Peritonitis

Abstract

Peritonitis is an inflammation of the peritoneum that is often caused by a bacterial infection.

Based on the etiology, peritonitis may be classified as primary or secondary. Primary
peritonitis usually occurs in patients with underlying ascites, whereas secondary peritonitis
affects those with a preexisting acute abdominal disease. Patients typically present with
severe abdominal pain and guarding, as well as nausea and vomiting. In most cases,
peritonitis constitutes a surgical emergency. Diagnosis is established based on the clinical
presentation, laboratory tests, imaging, and peritoneal fluid analysis. Treatment includes
administration of antibiotics as well as surgical interventions. Peritonitis may be further
complicated by ileus, sepsis, or abdominal compartment syndrome.

Etiology

Primary peritonitis (spontaneous bacterial peritonitis, or SBP)

 Absent acute abdominal disease

 Route of infection: hematogenous, lymphogenic, transmigration of bacteria through
the intestinal wall
 In patients with an underlying disease causing ascites (e.g., decompensated cirrhosis)
 Usually monomicrobial infection (∼ 90% of cases)
o Gram-negative: Escherichia coli, Klebsiella pneumoniae, Bacteroides
o Gram-positive: Streptococcus pneumoniae

Secondary peritonitis (more common)

 Pre-existing acute abdominal condition

o Hollow organ perforation: peptic ulcer, diverticulum, volvulus, cholecystitis
o Inflammation of intra-abdominal organs: appendicitis, diverticulitis,
necrotizing pancreatitis
o Postoperative complications: anastomosis insufficiency, unsterile puncture
site, or surgical procedure
o Traumatic (external perforation)
o Peritoneal dialysis
o Intra-abdominal abscess
 Mixed infection: aerobic (E. coli, Klebsiella, Enterobacter, Streptococci, Enterococci)
and anaerobic (Bacteroides species, Eubacteria, Clostridia)

Further causes

 Peritonitis in immunosuppressed (mainly HIV-positive) patients

 Chemical peritonitis: nonbacterial, caused by irritants such as blood, bile, urine, or
barium contrast in the peritoneal cavity

References:[1]

Clinical features
  General symptoms
o Diffuse abdominal pain with abdominal guarding and/or rebound tenderness
o Nausea, and vomiting
o Fever and chills (esp. in underlying infection, e.g., SBP)
o Possibly shoulder pain
o Ascites in SBP
 Physical examination
o Distressed patient, knees drawn up when supine , avoids movement
o Abdominal pain and rigidity, rebound tenderness
o Sparse peristaltic sounds (none in cases of ileus)

Peritonitis is considered a surgical emergency, as it may cause sepsis with shock and organ
failure!

References:[1]

Diagnostics

The diagnosis of peritonitis is based primarily on the physical manifestations. Laboratory

tests and peritoneal fluid analysis confirm the diagnosis, while imaging tests may detect help
to identify the underlying disease and exclude differential diagnoses.

 Laboratory tests
o CBC significant for leukocytosis
o Peritoneal fluid analysis (diagnostic paracentesis)
 Primary peritonitis (SBP)
 Neutrophil count of > 250 cells/μL
 Positive bacterial culture and/or Gram stain
 Serum-ascites albumin gradient (SAAG) > 1.1
 Secondary peritonitis
 Glucose < 50 mg/dL
 Peritoneal fluid LDH > serum LDH,
 pH < 7.0
 Imaging
o Ultrasound may detect
 Underlying disease: e.g., pancreatitis, appendicitis, cholangitis
 Peritoneal fluid
o Abdominal x-ray may detect:
 Air-fluid levels (e.g., in ileus)
 Free air secondary to organ perforation
o CT scan of the abdomen and pelvis
 Should not cause delay for surgical intervention if the diagnosis is
clinically made
 Test of choice for suspected visceral abscess
 Indicated if diagnosis is unclear based on clinical or other imaging
findings

References:[1]

Differential diagnoses
In certain conditions, patients show symptoms of peritonitis, although actual inflammation of
the peritoneum is absent.

 See differential diagnoses of acute abdomen.

 Metabolic: diabetic ketoacidosis; acute intermittent porphyria
 Further: hemolytic crisis; lead poisoning

The differential diagnoses listed here are not exhaustive.

Treatment

Primary peritonitis

 Treatment indications: fever > 37.8°C (100°F), neutrophil count in ascitic fluid > 250
cells/μL; altered mental status
 Broad-spectrum antibiotics : 3rd generation cephalosporins (e.g., cefotaxime,
ceftriaxone

Secondary peritonitis

 Approach: remove the source of infection and treat the underlying cause via
interventional procedures, eliminate bacteria via antibiotics, and maintain organ
function via fluid resuscitation and supportive care
 Interventional procedures
o Surgery
o Extensive laparoscopic irrigation (lavage), debridement, drainage
o Ultrasound or CT-guided percutaneous drainage of abscesses
o Scheduled revision surgery (second-look surgery) frequently necessary for
extensive disease
 General
o Hospital monitoring (possibly intensive care)
o Fluid replacement
 Medical
o Broad-spectrum antibiotics (several treatment options are possible)
 Piperacillin + tazobactam
 Ampicillin + sulbactam, possibly in combination with gentamicin
 Ciprofloxacin +/- metronidazole
 In severe peritonitis: carbapenems, e.g., imipenem or meropenem
o Analgesics, thrombosis prophylaxis

References:[2][1][3]

Complications

 Paralytic (adynamic) ileus

 Sepsis
 Adhesions
 Enterocutaneous fistulae
 Abdominal compartment syndrome
References:[1]

We list the most important complications. The selection is not exhaustive.

last updated 10/25/2017