Secondary peritonitis natural history: Difference between revisions
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==Prognosis== | ==Prognosis== | ||
Peritonitis is a frequent cause of morbidity.The prognosis greatly depends on the degree of intra-abdominal contamination, the severity of underlying disease, the immune response of the host and associated organ dysfunction.Associated mortality rates vary from < 1% to > 60% | Peritonitis is a frequent cause of morbidity.The prognosis greatly depends on the degree of intra-abdominal contamination, the severity of underlying disease, the immune response of the host and associated organ dysfunction.<ref name="MulierPenninckx2003">{{cite journal|last1=Mulier|first1=Stefaan|last2=Penninckx|first2=Freddy|last3=Verwaest|first3=Charles|last4=Filez|first4=Ludo|last5=Aerts|first5=Raymond|last6=Fieuws|first6=Steffen|last7=Lauwers|first7=Peter|title=Factors Affecting Mortality in Generalized Postoperative Peritonitis: Multivariate Analysis in 96 Patients|journal=World Journal of Surgery|volume=27|issue=4|year=2003|pages=379–384|issn=0364-2313|doi=10.1007/s00268-002-6705-x}}</ref> | ||
Associated mortality rates vary from < 1% to > 60% | |||
Factors affecting prognosis are: | Factors affecting prognosis are: | ||
* Age | * Age | ||
Revision as of 21:31, 12 February 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shivani Chaparala M.B.B.S [2]
Overview
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.
Natural History
Secondary peritonitis is the initial phase of infection after intestinal perforation which can progress to abscess, if left untreated. Severe abdominal infections are invariably progress to a high level of sepsis, endotoxin production and systemic inflammatory response syndrome (SIRS), which often results in multiple organ failure.[1][2]. If properly treated, typical cases of surgically correctable peritonitis (e.g. perforated peptic ulcer, appendicitis, and diverticulitis) have a mortality rate of about <10% in otherwise healthy patients, which rises to about 40% in the elderly, and/or in those with significant underlying illness, as well as in cases that present late (after 48h). If left untreated, generalized peritonitis is almost always fatal.
Complications
- Tertiary peritonitis usually follows operative attempts to treat secondary peritonitis and is almost always associated with a systemic inflammatory response. It is a persistent/recurrent infection with organisms of low virulence. The incidence of tertiary peritonitis in patients requiring ICU admission for severe abdominal infections may be as high as 50-74%.
- Surgical site infection and delayed wound healing- Depends on the degree of contamination. Measures taken to prevent postoperative infections such as peri-operative, systemic antibiotics, and lavage of the wound would not help to prevent this complication. In such instances, the wound should be kept open, and treated with wet-to-dry dressing several times a day. It occurs in 5-15% of patients.
- Laparotomy increases the risk of small Bowel obstruction due to post-operative adhesions.[3]
- Intraperitoneal adhesions, leading to bowel obstruction
- Sequestration of fluid and electrolytes, as revealed by decreased central venous pressure, may cause electrolyte disturbances, as well as significant hypovolaemia, possibly leading to shock and acute renal failure.
- A peritoneal abscess may form (e.g. above or below the liver, or in the lesser omentum).
- Sepsis may develop, so blood cultures should be obtained.
- The fluid may push on the diaphragm and cause breathing difficulties
- Development of abscess is the leading cause of persistent infection and development of tertiary peritonitis.
- The majority of abscess formation occurs subsequent to secondary peritonitis.The risk of abscess increases to 10-30% in cases of preoperative perforation of the hollow viscus, significant fecal contamination of the peritoneal cavity, bowel ischemia, delayed diagnosis and therapy of the initial peritonitis, and the need for reoperation, as well as in the setting of immunosuppression.
Prognosis
Peritonitis is a frequent cause of morbidity.The prognosis greatly depends on the degree of intra-abdominal contamination, the severity of underlying disease, the immune response of the host and associated organ dysfunction.[4] Associated mortality rates vary from < 1% to > 60% Factors affecting prognosis are:
- Age
- Blood pressure
- Cause of infection
- Site of origin of peritonitis
- Number of organs involved in multi-organ-failure (MOF)
- Pre-operative organ failure
- Presence of metabolic acidosis
- Serum albumin
- New York Heart Association cardiac function status
- Malnutrition
- Malignoma
- Fecal peritonitis
- Immunosuppression
The prognosis risk of peritonitis may be stratified using the Mannheim's Peritoneal index score (MPI) as shown below:[5][6]
| Riskfactor | Score |
|---|---|
| Age >50 years | 5 |
| Female sex | 5 |
| Organ failure | 7 |
| Malignancy | 4 |
| Origin of sepsis not colonic | 4 |
| Diffuse generalized peritonitis | 6 |
| Preoperative duration of peritonitis >24h | 4 |
Intraperitoneal exudates
|
|
Assessment of the prognosis of patients with peritonitis using MPI
- For a score of 27, the sensitivity was 66.67%, specificity was 100%, and positive predictive value for mortality is 100% at an accuracy of 94%.[5]
| Assessment of severity of peritonitis using MPI | ||
| Score | Mortality rate | Morbidity rate |
|---|---|---|
| <21 | 0% | 13.33% |
| 21-27 | 27.28% | 65.71% |
| >27 | 100% | 100% |
Factors that were found to be independently significant factors in predicting the mortality:
- Duration of pain for >24 h
- Organ failure on admission
- Female sex and
- Feculent exudate
- Early prognostic evaluation of abdominal sepsis is useful in the assessment of the severity of the disease and to select high-risk patients for early surgical reintervention.
References
- ↑ Wong PF, Gilliam AD, Kumar S, Shenfine J, O'Dair GN, Leaper DJ (2005). "Antibiotic regimens for secondary peritonitis of gastrointestinal origin in adults". Cochrane Database Syst Rev (2): CD004539. doi:10.1002/14651858.CD004539.pub2. PMID 15846719.
- ↑ Berne TV, Yellin AW, Appleman MD, Heseltine PN (1982). "Antibiotic management of surgically treated gangrenous or perforated appendicitis. Comparison of gentamicin and clindamycin versus cefamandole versus cefoperazone". Am J Surg. 144 (1): 8–13. PMID 6211996.
- ↑ Duron JJ (2003). "[Post-operative bowel obstruction. Part 2: Mechanical post-operative small bowel obstruction by bands and adhesions]". J Chir (Paris). 140 (6): 325–34. PMID 14978440.
- ↑ Mulier, Stefaan; Penninckx, Freddy; Verwaest, Charles; Filez, Ludo; Aerts, Raymond; Fieuws, Steffen; Lauwers, Peter (2003). "Factors Affecting Mortality in Generalized Postoperative Peritonitis: Multivariate Analysis in 96 Patients". World Journal of Surgery. 27 (4): 379–384. doi:10.1007/s00268-002-6705-x. ISSN 0364-2313.
- ↑ 5.0 5.1 Sharma S, Singh S, Makkar N, Kumar A, Sandhu MS (2016). "Assessment of Severity of Peritonitis Using Mannheim Peritonitis Index". Niger J Surg. 22 (2): 118–122. doi:10.4103/1117-6806.189009. PMC 5013738. PMID 27843277.
- ↑ Pacelli F, Doglietto GB, Alfieri S, Piccioni E, Sgadari A, Gui D; et al. (1996). "Prognosis in intra-abdominal infections. Multivariate analysis on 604 patients". Arch Surg. 131 (6): 641–5. PMID 8645072.