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Peritonitis

Peritonitis
Synonyms Surgical abdomen, acute abdomen[1]
Tuberculous peritonitis (6544825621).jpg
Peritonitis from tuberculosis
Pronunciation
Specialty Emergency medicine, general surgery
Symptoms Severe pain, swelling of the abdomen, fever[2][3]
Complications Shock, acute respiratory distress syndrome[4][5]
Usual onset Sudden[1]
Types Primary, secondary[1]
Causes Perforation of the intestinal tract, pancreatitis, pelvic inflammatory disease, cirrhosis, ruptured appendix[3]
Risk factors Ascites, peritoneal dialysis[4]
Diagnostic method Examination, blood tests, medical imaging[6]
Treatment Antibiotics, intravenous fluids, pain medication, surgery[3][4]
Frequency Relatively common[1]

Peritonitis is inflammation of the peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs.[2] Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss.[2][3] One part or the entire abdomen may be tender.[1] Complications may include shock and acute respiratory distress syndrome.[4][5]

Causes include perforation of the intestinal tract, pancreatitis, pelvic inflammatory disease, stomach ulcer, cirrhosis, or a ruptured appendix.[3] Risk factors include ascites and peritoneal dialysis.[4] Diagnosis is generally based on examination, blood tests, and medical imaging.[6]

Treatment often includes antibiotics, intravenous fluids, pain medication, and surgery.[3][4] Other measures may include a nasogastric tube or blood transfusion.[4] Without treatment death may occur within a few days.[4] Approximately 7.5% of people have appendicitis at some point in time.[1] About 20% of people with cirrhosis who are hospitalized have peritonitis.[1]

Signs and symptoms

Abdominal pain

The main manifestations of peritonitis are acute abdominal pain, abdominal tenderness and abdominal guarding, which are exacerbated by moving the peritoneum, e.g., coughing (forced cough may be used as a test), flexing one's hips, or eliciting the Blumberg sign (a.k.a. rebound tenderness, meaning that pressing a hand on the abdomen elicits less pain than releasing the hand abruptly, which will aggravate the pain, as the peritoneum snaps back into place). Rigidity (involuntary contraction of the abdominal muscles) is the most specific exam finding for diagnosing peritonitis (+ likelihood ratio: 3.9). The presence of these signs in a patient is sometimes referred to as peritonism.[7] The localization of these manifestations depends on whether peritonitis is localized (e.g., appendicitis or diverticulitis before perforation), or generalized to the whole abdomen. In either case, pain typically starts as a generalized abdominal pain (with involvement of poorly localizing innervation of the visceral peritoneal layer), and may become localized later (with the involvement of the somatically innervated parietal peritoneal layer). Peritonitis is an example of an acute abdomen.

Other symptoms

Complications

Causes

Infection

Non-infection

Risk factors

  • Previous history of peritonitis
  • History of alcoholism
  • Liver disease
  • Fluid accumulation in the abdomen
  • Weakened immune system
  • Pelvic inflammatory disease

Diagnosis

A diagnosis of peritonitis is based primarily on the clinical manifestations described above. Rigidity (involuntary contraction of the abdominal muscles) is the most specific exam finding for diagnosing peritonitis (+ likelihood ratio: 3.9). If peritonitis is strongly suspected, then surgery is performed without further delay for other investigations. Leukocytosis, hypokalemia, hypernatremia, and acidosis may be present, but they are not specific findings. Abdominal X-rays may reveal dilated, edematous intestines, although such X-rays are mainly useful to look for pneumoperitoneum, an indicator of gastrointestinal perforation. The role of whole-abdomen ultrasound examination is under study and is likely to expand in the future. Computed tomography (CT or CAT scanning) may be useful in differentiating causes of abdominal pain. If reasonable doubt still persists, an exploratory peritoneal lavage or laparoscopy may be performed. In patients with ascites, a diagnosis of peritonitis is made via paracentesis (abdominal tap): More than 250 polymorphonucleate cells per μL is considered diagnostic. In addition, Gram stain is almost always negative, whereas culture of the peritoneal fluid can determine the microorganism responsible and determine their sensitivity to antimicrobial agents.

Pathology

In normal conditions, the peritoneum appears greyish and glistening; it becomes dull 2–4 hours after the onset of peritonitis, initially with scarce serous or slightly turbid fluid. Later on, the exudate becomes creamy and evidently suppurative; in dehydrated patients, it also becomes very inspissated. The quantity of accumulated exudate varies widely. It may be spread to the whole peritoneum, or be walled off by the omentum and viscera. Inflammation features infiltration by neutrophils with fibrino-purulent exudation.

Treatment

Depending on the severity of the patient's state, the management of peritonitis may include:

  • General supportive measures such as vigorous intravenous rehydration and correction of electrolyte disturbances.
  • Antibiotics are usually administered intravenously, but they may also be infused directly into the peritoneum. The empiric choice of broad-spectrum antibiotics often consist of multiple drugs, and should be targeted against the most likely agents, depending on the cause of peritonitis (see above); once one or more agents grow in cultures isolated, therapy will be target against them.
  • Gram positive and gram negative organisms must be covered. Out of the cephalosporins, cefoxitin and cefotetan can be used to cover gram positive bacteria, gram negative bacteria, and anaerobic bacteria. Beta-lactams with beta lactamase inhibitors can also be used, examples include ampicillin/sulbactam, piperacillin/tazobactam, and ticarcillin/clavulanate.[11] Carbapenems are also an option when treating primary peritonitis as all of the carbapenems cover gram positives, gram negatives, and anaerobes except for ertapenem. The only fluoroquinolone that can be used is moxifloxacin because this is the only fluoroquinolone that covers anaerobes. Finally, tigecycline is a tetracycline that can be used due to its coverage of gram positives and gram negatives. Empiric therapy will often require multiple drugs from different classes.
  • Surgery (laparotomy) is needed to perform a full exploration and lavage of the peritoneum, as well as to correct any gross anatomical damage that may have caused peritonitis.[12] The exception is spontaneous bacterial peritonitis, which does not always benefit from surgery and may be treated with antibiotics in the first instance.

Prognosis

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. The mortality rate rises to about 40% in the elderly, or in those with significant underlying illness, as well as cases that present late (after 48 hours).

Without being treated, generalised peritonitis almost always causes death. The stage magician Harry Houdini died this way, having contracted streptococcus peritonitis after his appendix ruptured and was removed too late to prevent spread of the infection.

Etymology

The term "peritonitis" comes from Greek περιτόναιον peritonaion "peritoneum, abdominal membrane" and -itis "inflammation".[13]

References

  1. ^ a b c d e f g Ferri, Fred F. (2017). Ferri's Clinical Advisor 2018 E-Book: 5 Books in 1. Elsevier Health Sciences. pp. 979–980. ISBN 9780323529570.
  2. ^ a b c "Peritonitis - National Library of Medicine". PubMed Health. Retrieved 22 December 2017.
  3. ^ a b c d e f "Peritonitis". NHS. 28 September 2017. Retrieved 31 December 2017.
  4. ^ a b c d e f g h "Acute Abdominal Pain". Merck Manuals Professional Edition. Retrieved 31 December 2017.
  5. ^ a b "Acute Abdominal Pain". Merck Manuals Consumer Version. Retrieved 31 December 2017.
  6. ^ a b "Encyclopaedia : Peritonitis". NHS Direct Wales. 25 April 2015. Retrieved 31 December 2017.
  7. ^ "Biology Online's definition of peritonism". Retrieved 2008-08-14.
  8. ^ "Causes". Mayo Clinic. Retrieved July 2, 2016.
  9. ^ Arfania D, Everett ED, Nolph KD, Rubin J (1981). "Uncommon causes of peritonitis in patients undergoing peritoneal dialysis". Archives of Internal Medicine. 141 (1): 61–64. doi:10.1001/archinte.141.1.61. PMID 7004371.
  10. ^ Ljubin-Sternak, Suncanica; Mestrovic, Tomislav (2014). "Review: Clamydia trachonmatis and Genital Mycoplasmias: Pathogens with an Impact on Human Reproductive Health". Journal of Pathogens. 2014 (183167): 1. doi:10.1155/2014/183167. PMC 4295611. PMID 25614838.
  11. ^ Appropriate Prescribing of Oral Beta-Lactam Antibiotics
  12. ^ "Peritonitis: Emergencies: Merck Manual Home Edition". Retrieved 2007-11-25.
  13. ^ peritonitis - Online Etymology Dictionary

External links

Classification
External resources