Peritonitis

Peritonitis
Intra-abdominal infections

Two major clinical manifestations

Early or diffuse infection results

in localised or generalised
peritonitis

Bacterial peritonitis is classified as

primary or secondary

Late and localised infections

produces an intra-abdominal
abscess
Pathophysiology depend on
competing factors of bacterial
virulence and host defences
Primary peritonitis
Diffuse bacterial infection without loss of integrity of GI tract
Often occurs in adolescent girls
Streptococcus pneumonia commonest organism involved

Ascites, secondary to cirrhosis of the liver, may become

infected spontaneously.

Secondary peritonitis
Acute peritoneal infection
Often involves multiple organisms - both aerobes and anaerobes
Commonest organisms are E. coli and Bacteroides fragilis
Secondary peritonitis
Etiology
Etiology (secondary peritonitis )
• Perforation of a viscus into the
peritoneal cavity
• Trauma
• Infected intraperitoneal blood from any
source (eg, trauma, surgery, ectopic pregnancy)
can become infected and lead to peritonitis.
• Foreign bodies
• Pancreatitis
Etiology (secondary peritonitis )
• Strangulating intestinal obstruction
• Pelvic inflammatory disease (PID)
• Vascular catastrophes (mesenteric
thrombosis or embolism).
• In sexually active women: gonococcus and
chlamydia are most common.
• IUD long-lasting
• Anastomotic dehiscence
 Etiology (secondary peritonitis )

• Peritoneo-systemic shunts, in common with other long-lasting

• peritoneal drains, tend to become infected and lead to peritonitis.

• Drains of any type may furnish an entry for bacteria into the
peritoneal cavity.

• Barium introduced into the peritoneal cavity via an enema through a

perforated diverticulum can lead to acute and later to chronic
peritonitis because of the combination of barium and infection.

• Meconium peritonitis can occur from perforation of the bowel in

utero.

• Peritoneal dialysis
 Peritonitis, symptoms
• Abdominal pain
• Abdominal tenderness
• Fluid in the abdomen
• Inability to pass feces or gas („ silent „ abdomen )
• Distended abdomen
• Fever
• Low urine output
• Nausea and vomiting
• Point tenderness
• Thirst
Infected ascites
 Symptoms, Signs, and
Complications
The symptoms of peritonitis depend on the virulence
and extent of the infection.

In severe cases of generalized peritonitis, tenderness occurs over

the entire abdomen with vomiting and high fever.

Peristalsis is absent. (An old clinical rule: A silent abdomen demands

a laparotomy.)
Note: a stone in the urether can also causes strong pain and absence of
intestinal movements and sounds!
A postoperative paralysis does not need operation !
 Symptoms, Signs, and
Complications
• The loss of fluids into the peritoneal
cavity and bowel leads to severe
dehydration and electrolyte
disturbances
• Adult respiratory distress syndrome
also develops rapidly.
• Kidney failure, liver failure, and
disseminated intravascular coagulation
follow.
 Complications
Intraabdominal abscesses
inraperitoneal and/ or hepatic abscess

• Intarabdominal adhesions and bands

causes later obstruction ( early in weeks,
late in years )
• No specific prophilaxis in prevention
Intraabdominal abscess

CT SCAN
Intraabdominal abscess
CT SCAN
Inraabominal band
 Perforated abdominal esophagus

Iatrogenic perforations (eg, from an esophagoscope, balloon

dilator, or bougie) above or below the diaphragm.

Forceful vomiting with a full stomach may cause esophageal rupture

(Boerhaave's syndrome), which is the most serious type of emetic
injury. Pain in the left upper quadrant, left chest, or shoulder after any of
these occurrences should alert the physician to order an immediate
meglumine diatrizoate (Gastrografin) swallow.

If a perforation is noted, immediate operation is necessary

because the mortality from peritonitis or empyema increases rapidly with
delay.
 Perforated gastric or duodenal ulcer

tends to cause the one of most serious cases of peritonitis; the mortality
rate is nearly 20%. There may be a history of peptic ulcer disease, but in
about 33% of cases, the first symptom is a sudden attack of severe
epigastric pain.
A patient examined shortly after onset may be relatively free of pain and
show only mild tenderness and diminished or absent peristalsis.
However, within a few hours, vomiting, tenderness, and spasm, either in
the epigastrium or over the whole abdomen, develop.
 Perforated Appendix
It can occur at any age but is
the most common cause of
peritonitis in children and
young adults.
In children, because of a poorly
developed omentum,
peritonitis is likely to be
generalized;
in adults, local peritonitis and
abscess formation are more
common.
Tenderness in the right lower
quadrant or over the entire
abdomen indicates the
extent of inflammation.
 Perforated colon

caused by obstruction, diverticulitis, inflammatory diseases, and

toxic megacolon.

Perforated diverticulitis of the sigmoid or right colon is the most

common cause of peritonitis from a perforated colon.
Patients receiving prednisone or immunosuppressive drugs can also
increase the danger of perforation.
Crohn’s disease, ulcerative colitis
Acute necrotizing enterocolitis

Ulcerative colitis
Sigmoid diverticulosis
Perforated colon, diverticulum
 Vascular lesions of the intestine or colon

Usually, the superior mesenteric distribution is involved, but the area

supplied by the inferior mesenteric artery can be devitalized by division
of this artery during resection of an aortic aneurysm.

A history of abdominal angina for weeks or months preceding an acute

onset of peritonitis suggests thrombotic occlusion of the superior
mesenteric artery or its branches in association with atherosclerotic
disease of these vessels.

Alternatively, a history of recent atrial arrhythmia, MI, or endocarditis

strongly suggests embolization to the superior mesenteric artery and
its resultant intestinal ischemia

Mesenteric venous thrombosis

 Perforated gallbladder or biliary tree

Acute cholecystitis can lead to perforation of the gallbladder, which

usually leads to a local abscess but occasionally to generalized peritonitis.

Operation should include cholecystectomy. The common cause of bile

peritonitis arising from the bile ducts is iatrogenic damage during
cholecystectomy or EST.

Cholecystitis acalculosa, poor blood supply of gallbladder

 Nonocclusive intestinal ischemia
is the partial- or full-thickness necrosis of intestine in the absence of
obvious organic vascular occlusion.
It may be caused by prolonged shock or cardiopulmonary
bypass, during which mesenteric blood flow decreases.
In cases in which this diagnosis is considered, arteriography must be
performed.

Demonstration of an organic vascular lesion will lead to operation,

whereas diffuse spasm may respond to vasodilator therapy.
Transmural bowel necrosis and peritonitis must be treated by bowel
resection.
 Pancreatitis
can cause an exudate that at first is retroperitoneal but soon involves the
peritoneal cavity.

It is a chemical peritonitis, initially with a high level of amylase in the

exudate; later, contamination with organisms from the GI tract may
occur. Infected pancreatitis.

If the diagnosis seems certain and trauma was not a factor, laparotomy
usually is avoided and reserved for the complications of pancreatic
necrosis, abscess, or pseudocyst.
However, failure to improve may be an indication for earlier operation.
Fungal peritonitis
usually with Candida, can occur, especially in postoperative patients
who have had persistent peritonitis treated with antibiotics. Candidal
peritonitis can be treated with IV amphotericin B, but the prognosis is
grave.

Peritoneal dialysis frequently is complicated by peritonitis;

cloudy effluent may indicate its presence.
Inlying catheters or shunts used for ascites can lead to bacterial invasion,
notably by Staphylococcus epidermidis and Staphylococcus aureus.
Treatment is with antibiotics, as determined by culture and sensitivity;
removal of shunts, if necessary; or hemodialysis, as a last resort.
Tubo-ovarian abscess
develops in about 15% of women with salpingitis.
It can accompany acute or chronic infection and may require prolonged
hospitalization, sometimes with surgical percutaneous drainage.

Rupture of the abscess is a surgical emergency, rapidly

progressing from severe lower abdominal pain to nausea, vomiting,
generalized peritonitis, and septic shock.

Pyosalpinx, in which one or both fallopian tubes are filled with pus,
may also be present.
The fluid may be sterile, but WBCs predominate in it.
 Postoperative peritonitis
Operative injury to a viscus (biliary tree, ureter, bladder, GI tract)
requires surgical correction.

Anastomotic dehiscence is a serious problem that also requires early

reoperation.

Retained foreign bodies (eg, a sponge) may cause severe abscess or

inflammatory adhesions and fibrosis that persist until the sponge is
removed surgically or, rarely, discharged spontaneously.
 Diagnosis
ANAMNESIS, PHYSICAL EXAMINATION
Chest x-rays: diff.dg ( pneumonia )
Plain abdominal x-rays should be taken in both supine and upright
positions.
The presence of gas beneath the diaphragm points to a perforation of
the GI tract. If the diagnosis is in doubt, (Gastrografin) passed into the
stomach through an inlying nasogastric tube will demonstrate the
perforation. (Meglumine diatrizoate does not irritate the peritoneum as
does standard barium.)
Ultrasound: can help in differential diagnosis.( gallstone, measurement
of gallbladder wall, localisation and amount of intraabdominal fluid
collection, sign of tumors, kidney stone )
Laparotomy or laparoscopy is the most important diagnostic
measure.
 Treatment of peritonitis

Primarily involves treatment of the underlying disease.

General therapy includes antibiotics, nasogastric intubation and suction,

respiratory care, and fluid and electrolyte replacement.
The most effective antibiotic regimen to give before results of cultures are
available is debatable.
Third-generation cephalosporins are effective and probably safest. A
combination of gentamicin and clindamycin is effective but dangerous if
renal function is diminished.
 Surgical management

The management of secondary peritonitis involves :

Elimination of the source of infection
Reduction of bacterial contamination of the peritoneal cavity
Prevention of persistent or recurrent intra-abdominal
infections
Could be combined with fluid resuscitation, antibiotics and ICU
management
Source control achieved by closure or exteriorisation of perforation
Bacterial contamination reduced by aspiration of faecal matter and
pus
Recurrent infection prevented by the used of:
Drains
Planned re-operations
Leaving the wound open / in case of serious pancreatitis
 Peritoneal lavage

Peritoneal lavage often used but benefit is unproven

Simple swabbing of pus from peritoneal cavity may be of same
value
Has been suggested that lavage may spread infection or damage
peritoneal surface
No benefit of adding antibiotics to lavage fluid
No benefit of adding Chlorhexidine or Betadine to lavage fluid
If used, lavage with large volume of crystalloid solution probably
has best outcome