Peritonitis overview

Jump to navigation Jump to search

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]

Synonyms and keywords: Acute bacterial peritonitis, acute generalized peritonitis, acute peritonitis, abscess of suppurative peritonitis, acute suppurative peritonitis, purulent peritonitis, subphrenic peritonitis, pelvic peritonitis, acute serositis, aseptic peritonitis, chronic peritonitis, continuous ambulatory peritoneal dialysis associated peritonitis, fungal peritonitis, granulomatous peritonitis, peritoneal dialysis-associated peritonitis, serositis, chemical peritonitis, neonatal peritonitis, tuberculous peritonitis, peritoneal abscess, spontaneous bacterial peritonitis, female, benign paroxysmal peritonitis, pyogranulomatous serositis, perforation peritonitis, CAPD peritonitis, primary peritonitis, secondary peritonitis, tertiary peritonitis, Culture-negative neutrocytic ascites, Monomicrobial non-neutrocytic bacterascites.

Overview

Peritonitis defined as inflammation of peritoneum ( serosal membrane lining the abdominal cavity and abdominal viscera) is associated with high mortality rate due to bacteremia and sepsis syndrome. Most common causes of peritonitis ~ 80% in adults include perforation of the gastrointestinal or biliary tract.Other causes include Cirrhosis (frequently the result of alcoholism), and peritoneal dialysis associated peritonitis. Peritonitis can also result from injury, contamination with microorganisms, chemicals, or both. It may be localised or generalised, generally has an acute course, and may depend on either infection (often due to rupture of a hollow viscus) or on a non-infectious process.Chronic peritonitis is usually seen in tuberculous infection.Patients usually present with severe abdominal pain, and tenderness, fever, chills, nausea and vomiting. Peritonitis generally represents an emergency medical/surgical condition that requires prompt medical attention and treatment.

Definition

Peritonitis is defined as inflammation of the peritoneum (a tissue that lines the inner wall of the abdominal cavity and covers most of the abdominal organs) from any cause.[1] Contrast to peritonitis, Intrabdominal infection is defined as the inflammation of peritoneum due to infectious cause.[1]

Historical Perspective

The first reports of SBP appeared in the German and French literatures between 1907 and 1958. Krencker 1907; Brule et al 1939; Cachin 1955; Navasa et al 1999 described that ascitic fluid infections were most common in patients with cirrhosis. Spontaneous bacterial peritonitis (SBP), reported by Caroli and Platteborse (1958) has had its importance increased since Kerr and colleagues (1963) and Conn (1964) published two papers about this cirrhosis complication almost simultaneously. Kerr and colleagues (1963) described 11 episodes of ascitic fluid infection in 9 cirrhotic patients while Harold O.Conn , M.D, a world-renowned hepatologist (1964) introduced the term “spontaneous bacterial peritonitis” for the first time in English literature. [2][3][4][5]

Classification

Peritonitis can be classified based on the etiology or based on the ascitic fluid analysis or base on the clinical setting in which peritonitis is present. Among them the major classication is based on the etiology, peritonitis can be classified into 3 subtypes: primary, secondary, and tertiary peritonitis.

Primary or Spontaneous Peritonitis Secondary Peritonitis Tertiary Peritonitis
  • Primary peritonitis/ spontaneous bacterial peritonitis (SBP) represents a group of diseases with different causes characterized by ascitic fluid infection of the peritoneal cavity without an evident surgically treatable intra-abdominal source of infection. It is usually associated with cirrhosis and ascites in adults.[6] Primary peritonitis lacks an identifiable anatomical derangement.[7]
  • Secondary peritonitis is defined as the infection of the peritoneum due to spillage of organisms into the peritoneal cavity resulting from hollow viscus perforation, anastomotic leak, ischemic necrosis, or other injuries of the gastrointestinal tract.[8]
  • Tertiary peritonitis is defined as the persistant or recurrent intra-abdominal infection that occur in ≥48 hours following the successful and adequate surgical source control of primary or secondary peritonitis.[8][9][10]

Pathophysiology

Peritonitis results from contamination of normal sterile peritoneal cavity with infections or chemical irritants.Release of bile or gastric juices initially causes chemical peritonitis, infection occurs when bacteria enter and contaminate the peritoneal cavity.Bacterial peritonitis is usually caused by normal enteric flora like E.coli, Klebsiella. Inflammatory process causes shift of fluid into the peritoneal cavity(third spacing) which leads to hypovolemia, septicemia and multi-organ failure resulting in death of the patient if not adequately diagnosed and treated early.

Causes

There are two forms of peritonitis.Spontaneous bacterial peritonitis (SBP) is the result of an infection of the fluid in the peritoneal cavity. Liver or kidney failure can cause this condition. Patients on peritoneal dialysis for kidney failure are also at an increased risk for SBP.Secondary peritonitis is usually due to an infection that has spread from GI tract due to perforation of the hollow viscus.Peritonitis most often can be caused by abdominal wound or injury, ruptured appendix, perforated gastro-duodenal ulcers, perforated colon, diverticulitis, pancreatitis, cirrhosis of the liver, inflammatory bowel disease, infections of the gallbladder and bloodstream, invasive medical procedures.

Overview

The most common cause of peritonitis is perforation of a hollow viscus such as perforation of the distal esophagus (Boerhaave syndrome), of the stomach (peptic ulcer, gastric carcinoma), of the duodenum (peptic ulcer), of the remaining intestine (e.g. appendicitis, diverticulitis, Meckel's diverticulum, IBD, intestinal infarction, intestinal strangulation, colorectal carcinoma, meconium peritonitis), or of the gallbladder (cholecystitis). Other causes of infected peritonitis include spontaneous bacterial peritonitis and disruption of the peritoneum, such as in cases of trauma, surgical wounds, continuous peritoneal dialysis, and intra-peritoneal chemotherapy. Causes of non-infected peritonitis include endometriosis, blunt abdominal trauma, gastric carcinoma, peptic ulcer, pelvic trauma, and pancreatitis.

Differential Diagnosis

Epidemiology and Demographics

Risk Factors

Patients with liver disease are at increased risk. Risk factors for liver disease include alcoholic cirrhosis and other diseases that lead to cirrhosis, such as viral hepatitis (Hepatitis B or C). Spontaneous peritonitis also occurs in patients who are on dialysis for kidney failure.

Screening

Natural History, Complications and Prognosis

With treatment, patients usually do well. Without treatment, the outcome is usually poor. However, in some cases, patients do poorly even with prompt and appropriate treatment.

Diagnosis

Diagnostic Criteria

History and Symptoms

The main manifestations of peritonitis are acute abdominal pain, tenderness, and guarding, which are exacerbated by moving the peritoneum, e.g. coughing, flexing the hips, or eliciting the Blumberg sign (a.k.a. rebound tenderness, meaning that pressing a hand on the abdomen elicits pain, but releasing the hand abruptly will aggravate the pain, as the peritoneum snaps back into place).

Abdominal pain and tenderness: The localization of these manifestations depends on whether peritonitis is localized (e.g. appendicitis or diverticulitis before perforation), or generalized to the whole abdomen; even in the latter case, pain typically starts at the site of the causing disease. Peritonitis is an example of acute abdomen.

Physical Examination

Laboratory Findings

A diagnosis of peritonitis is based primarily on clinical grounds, that is on the clinical manifestations described above; if they support a strong suspicion of peritonitis, no further investigation should delay surgery. Leukocytosis and acidosis may be present, but they are not specific findings. Plain abdominal X-rays may reveal dilated, oedematous intestines, although it is mainly useful to look for pneumoperitoneum (free air in the peritoneal cavity), which may also be visible on chest X-rays. If reasonable doubt still persists, an exploratory peritoneal lavage may be performed (e.g. in cause of trauma, in order to look for white blood cells, red blood cells, or bacteria).

Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Surgery (laparotomy) is needed to perform a full exploration and lavage of the peritoneum, as well as to correct any gross anatomical damage which may have caused peritonitis.[11] The exception is spontaneous bacterial peritonitis, which does not benefit from surgery.

Prevention

References

  1. 1.0 1.1 Wittmann DH, Schein M, Condon RE (1996) Management of secondary peritonitis. Ann Surg 224 (1):10-8. PMID: 8678610
  2. Ribeiro TC, Chebli JM, Kondo M, Gaburri PD, Chebli LA, Feldner AC (2008). "Spontaneous bacterial peritonitis: How to deal with this life-threatening cirrhosis complication?". Ther Clin Risk Manag. 4 (5): 919–25. PMC 2621420. PMID 19209274.
  3. Garcia-Tsao, Guadalupe (2004). "Spontaneous bacterial peritonitis: a historical perspective". Journal of Hepatology. 41 (4): 522–527. doi:10.1016/j.jhep.2004.09.001. ISSN 0168-8278.
  4. CONN HO (1964). "SPONTANEOUS PERITONITIS AND BACTEREMIA IN LAENNEC'S CIRRHOSIS CAUSED BY ENTERIC ORGANISMS. A RELATIVELY COMMON BUT RARELY RECOGNIZED SYNDROME". Ann Intern Med. 60: 568–80. PMID 14138877.
  5. Crossley IR, Williams R (1985). "Spontaneous bacterial peritonitis". Gut. 26 (4): 325–31. PMC 1432517. PMID 3884467.
  6. Wiest R, Krag A, Gerbes A (2012) Spontaneous bacterial peritonitis: recent guidelines and beyond. Gut 61 (2):297-310. DOI:10.1136/gutjnl-2011-300779 PMID: 22147550
  7. 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
  8. 8.0 8.1 Calandra T, Cohen J, International Sepsis Forum Definition of Infection in the ICU Consensus Conference (2005) The international sepsis forum consensus conference on definitions of infection in the intensive care unit. Crit Care Med 33 (7):1538-48. PMID: 16003060
  9. Evans HL, Raymond DP, Pelletier SJ, Crabtree TD, Pruett TL, Sawyer RG (2001) Tertiary peritonitis (recurrent diffuse or localized disease) is not an independent predictor of mortality in surgical patients with intraabdominal infection. Surg Infect (Larchmt) 2 (4):255-63; discussion 264-5. DOI:10.1089/10962960152813296 PMID: 12593701
  10. 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
  11. "Peritonitis: Emergencies: Merck Manual Home Edition". Retrieved 2007-11-25.


Template:WikiDoc Sources