ajg.2011.204.
Amato G, Romano G, Agrusa A, Cassata G, Salamone G, Gulotta G. Prosthetic strap system for simplified ventral hernia repair: results of a porcine experimental model. Hernia. 2010 Aug;14(4):389–95. doi:10.1007/s10029-010-0650-7. Epub 2010 Mar 24.
Amato G, Agrusa A, Romano G, Salamone G, Gulotta G, Silvestri F, Bussani R. Muscle degeneration in inguinal hernia specimens. Hernia. 2012 Jun;16(3):327–31. doi:10.1007/s10029-011-0890-1. Epub 2011 Oct 21.
Cocorullo G, Tutino R, Falco N, Salamone G, Gulotta G. Three-port colectomy: reduced port laparoscopy for general surgeons. A single center experience. Ann Ital Chir. 2016 Mar;10:87. pii: S0003469X16024891. (Epub ahead of print).
Salamone G, Licari L, Agrusa A, Romano G, Cocorullo G, Falco N, Tutino R, Gulotta G. Usefulness of ileostomy defunctioning stoma after anterior resection of rectum on prevention of anastomotic leakage A retrospective analysis. Ann Ital Chir. 2016;87:155–60.
Salamone G, Licari L, Agrusa A, Romano G, Cocorullo G, Gulotta G. Deep seroma after incisional hernia repair. Case reports and review of the literature. Ann Ital Chir. 2015 May;12:86. (ePub). pii: S2239253X15022938.
Agrusa A, Romano G, Cucinella G, Cocorullo G, Bonventre S, Salamone G, Di Buono G, De Vita G, Frazzetta G, Chianetta D, Sorce V, Bellanca G, Gulotta G. Laparoscopic, three-port and SILS cholecystectomy: a retrospective study. G Chir. 2013 Sep–Oct;34(9–10):249–53.
Agrusa A, Frazzetta G, Chianetta D, Di Giovanni S, Gulotta L, Di Buono G, Sorce V, Romano G, Gulotta G. “Relaparoscopic” management of surgical complications: The experience of an Emergency Center. Surg Endosc. 2016;30:2804. doi:10.1007/s00464-015-4558-2.
Agrusa A, Romano G, Chianetta D, De Vita G, Frazzetta G, Di Buono G, Sorce V, Gulotta G. Right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literature review. World Journal of Emergency Surgery. 2014;9:33. doi:10.1186/1749-7922-9-33.
Agrusa A, Romano G, Lo Re G, Di Buono G, Vernuccio F, Galfano MC, Midiri F, Gulotta G. Hemoperitoneum following mild blunt abdominal trauma: First presentation of Crohn’s disease. Acta Medica Mediterranea. 2014;30(2):315–318.
Amato G, Romano G, Salamone G, Agrusa A, Saladino VA, Silvestri F, Bussani R. Damage to the vascular structures in inguinal hernia specimens. Hernia. 2012 Feb;16(1):63–7. doi:10.1007/s10029-011-0847-4. Epub 2011 Jul 8.
Salamone G, Atzeni J, Agrusa A, Gulotta G. A rare case of abdominal cocoon. Ann Ital Chir. 2013 Oct;5:84. (ePub). pii: S2239253X13021531.
Amato G, Agrusa A, Romano G, Salamone G, Cocorullo G, Mularo SA, Marasa S, Gulotta G. Histological findings in direct inguinal hernia: investigating the histological changes of the herniated groin looking forward to ascertain the pathogenesis of hernia disease. Hernia. 2013 Dec;17(6):757–63. doi:10.1007/s10029-012-1032-0. Epub 2013 Jan 4.
Salamone G, Licari L, Atzeni J, Tutino R, Gulotta G. Histologic considerations about a rare case of recurrent incisional hernia on McBurney incision. Ann Ital Chir. 2014 Dec;3:85. (ePub). pii: S2239253X14022828.
Agrusa A, Romano G, Di Buono G, Dafnomili A, Gulotta G. Laparoscopic approach in abdominal emergencies: a 5-year experience at a single center. G Chir. 2012;33(11–12):400–403.
Neri A, Marrelli D, Scheiterle M, Di Mare G, Sforza S, Roviello F. Re-evaluation of Mannheim prognostic index in perforative peritonitis: prognostic role of advanced age. A prospective cohort study. Int J Surg. 2015 Jan;13:54–9. doi:10.1016/j.ijsu.2014.11.035. Epub 2014 Dec 2.