Background: Initiation of early appropriate antibiotic therapy influences the outcome of perforation peritonitis, which otherwise is delayed till culture reports are available. The knowledge of microbial profile and sensitivity of peritoneal fluid culture with respect to the anatomical site of perforation peritonitis will help in initiation of early appropriate antibiotic therapy in the post-operative period.Methods: A cross-sectional study conducted from January 2017 to December 2017 where intraoperative peritoneal fluid sample in patients of perforation peritonitis was subjected to culture (aerobic and anaerobic) and sensitivity and results analysed with respect to anatomical site of perforation.Results: 50 patients were studied. The most common site of perforation was ileum (32%) followed by appendix (18%) and stomach (18%). In aerobic culture, the culture positivity rate was highest in colonic perforation (100%) and least in gastric perforation (44.4%). The most common organism isolated in all sites of perforation peritonitis was E. coli followed by Klebsiella spp. In anaerobic culture, although facultative anaerobes were isolated, no strict anaerobe was isolated. The most sensitive antibiotics covering all isolated organisms were gentamycin (p=0.006), colistin (p=0.018), piperacillin and tazobactum (p=0.022).Conclusions: The predominant differential normal flora according to site of gastrointestinal tract was not reflected in the peritoneal fluid culture of patients with perforation peritonitis and E. coli was the most common organism isolated in all sites of perforation peritonitis. The antibiotic sensitivity profile showed the increasing resistance against third generation cephalosporins. Aminoglycosides, piperacillin and tazobactum, meropenem and colistin showed a significant antimicrobial activity against organisms isolated from cases of perforation peritonitis.

INTRODUCTION: Groove pancreatitis(GP) is a rare special form of chronic pancreatitis localised to pancreaticoduodenal groove, presents commonly with signs and symptoms of duodenal obstruction, mimicks pancreatic cancer radiologically and the surgeon proceeds with inadvertent whipples procedure. PRESENTATION OFCASE: A28yr old gentleman, alcoholic presented with duodenal obstruction for 3days. CECTabdomen was suggestive of exophytic lesion from second part of duodenum ?duodenal diverticulum. UGIE showed large growth with overlying abnormal mucosa causing luminal compromise in second part of duodenum. Biopsy was taken which showed normal villous pattern. Patient was managed conservatively and improved gradually. On further evaluation, EUS showed 5×5.5cm cystic space occupying lesion in close relation to second part of duodenum and head of pancreas ?origin. EUS guided FNAC showed features suggestive of adenocarcinoma. With this pathological diagnosis, patient was taken up for Whipple's procedure, intraoperatively, 3cm mass lesion was noted in the pancreaticoduodenal groove. HPE of the specimen showed a haemorraghic nodule (3×1.8×1.2cm) in the duodenal wall and changes of chronic pancreatitis in the pancreticoduodenal groove suggestive of GP. Postoperative period and follow up of 6 months was uneventful. DISCUSSION: In GP, EUS guided FNAC may reveal large gaint cells, spindle cells or hyperplasia of brunner glands depending on the area of sampling and these features mimic neoplasia as observed in our case. MRI criteria given by Kalb et al show diagnostic accuracy of 87.2% for GP and negative predictive value of 92.9% to rule out pancreatic cancer. Arvanitakis et al showed stepwise management approach is effective in GP and with combination of medical and endoscopic treatment, complete clinical response rate was observed in 80%. CONCLUSION: It is important to diagnose and differentiate GP from pancreatic cancer preoperatively and avoid morbidity from unnecessary pancreaticoduodenectomy in patients of GP.

Candida is a commensal found even in the gut of healthy individuals and varying rate of incidence have been reported in autopsy studies. Pathological role of Candida is rarely seen in stomach and first part of duodenum as low pH and commensal bacteria inhibits its growth. Any imbalance in these factors or immunocompromised status can lead to fungal overgrowth. Most of the cases of duodenal perforation are seen as the complications of H. pylori infection, due to the intake of non-steroidal anti-inflammatory drugs (NSAIDS) or traumatic/iatrogenic. Authors are reporting first case of a 35year old male who presented with duodenal perforation peritonitis with perforation edge biopsy revealing the presence of fungal hyphae. Fungal microorganisms as a cause of duodenal perforation per se, is very rare.

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