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{{Peritonitis}}
{{Peritonitis}}
{{CMG}}
{{CMG}} {{AE}} {{SCh}}
 
==Overview==
==Overview==
Peritonitis may be classified according to the etiology into 3 subtypes: primary, secondary, and tertiary peritonitis.
==Classification==
==Classification==
There are three specific types of peritonitis:
 
* '''Spontaneous peritonitis''': [[Spontaneous peritonitis]] is usually caused by [[ascites]], a collection of fluid in the[[peritoneal cavity]]. This usually occurs from [[liver]] or [[kidney failure]].
=== Classification Based on Etiology ===
* '''Secondary peritonitis''':[[Secondary peritonitis]] is an [[inflammation]] of the [[peritoneum]], the tissue lining the[[abdominal cavity]]. Secondary means it is due to another condition, most commonly the spread of an [[infection]] from the [[digestive tract]].
Peritonitis is classified based on the cause of the inflammatory process and the character of microbial contamination as follows:<ref name="pmid8678610">{{cite journal| author=Wittmann DH, Schein M, Condon RE| title=Management of secondary peritonitis. | journal=Ann Surg | year= 1996 | volume= 224 | issue= 1 | pages= 10-8 | pmid=8678610 | doi= | pmc=1235241 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8678610  }} </ref><ref name="pmid9451931">Nathens AB, Rotstein OD, Marshall JC (1998) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9451931 Tertiary peritonitis: clinical features of a complex nosocomial infection.] ''World J Surg'' 22 (2):158-63. PMID: [https://pubmed.gov/9451931 9451931]</ref><ref name="pmid24812458">Mishra SP, Tiwary SK, Mishra M, Gupta SK (2014) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=24812458 An introduction of Tertiary Peritonitis.] ''J Emerg Trauma Shock'' 7 (2):121-3. [http://dx.doi.org/10.4103/0974-2700.130883 DOI:10.4103/0974-2700.130883] PMID: [https://pubmed.gov/24812458 24812458]</ref>
* '''Dialysis associated peritonitis''': [[Dialysis-associated peritonitis]] is [[inflammation]] of the lining of the [[abdominal cavity]] ([[peritoneum]]), which occurs in those who receive [[peritoneal dialysis]].
{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Peritonitis}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01='''Primary peritonitis'''|C02='''Secondary peritonitis'''|C03='''Tertiary peritonitis'''}}
{{familytree | | |!| | | | | | |!| | | | | | |!| }}
{{familytree |boxstyle=text-align: left; | | B01 | | | | | |!| | | | | | B02 |B01= ❑ Spontaneous peritonitis<br>❑ Peritonitis in patients with CAPD<br>❑ Tuberculous peritonitis |B02= ❑ Peritonitis without evidence for pathogens<br>❑ Peritonitis with fungi<br>❑ Peritonitis with low-grade pathogenic bacteria}}
{{familytree | | | | |,|-|-|-|-|+|-|-|-|-|.| | | | | }}
{{familytree | | | | |!| | | | |!| | | | |!| | | | | | }}
{{familytree |boxstyle=text-align: left; | | | | D02 | | | D03 | | | D04 | | |D02='''Acute perforation peritonitis'''<br>❑ Gastrointestinal perforation<br>❑ Intestinal ischemia<br>❑ Pelviperitonitis and other forms|D03='''Postoperative peritonitis'''<br>❑ Anastomotic leak<br>❑ Accidental perforation and devascularization|D04='''Post-traumatic peritonitis'''<br>❑ After blunt abdominal trauma<br>❑ After penetrating abdominal trauma}}
{{familytree | | | | | | | | | | | | | | | | | | | }}
{{familytree/end}}
 
=== Classification Based on Ascitic Fluid Analysis ===
Peritonitis is classified as follows based ascitic fluid analysis:<ref name="pmid25819304">Dever JB, Sheikh MY (2015) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=25819304 Review article: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention.] ''Aliment Pharmacol Ther'' 41 (11):1116-31. [http://dx.doi.org/10.1111/apt.13172 DOI:10.1111/apt.13172] PMID: [https://pubmed.gov/25819304 25819304]</ref>
 
{| border="2" cellpadding="4" cellspacing="0" style="margin: 1em 1em 1em 0; background: #f9f9f9; border: 1px #aaa solid; border-collapse: collapse;" width="75%"
! '''Variants of Spontaneous bacterial peritonitis (SBP)''' !! '''Ascitic fluid analysis and other information'''
|-
| '''SBP culture postive'''
|
* PMNs ≥250 cells/mm3 and culture positivity usually for a single organism
 
* Patients with cirrhosis and ascites in the presence or absence of symptoms and signs
|-
|'''Culture-negative neutrocytic ascites'''(CNNA) or '''culture-negative SBP'''<ref name="pmid6500513">{{cite journal| author=Runyon BA, Hoefs JC| title=Culture-negative neutrocytic ascites: a variant of spontaneous bacterial peritonitis. | journal=Hepatology | year= 1984 | volume= 4 | issue= 6 | pages= 1209-11 | pmid=6500513 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6500513  }} </ref>
|
* PMNs ≥250 cells/mm3 and culture negativity
* Poor culture technique and prior antibiotics or low opsonic activity in ascitic fluid. Commonly encountered phenotype and requires antibiotic therapy
|-
| '''Monomicrobial bacterascites'''<ref name="pmid2210672">{{cite journal| author=Runyon BA| title=Monomicrobial nonneutrocytic bacterascites: a variant of spontaneous bacterial peritonitis. | journal=Hepatology | year= 1990 | volume= 12 | issue= 4 Pt 1 | pages= 710-5 | pmid=2210672 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2210672  }} </ref>
|
* PMNs <250 cells/mm3 and culture positivity for a single organism
* Ascitic fluid infection which may resolve spontaneously or progress to SBP. Similar mortality to SBP and should be treated the same
|-
|
|
|-
! '''Other varieties of ascitic fluid infections''' !! '''Ascitic fluid analysis and other information'''
|-
|'''Polymicrobial bacterascites'''<ref name="pmid3778046">{{cite journal| author=Runyon BA, Hoefs JC, Canawati HN| title=Polymicrobial bacterascites. A unique entity in the spectrum of infected ascitic fluid. | journal=Arch Intern Med | year= 1986 | volume= 146 | issue= 11 | pages= 2173-5 | pmid=3778046 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3778046  }} </ref>
|
* PMNs <250 cells/mm3 and culture positivity (polymicrobial)
 
* Needle perforation
|-
|'''Secondary peritonitis'''
|
* PMNs ≥250 cells/mm3 and culture positivity (polymicrobial)
 
* Intraperitoneal source of infection, e.g. diverticulitis
|}<br clear="left" />
 
=== Classification Based on Clinical Setting ===
Peritonitis is classified as follows based ascitic fluid analysis:<ref name="pmid25819304">Dever JB, Sheikh MY (2015) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=25819304 Review article: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention.] ''Aliment Pharmacol Ther'' 41 (11):1116-31. [http://dx.doi.org/10.1111/apt.13172 DOI:10.1111/apt.13172] PMID: [https://pubmed.gov/25819304 25819304]</ref>
{| border="2" cellpadding="4" cellspacing="0" style="margin: 1em 1em 1em 0; background: #f9f9f9; border: 1px #aaa solid; border-collapse: collapse;" width="75%"
! '''Clinical varient of Spontaneous bacterial peritonitis''' !! '''Explanation'''
|-
| '''Health care-associated SBP (HCA)'''
|
* Diagnosis of peritonitis within 48 hours of hospital admission in patients with any prior health care contact in the past 90 days (e.g. recent hospitalisation, nursing home, dialysis centres and other health care setting).
|-
| '''Nosocomial SBP'''
|
* Diagnosis of peritonitis 48 hours after the hospital admission.
|-
| '''Community acquired SBP (CA)'''
|
* Diagnosis of peritonitis within 48 hours of hospital admission, but no history of prior health care contact in the past 90 days.
|-
| '''Multi-drug resistant SBP'''
|
* Associate with prior history of antibiotic exposure and treat peritonitis based on culture sensitivities.
|-
| '''Recurrent SBP'''
|
* Recurrent episodes of peritonitis increases risk of mortality compared to first episode mortality of SBP. Prophylactic antibiotics can reduce the mortality.
|}<br clear="left" />
 
=== Classification Based on the clinical view point===
Peritonitis may be classified based on the prognosis into the following types:<ref name="pmid16060697">{{cite journal| author=Blot S, De Waele JJ| title=Critical issues in the clinical management of complicated intra-abdominal infections. | journal=Drugs | year= 2005 | volume= 65 | issue= 12 | pages= 1611-20 | pmid=16060697 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16060697  }} </ref>
*'''Uncomplicated''': In uncomplicated peritonitis, the infection only involves a single organ and no anatomical disruption is present. Usually, patients with such infections can be managed with surgical resection alone and no antimicrobial therapy besides peri-operative prophylaxis is necessary.
*'''Complicated''':The infectious process proceeds beyond the organ that is the source of the infection, and causes either ''localised'' peritonitis, also referred to as abdominal abscess, or ''diffuse'' peritonitis, depending on the ability of the host to contain the process within a part of the abdominal cavity.They are the important cause of morbidity and more frequently associated with poor prognosis.However, an early clinical diagnosis, followed by adequate source control to stop ongoing contamination and restore anatomical structures and physiological function, as well as prompt initiation of appropriate empirical therapy, can limit the associated mortality.
 
===Classification based on the etiological agents===
* Peritonitis, caused by enteric organisms such as E.coli, Klebsiella, staphylococci, streptococci, anaerobes.
* Peritonitis, caused by bacteria residing out of GI tract such as gonococci, pneumococci.
* Aseptic peritonitis resulting from irritation of the peritoneal cavity from the extravasation of fluids such as blood, gastric juice.
 
===Classification according to the extension of inflammatory process===
* Local:
* Diffuse:
* Generalized:
 
===Classification based on the pathological alterations in the clinical course of peritonitis===
* Reactive: In the first 24 hours when there are maximal manifestations of local signs of peritonitis.
* Toxic: In 24-72 hours, when there is increased general intoxication with a gradual reduction in the local signs of peritonitis.
* Terminal: It is often the severe stage of peritonitis, usually after 72 hours characterized by irreversible intoxication in the background of a sharply expressed local manifestations of peritonitis.


==References==
==References==
{{reflist|2}}
{{reflist|2}}


 
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Latest revision as of 15:03, 30 January 2017

Peritonitis Main Page

Patient Information

Overview

Causes

Classification

Spontaneous Bacterial Peritonitis
Secondary Peritonitis

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shivani Chaparala M.B.B.S [2]

Overview

Peritonitis may be classified according to the etiology into 3 subtypes: primary, secondary, and tertiary peritonitis.

Classification

Classification Based on Etiology

Peritonitis is classified based on the cause of the inflammatory process and the character of microbial contamination as follows:[1][2][3]

 
 
 
 
 
 
 
 
Peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary peritonitis
 
 
 
 
Secondary peritonitis
 
 
 
 
Tertiary peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Spontaneous peritonitis
❑ Peritonitis in patients with CAPD
❑ Tuberculous peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
❑ Peritonitis without evidence for pathogens
❑ Peritonitis with fungi
❑ Peritonitis with low-grade pathogenic bacteria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute perforation peritonitis
❑ Gastrointestinal perforation
❑ Intestinal ischemia
❑ Pelviperitonitis and other forms
 
 
Postoperative peritonitis
❑ Anastomotic leak
❑ Accidental perforation and devascularization
 
 
Post-traumatic peritonitis
❑ After blunt abdominal trauma
❑ After penetrating abdominal trauma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Classification Based on Ascitic Fluid Analysis

Peritonitis is classified as follows based ascitic fluid analysis:[4]

Variants of Spontaneous bacterial peritonitis (SBP) Ascitic fluid analysis and other information
SBP culture postive
  • PMNs ≥250 cells/mm3 and culture positivity usually for a single organism
  • Patients with cirrhosis and ascites in the presence or absence of symptoms and signs
Culture-negative neutrocytic ascites(CNNA) or culture-negative SBP[5]
  • PMNs ≥250 cells/mm3 and culture negativity
  • Poor culture technique and prior antibiotics or low opsonic activity in ascitic fluid. Commonly encountered phenotype and requires antibiotic therapy
Monomicrobial bacterascites[6]
  • PMNs <250 cells/mm3 and culture positivity for a single organism
  • Ascitic fluid infection which may resolve spontaneously or progress to SBP. Similar mortality to SBP and should be treated the same
Other varieties of ascitic fluid infections Ascitic fluid analysis and other information
Polymicrobial bacterascites[7]
  • PMNs <250 cells/mm3 and culture positivity (polymicrobial)
  • Needle perforation
Secondary peritonitis
  • PMNs ≥250 cells/mm3 and culture positivity (polymicrobial)
  • Intraperitoneal source of infection, e.g. diverticulitis


Classification Based on Clinical Setting

Peritonitis is classified as follows based ascitic fluid analysis:[4]

Clinical varient of Spontaneous bacterial peritonitis Explanation
Health care-associated SBP (HCA)
  • Diagnosis of peritonitis within 48 hours of hospital admission in patients with any prior health care contact in the past 90 days (e.g. recent hospitalisation, nursing home, dialysis centres and other health care setting).
Nosocomial SBP
  • Diagnosis of peritonitis 48 hours after the hospital admission.
Community acquired SBP (CA)
  • Diagnosis of peritonitis within 48 hours of hospital admission, but no history of prior health care contact in the past 90 days.
Multi-drug resistant SBP
  • Associate with prior history of antibiotic exposure and treat peritonitis based on culture sensitivities.
Recurrent SBP
  • Recurrent episodes of peritonitis increases risk of mortality compared to first episode mortality of SBP. Prophylactic antibiotics can reduce the mortality.


Classification Based on the clinical view point

Peritonitis may be classified based on the prognosis into the following types:[8]

  • Uncomplicated: In uncomplicated peritonitis, the infection only involves a single organ and no anatomical disruption is present. Usually, patients with such infections can be managed with surgical resection alone and no antimicrobial therapy besides peri-operative prophylaxis is necessary.
  • Complicated:The infectious process proceeds beyond the organ that is the source of the infection, and causes either localised peritonitis, also referred to as abdominal abscess, or diffuse peritonitis, depending on the ability of the host to contain the process within a part of the abdominal cavity.They are the important cause of morbidity and more frequently associated with poor prognosis.However, an early clinical diagnosis, followed by adequate source control to stop ongoing contamination and restore anatomical structures and physiological function, as well as prompt initiation of appropriate empirical therapy, can limit the associated mortality.

Classification based on the etiological agents

  • Peritonitis, caused by enteric organisms such as E.coli, Klebsiella, staphylococci, streptococci, anaerobes.
  • Peritonitis, caused by bacteria residing out of GI tract such as gonococci, pneumococci.
  • Aseptic peritonitis resulting from irritation of the peritoneal cavity from the extravasation of fluids such as blood, gastric juice.

Classification according to the extension of inflammatory process

  • Local:
  • Diffuse:
  • Generalized:

Classification based on the pathological alterations in the clinical course of peritonitis

  • Reactive: In the first 24 hours when there are maximal manifestations of local signs of peritonitis.
  • Toxic: In 24-72 hours, when there is increased general intoxication with a gradual reduction in the local signs of peritonitis.
  • Terminal: It is often the severe stage of peritonitis, usually after 72 hours characterized by irreversible intoxication in the background of a sharply expressed local manifestations of peritonitis.

References

  1. Wittmann DH, Schein M, Condon RE (1996). "Management of secondary peritonitis". Ann Surg. 224 (1): 10–8. PMC 1235241. PMID 8678610.
  2. Nathens AB, Rotstein OD, Marshall JC (1998) Tertiary peritonitis: clinical features of a complex nosocomial infection. World J Surg 22 (2):158-63. PMID: 9451931
  3. Mishra SP, Tiwary SK, Mishra M, Gupta SK (2014) An introduction of Tertiary Peritonitis. J Emerg Trauma Shock 7 (2):121-3. DOI:10.4103/0974-2700.130883 PMID: 24812458
  4. 4.0 4.1 Dever JB, Sheikh MY (2015) Review article: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention. Aliment Pharmacol Ther 41 (11):1116-31. DOI:10.1111/apt.13172 PMID: 25819304
  5. Runyon BA, Hoefs JC (1984). "Culture-negative neutrocytic ascites: a variant of spontaneous bacterial peritonitis". Hepatology. 4 (6): 1209–11. PMID 6500513.
  6. Runyon BA (1990). "Monomicrobial nonneutrocytic bacterascites: a variant of spontaneous bacterial peritonitis". Hepatology. 12 (4 Pt 1): 710–5. PMID 2210672.
  7. Runyon BA, Hoefs JC, Canawati HN (1986). "Polymicrobial bacterascites. A unique entity in the spectrum of infected ascitic fluid". Arch Intern Med. 146 (11): 2173–5. PMID 3778046.
  8. Blot S, De Waele JJ (2005). "Critical issues in the clinical management of complicated intra-abdominal infections". Drugs. 65 (12): 1611–20. PMID 16060697.

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