Peritonitis

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]

Peritonitis
SynonymsSurgical abdomen, acute abdomen[1]
Tuberculous peritonitis (6544825621)
Peritonitis from tuberculosis
Pronunciation
  • /pɛrɪtəˈnaɪtɪs/
SpecialtyEmergency medicine, general surgery
SymptomsSevere pain, swelling of the abdomen, fever[2][3]
ComplicationsShock, acute respiratory distress syndrome[4][5]
Usual onsetSudden[1]
TypesPrimary, secondary[1]
CausesPerforation of the intestinal tract, pancreatitis, pelvic inflammatory disease, cirrhosis, ruptured appendix[3]
Risk factorsAscites, peritoneal dialysis[4]
Diagnostic methodExamination, blood tests, medical imaging[6]
TreatmentAntibiotics, intravenous fluids, pain medication, surgery[3][4]
FrequencyRelatively common[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 polymorphonuclear 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

External resources
Acute abdomen

An acute abdomen refers to a sudden, severe abdominal pain. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need surgical treatment.

Asbury Latimer

Asbury Churchwell Latimer (July 31, 1851 – February 20, 1908) was a United States Representative and Senator from South Carolina. Born near Lowndesville, South Carolina, he attended the common schools, engaged in agricultural pursuits, and in 1880 moved to Belton, South Carolina and devoted his time to farming.

Latimer was elected as a Democrat to the Fifty-third and to the four succeeding Congresses (March 4, 1893 – March 3, 1903). He did not seek renomination in 1902, having become a candidate for US Senator. He was elected to the U.S. Senate and served from March 4, 1903, until his death in 1908.

During his service in the Senate, he was appointed in 1907 a member of the United States Immigration Commission.

He died of peritonitis in Washington, D.C. in 1908; interment was in Belton Cemetery, Belton, South Carolina.

Ascites

Ascites is the abnormal buildup of fluid in the abdomen. Technically, it is more than 25 mL of fluid in the peritoneal cavity. Symptoms may include increased abdominal size, increased weight, abdominal discomfort, and shortness of breath. Complications can include spontaneous bacterial peritonitis.In the developed world, the most common cause is liver cirrhosis. Other causes include cancer, heart failure, tuberculosis, pancreatitis, and blockage of the hepatic vein. In cirrhosis, the underlying mechanism involves high blood pressure in the portal system and dysfunction of blood vessels. Diagnosis is typically based on an examination together with ultrasound or a CT scan. Testing the fluid can help in determining the underlying cause.Treatment often involves a low salt diet, medication such as diuretics, and draining the fluid. A transjugular intrahepatic portosystemic shunt (TIPS) may be placed but is associated with complications. Effects to treat the underlying cause, such as by a liver transplant may be considered. Of those with cirrhosis, more than half develop ascites in the ten years following diagnosis. Of those in this group who develop ascites, half will die within three years. The term is from the Greek askítes meaning "baglike".

Blumberg sign

Blumberg's sign, also referred to as rebound tenderness, is a clinical sign that is elicited during physical examination of a patient's abdomen by a doctor or other health care provider. It is indicative of peritonitis. It refers to pain upon removal of pressure rather than application of pressure to the abdomen. (The latter is referred to simply as abdominal tenderness.)

David Arellano

David Alfonso Arellano Moraga (29 July 1902, in Santiago, Chile – 3 May 1927, in Valladolid) was a Chilean footballer, founder and martyr of the Colo Colo football club. Played as lefty Insider, was scorer of 1926 South American Championship (Copa América) and is considered one of the better Chilean football players of history.

Familial Mediterranean fever

Familial Mediterranean fever (FMF) is a hereditary inflammatory disorder. FMF is an autoinflammatory disease caused by mutations in Mediterranean fever gene, which encodes a 781–amino acid protein called pyrin. While all ethnic groups are susceptible to FMF, it "usually occurs in people of Mediterranean origin—including Sephardic Jews, Mizrahi Jews, Armenians, Azerbaijanis, Arabs, Kurds, Greeks, Turks, and Italians".The disorder has been given various names, including familial paroxysmal polyserositis, periodic peritonitis, recurrent polyserositis, benign paroxysmal peritonitis, periodic disease or periodic fever, Reimann periodic disease or Reimann syndrome, Siegal-Cattan-Mamou disease, and Wolff periodic disease. Note that "periodic fever" can also refer to any of the periodic fever syndromes.

Feline infectious peritonitis

Feline infectious peritonitis (FIP) is the name given to an uncommon, but usually fatal, aberrant immune response to infection with feline coronavirus (FCoV).

Fitz-Hugh–Curtis syndrome

Fitz-Hugh–Curtis syndrome is a rare complication of pelvic inflammatory disease (PID) involving liver capsule inflammation leading to the creation of adhesions. The condition is named after the two physicians, Thomas Fitz-Hugh, Jr and Arthur Hale Curtis who first reported this condition in 1934 and 1930 respectively.

Gastrointestinal perforation

Gastrointestinal perforation, also known as ruptured bowel, is a hole in the wall of part of the gastrointestinal tract. The gastrointestinal tract includes the esophagus, stomach, small intestine, and large intestine. Symptoms include severe abdominal pain and tenderness. When the hole is in the stomach or early part of the small intestine the onset of pain is typically sudden while with a hole in the large intestine onset may be more gradual. The pain is usually constant in nature. Sepsis, with an increased heart rate, increased breathing rate, fever, and confusion may occur.The cause can include trauma such as from a knife wound, eating a sharp object, or a medical procedure such as colonoscopy, bowel obstruction such as from a volvulus, colon cancer, or diverticulitis, stomach ulcers, ischemic bowel, and a number of infections including C. difficile. A hole allows intestinal contents to enter the abdominal cavity. The entry of bacteria results in a condition known as peritonitis or in the formation of an abscess. A hole in the stomach can also lead to a chemical peritonitis due to gastric acid. A CT scan is typically the preferred method of diagnosis; however, free air from a perforation can often be seen on plain X-ray.Perforation anywhere along the gastrointestinal tract typically requires emergency surgery in the form of an exploratory laparotomy. This is usually carried out along with intravenous fluids and antibiotics. A number of different antibiotics may be used such as piperacillin/tazobactam or the combination of ciprofloxacin and metronidazole. Occasionally the hole can be sewn closed while other times a bowel resection is required. Even with maximum treatment the risk of death can be as high as 50%. A hole from a stomach ulcer occurs in about 1 per 10,000 people per year, while one from diverticulitis occurs in about 0.4 per 10,000 people per year.

Gloria Grahame

Gloria Grahame Hallward (November 28, 1923 – October 5, 1981), known professionally as Gloria Grahame, was an American stage, film, television actress and singer. She began her acting career in theatre, and in 1944 made her first film for MGM. Despite a featured role in It's a Wonderful Life (1946), MGM did not believe she had the potential for major success, and sold her contract to RKO Studios. Often cast in film noir projects, Grahame was nominated for an Academy Award for Best Supporting Actress for Crossfire (1947), and would later win the award for her work in The Bad and the Beautiful (1952). She achieved her highest profile with Sudden Fear (1952), Human Desire (1953), The Big Heat (1953), and Oklahoma! (1955), but her film career began to wane soon afterwards.

Grahame returned to work on the stage, but continued to appear in films and television productions, usually in supporting roles. In 1974, she was diagnosed with breast cancer. It went into remission less than a year later and Grahame returned to work. In 1980, the cancer returned but Grahame refused to accept the diagnosis or seek treatment. Choosing instead to continue working, she traveled to Britain to appear in a play. Her health, however, declined rapidly and she developed peritonitis after undergoing a procedure to remove fluid from her abdomen in September 1981. She returned to New York City, where she died in October 1981.

J. D. B. De Bow

James Dunwoody Brownson De Bow (July 20, 1820 – February 27, 1867) was an American publisher and statistician, best known for his influential magazine De Bow's Review, who also served as head of the U.S. Census from 1853 to 1857.

Jack Darragh

John Proctor "Jack" Darragh (December 4, 1890 – June 28, 1924) was a Canadian professional ice hockey player. Darragh played the forward position for the Ottawa Senators in the National Hockey League (NHL) and its predecessor the National Hockey Association (NHA). Darragh was a member of four Stanley Cup championship teams (1911, 1920, 1921, 1923) and a NHA championship team (1915). Jack is the brother of NHL hockey player Harold Darragh.

James William Good

James William Good (September 24, 1866 – November 18, 1929) was an American politician from the state of Iowa, who served in the U.S. House of Representatives and the Cabinet of President Herbert Hoover as Secretary of War. He was a member of the Republican Party.

Lady Cynthia Mosley

Lady Cynthia Blanche Mosley (23 August 1898 – 16 May 1933), nicknamed "Cimmie", was a British politician of Anglo-American parentage and the first wife of the British Fascist and New Party politician Sir Oswald Mosley, who was a Member of Parliament in the Conservative and Labour parties.

Meconium peritonitis

Meconium peritonitis refers to rupture of the bowel prior to birth, resulting in fetal stool (meconium) escaping into the surrounding space (peritoneum) leading to inflammation (peritonitis). Despite the bowel rupture, many infants born after meconium peritonitis in utero have normal bowels and have no further issues.

Infants with cystic fibrosis are at increased risk for meconium peritonitis.

Peritoneum

The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of mesothelium supported by a thin layer of connective tissue. This peritoneal lining of the cavity supports many of the abdominal organs and serves as a conduit for their blood vessels, lymphatic vessels, and nerves.

The abdominal cavity (the space bounded by the vertebrae, abdominal muscles, diaphragm, and pelvic floor) is different from the intraperitoneal space (located within the abdominal cavity but wrapped in peritoneum). The structures within the intraperitoneal space are called "intraperitoneal" (e.g., the stomach and intestines), the structures in the abdominal cavity that are located behind the intraperitoneal space are called "retroperitoneal" (e.g., the kidneys), and those structures below the intraperitoneal space are called "subperitoneal" or "infraperitoneal" (e.g., the bladder).

Richter's hernia

A Richter's hernia occurs when the antimesenteric wall of the intestine protrudes through a defect in the abdominal wall. This is discrete from other types of abdominal hernias in that only one intestinal wall protrudes through the defect, such that the lumen of the intestine is incompletely contained in the defect, while the rest remains in the peritoneal cavity. If such a herniation becomes necrotic and is subsequently reduced during hernia repair, perforation and peritonitis may result. A Richter's hernia can result in strangulation and necrosis in the absence of intestinal obstruction. It is a relatively rare but dangerous type of hernia.Richter's hernia have also been noted in laparoscopic port-sites, usually when the fascia is not closed for ports larger than 10mm. A high index of suspicion is required in the post operative period as this sinister problem can closely mimic more benign complications like port-site haematomas.Treatment is resection and anastomosis.

Mortality increases with delay in surgical intervention.

Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is the development of a bacterial infection in the peritoneum, despite the absence of an obvious source for the infection. It is specifically an infection of the ascitic fluid – an increased volume of peritoneal fluid. Ascites is most commonly a complication of cirrhosis of the liver. It can also occur in patients with nephrotic syndrome. SBP has a high mortality rate.The diagnosis of SBP requires paracentesis, a sampling of the peritoneal fluid taken from the peritoneal cavity. If the fluid contains large numbers of white blood cells known as neutrophils (>250 cells/µL), infection is confirmed and antibiotics will be given, without waiting for culture results. In addition to antibiotics, infusions of albumin are usually administered.Other life-threatening complications such as kidney malfunction and increased liver insufficiency can be triggered by spontaneous bacterial peritonitis. 30%of SBP patients develop kidney malfunction and is one of the strongest predictors for mortality. Where there are signs of this development albumin infusion will also be given.Spontaneous fungal peritonitis (SFP) can also occur and this can sometimes accompany a bacterial infection.

Diseases of the digestive system (primarily K20–K93, 530–579)
Upper GI tract
Lower GI tract:
Intestinal/
Enteropathy
GI bleeding/BIS
Accessory
Abdominopelvic
Acute
Chronic
Processes
Specific
locations

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