Management of

Secondary Peritonitis
Pembimbing : dr Bambang Arianto, Sp.B

Oleh : Gusti Pindo Asa A

Abstract
Intra-abdominal infection are a common cause of nosocomial
sepsis and are associated with a severe morbility, ortality and
sanitary economy implications.

Primary peritonitis
Is a peritoneal diffuse infection that arises without any septic
focus finding: it interests cirhotic patients with ascites
(decreased protein synthesis and decreased
complementaryactivity): sepsis hepato-renal syndrome.
Is mainly monomicrobic and usually doesnt require a surgical
approach

Secondary peritonitis
Caused by chemical, physical or biological aggregasion of the
peritoneal sierosa.
It takes origin from flogistic, perforative, neoplastic, vascular
phatology or from trauma of an abdominal organ and/or from
trauma of the wall

Tertiary Peritonitis
The persistence or recurence of intraabdominal infection after
adequate treatment for primary or secondary peritonitis ( lack
of response to surgical and antibiotic therapy)

 Causes of peritonitis reported in literature are:

Appendicitis
Acute cholecystitis
Peptic ulcera perforation
Intestinal ischemia/necrosis
Postoperative complication
Others causes (diverticula)
Iatrogenic

35%
20%
15%
10%
10%
9%
1%

Diagnosis
The main sign in secondary peritonitis:
Fever, pain, lacking of perstalsis with no fecal or gas emmisions

Post operative hyperpyrexia could prelude to serius abdominal

infection, however in many case it is not found.

 The main physical signs suggesting peritonitis :

Hypomobility, cutaneous hyperaesthesia, tension of parietal
muscles, rigidity, lack of of hepatic dullnes and ausculatory
silence

 Laboratory
Haematology :
Leukocytosis
Metabolic asidosis

Radiology :
USG Data
Rontgen data

Differential diagnose
Implies exclusion of pulmonary pathologies ( lobar inferior
pneuomonia) , of cardiac pathology (acute myocardial
infarction), of neurological pathologies, of urogical pathologies
(pyelonefritis, urinary lithiasis) of gynecological pathologies
(adnexitis, cyst), of toxic and methabolic pathologies (DM,
Uraemia) of infection ( Typhoid fever, TBC, spontaneus
bacterial peritonitis), of haemotological (leukaemia, sicle cells
anemia)

Pathophysiology
The mecanisme of peritoneal defense can be distinguished in
mechanims of removal
Mesothelial cells provide an intense biological answer and
play important role: they promove the clearance of
contaminated fluid and induced formation of adhesion fibrin
mediated to circumscribe localization of microbial agent

Treatment
Triaging
Antimicrobial Therapy
Surgery

Triaging
The treatment of the surgical should be preceded by
attribution to patients of some score (APACHE II, MPI) during
clinical triaging.
APACHE II : it calculates various physiological variable during
the first 24 hours in hospital together with age and state of
health of the patient.

 MPI : based on the analysis of 17 possible factors of risk, 8 of

which particulary important to obtain a prognosis:

Age
Sex
Organ damaged
Cancer
Duration of the peritontis
Colon involvment
Extension of the peritonitis
Character (clean, purulent or faecal) of the peritoneal fluid

 The advantage : its simplier and provides the possibility to

acquire retrospective data normally present in the surgical
registries.

 <20 = mortality rate 0%-2.3%

20-30 = mortality rate 65%
>30 = mortality rate up to 100%

Antimicrobial therapy
In mild-to-moderated community-aquired infections, should
not be used antibiotics with low toxixity like ampisislin,
cefazolin, metronidazole, clavulanate should be preferred.
Severe disease or higher risk should be treated againts
facultative bacteria and gram negative aerobic : meropem,
imipenem, ceftriaxone, cefotaxime, cefepime
Nosocomial abdominal infection : identify microbiological first

Surgery
Could imply removal of the organ source of infection
(cholecystectomy, appendictomy)
Repair of perforative lesions (stomach, deudenum)
Bowel resections (diverticula, intestinal infarction, jejunum,
colon, sigma perforations)
The primary objective remains the removal of infection source as
soon as possible.

Conlusion
The peritonitis are nowaday characterized by high mortality
Early diagnosis, intensive supportive care, timely adoption of
correct antimicrobial treatment (empirical and antibiogradriven) and surgical control of infection sources as soon as
possible play fundamental role in prognosis of patients.