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Review
. 2025 Sep 24;17(9):e93101.
doi: 10.7759/cureus.93101. eCollection 2025 Sep.

Risk Stratification Tools and Scoring Systems in Perforated Viscus: A Systematic Review

Murhaf Assaf  1 , Shrey K Solanki  2 , Ridham N Patel  3 , Kinza Ali  4   5 , Miqdad Qandeel  6 , Nimrah Majeed  7 , Shabeh E Roshan Ali  8 , Mazin Osman  9 , Kiranjot Kaur  10   11   12 , Shahid Khan  13
Affiliations
Review

Risk Stratification Tools and Scoring Systems in Perforated Viscus: A Systematic Review

Murhaf Assaf et al. Cureus. .

Abstract

Perforated viscus remains a high-risk surgical emergency with significant mortality despite advances in perioperative care. Accurate risk stratification is essential to guide triage, surgical decision-making, and postoperative management. The available scoring tools are the Boey score (three-variable risk model: shock, comorbidity, delay >24 hours), Peptic Ulcer Perforation (PULP) score, Mannheim Peritonitis Index (MPI), Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM), and Acute Physiology and Chronic Health Evaluation II (APACHE-II), each addressing different dimensions of patient risk, ranging from physiological stability to intra-abdominal severity. Simpler models such as Boey and MPI are valuable in emergency and resource-limited settings due to their bedside applicability. In contrast, PULP and APACHE-II offer greater precision by integrating systemic comorbidities and biochemical indices, making them more suitable for tertiary centers. POSSUM provides a balanced approach by combining physiology with operative severity, though it may overestimate mortality. No single model is universally applicable, highlighting the need for context-specific use. Future research should focus on hybrid scoring systems that merge clinical simplicity with modern predictive analytics for broader global relevance.

Keywords: apache-ii; mannheim peritonitis index; perforated viscus; possum; risk stratification; scoring systems.

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Conflict of interest statement

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. PRISMA flow diagram
PRISMA, Preferred Reporting Items for Systematic reviews and Meta-Analyses
See this image and copyright information in PMC

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