Sandbox22: Difference between revisions

Jump to navigation Jump to search
 
(17 intermediate revisions by the same user not shown)
Line 3: Line 3:
{{CMG}};{{AE}}{{MehdiP}}
{{CMG}};{{AE}}{{MehdiP}}
==Overview==
==Overview==
[[Altered mental status classification#Classification|Peritonitis]] defined as [[inflammation]] of [[peritoneum]] (serosal membrane lining the [[abdominal cavity]] and abdominal viscera) and is associated with high mortality rate secondary to [[bacteremia]] and [[sepsis syndrome]]. Most common cause of peritonitis in approximately 80% adults is [[perforation]] of the [[Gastrointestinal tract|gastrointestinal]] or [[biliary tract]]. Other less common causes include [[liver cirrhosis]], and [[peritoneal dialysis]] associated peritonitis. Peritonitis can also result from injury, contamination with microorganisms, chemicals or both. It may be localized or generalized, and can have an acute course in infection secondary to rupture of a hollow viscus or follows a chronic course as seen in [[Tuberculosis|tuberculous]] peritonitis. Patients present with severe [[abdominal pain]] associated with [[fever]], [[chills]], [[nausea and vomiting]]. Peritonitis must be differentiated from other diseases affecting the peritoneum such as peritoneal [[abscess]], peritoneal [[mesothelioma]] and [[peritoneal carcinomatosis]] which presents with [[ascites]] and [[abdominal pain]]. Peritonitis is a emergency medical condition requiring prompt medical attention and treatment.


==Causes==
==Causes==
Line 10: Line 11:
|
|
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
! colspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |
!align="center" style="background:#4479BA; color: #FFFFFF;" |
!align="center" style="background:#4479BA; color: #FFFFFF;" |Common causes
!align="center" style="background:#4479BA; color: #FFFFFF;" |Common causes
!align="center" style="background:#4479BA; color: #FFFFFF;" |Less common causes
!align="center" style="background:#4479BA; color: #FFFFFF;" |Less common causes
!align="center" style="background:#4479BA; color: #FFFFFF;" |Comment
|-
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Spontaneous bacterial peritonitis]]
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Spontaneous bacterial peritonitis]]
Line 23: Line 25:
* [[Streptococcus salivarius]]
* [[Streptococcus salivarius]]
* Poly-microbial infection
* Poly-microbial infection
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |To see a complete list of causes, click [[Spontaneous bacterial peritonitis causes|here]].
|-
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Secondary peritonitis]]
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Secondary peritonitis]]
Line 35: Line 38:
* [[Enterococcus]]
* [[Enterococcus]]
* [[Candida]]
* [[Candida]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |To see a complete list of causes, click [[Secondary peritonitis causes|here]].
|}
<br>
|}
|}


==Classification==
==Classification==
Peritonitis is classified based on the cause of the inflammatory process and the character of microbial contamination as follows:<ref name="pmid8678610">{{cite journal| author=Wittmann DH, Schein M, Condon RE| title=Management of secondary peritonitis. | journal=Ann Surg | year= 1996 | volume= 224 | issue= 1 | pages= 10-8 | pmid=8678610 | doi= | pmc=1235241 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8678610  }} </ref><ref name="pmid9451931">Nathens AB, Rotstein OD, Marshall JC (1998) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9451931 Tertiary peritonitis: clinical features of a complex nosocomial infection.] ''World J Surg'' 22 (2):158-63. PMID: [https://pubmed.gov/9451931 9451931]</ref><ref name="pmid24812458">Mishra SP, Tiwary SK, Mishra M, Gupta SK (2014) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=24812458 An introduction of Tertiary Peritonitis.] ''J Emerg Trauma Shock'' 7 (2):121-3. [http://dx.doi.org/10.4103/0974-2700.130883 DOI:10.4103/0974-2700.130883] PMID: [https://pubmed.gov/24812458 24812458]</ref>
<br>
{| align="center"
|-
|
{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Peritonitis}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01='''Primary peritonitis'''|C02='''Secondary peritonitis'''|C03='''Tertiary peritonitis'''}}
{{familytree | | |!| | | | | | |!| | | | | | |!| }}
{{familytree |boxstyle=text-align: left; | | B01 | | | | | |!| | | | | | B02 |B01= ❑ Spontaneous peritonitis<br>❑ Peritonitis in patients with CAPD<br>❑ Tuberculous peritonitis |B02= ❑ Peritonitis without evidence for pathogens<br>❑ Peritonitis with fungi<br>❑ Peritonitis with low-grade pathogenic bacteria}}
{{familytree | | | | |,|-|-|-|-|+|-|-|-|-|.| | | | | }}
{{familytree | | | | |!| | | | |!| | | | |!| | | | | | }}
{{familytree |boxstyle=text-align: left; | | | | D02 | | | D03 | | | D04 | | |D02='''Acute perforation peritonitis'''<br>❑ Gastrointestinal perforation<br>❑ Intestinal ischemia<br>❑ Pelviperitonitis and other forms|D03='''Postoperative peritonitis'''<br>❑ Anastomotic leak<br>❑ Accidental perforation and devascularization|D04='''Post-traumatic peritonitis'''<br>❑ After blunt abdominal trauma<br>❑ After penetrating abdominal trauma}}
{{familytree | | | | | | | | | | | | | | | | | | | }}
{{familytree/end}}
<br>
|}
==Differential diagnosis==
{| align="center"
|-
|
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
! colspan="2" rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" | Classification of acute abdomen based on etiology
! colspan="1" rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Presentation
! colspan="3" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Symptoms
! colspan="3" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Signs
! colspan="2" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Diagnosis
! colspan="1" rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" | Comments
|-
! colspan="1" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Fever
! align="center" style="background:#4479BA; color: #FFFFFF;" |Abdominal Pain
! align="center" style="background:#4479BA; color: #FFFFFF;" |Jaundice
! colspan="1" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Guarding
! align="center" style="background:#4479BA; color: #FFFFFF;" |Rebound Tenderness
! align="center" style="background:#4479BA; color: #FFFFFF;" |Bowel sounds
! colspan="1" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" | Lab Findings
! align="center" style="background:#4479BA; color: #FFFFFF;" |Imaging
|-
! colspan="1" rowspan="8" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Common causes of Peritonitis
! colspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Primary Peritonitis
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Spontaneous bacterial peritonitis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Ascitic fluid [[PMN]]>250 cells/mm<small>³</small>


==Differential diagnosis==
* Culture: Positive for single organism
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound for evaluation of liver cirrhosis
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|-
! colspan="1" rowspan="7" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Secondary Peritonitis
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Perforated [[Gastric ulcer|gastric]] and [[duodenal ulcer]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | Diffuse
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Ascitic fluid
** [[LDH]] > serum [[LDH]]
 
** Glucose < 50mg/dl
 
** Total protein > 1g/dl
 
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Air under [[diaphragm]] in upright [[CXR]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Upper GI [[endoscopy]] for diagnosis
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Acute cholangitis
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | [[RUQ]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Abnormal [[LFT]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows [[biliary]] dilatation
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Biliary drainage ([[Endoscopic retrograde cholangiopancreatography|ERCP]]) + IV antibiotics
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Acute Cholecystitis|Acute cholecystitis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | [[RUQ]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Hyperbilirubinemia]]
* [[Leukocytosis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows gallstone and evidence of inflammation
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Murphy's sign|Murphy’s sign]]
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |  [[Acute pancreatitis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | [[Epigastric]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +/-
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[amylase]] / [[lipase]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows evidence of [[inflammation]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Pain radiation to back
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Acute appendicitis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | RLQ
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows evidence of [[inflammation]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]], [[decreased appetite]]
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Diverticulitis|Acute diverticulitis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | LLQ
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +/-
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan and ultrasound shows evidence of inflammation
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Salpingitis|Acute salpingitis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | LLQ/ RLQ
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +/-
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +/-
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Pelvic ultrasound]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Vaginal discharge]]
|-
! colspan="2" rowspan="4" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Hollow Viscous Obstruction
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Small intestine obstruction
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | +/-
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive then absent
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Abdominal X-ray|Abdominal X ray]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]] associated with [[constipation]], [[Abdominal distension|abdominal distention]]
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Volvulus]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan and [[Abdominal x-ray|abdominal X ray]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]] associated with [[constipation]], [[Abdominal distension|abdominal distention]]
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Biliary colic]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |RUQ
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |+
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[bilirubin]] and [[alkaline phosphatase]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]]
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Renal colic]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Flank pain]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Hematuria]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan and ultrasound
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Colicky [[abdominal pain]] associated with [[Nausea and vomiting|nausea & vomiting]]
|-
! rowspan="4" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Vascular Disorders
! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Ischemic causes
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Mesenteric ischemia]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+/-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Periumbilical
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]] and [[lactic acidosis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]], normal physical examination
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Ischemic colitis|Acute ischemic colitis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+/-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive then absent
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]]
|-
! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Hemorrhagic causes
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Ruptured abdominal aortic aneurysm]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Normal
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Unstable hemodynamics
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |Intra-abdominal or [[retroperitoneal hemorrhage]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Anemia]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |History of [[trauma]]
|-
! rowspan="3" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Gynaecological Causes
! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Ovarian cyst|Ovarian Cyst]] Complications
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |Torsion of the cyst
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |RLQ / LLQ
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+/-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+/-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[ESR]] and [[CRP]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Sudden onset sever pain with [[nausea and vomiting]]
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |Cyst rupture
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |RLQ / LLQ
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+/-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+/-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[ESR]] and [[CRP]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Sudden onset sever pain with [[nausea and vomiting]]
|-
!style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pregnancy
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |Ruptured [[ectopic pregnancy]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |RLQ / LLQ
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Positive [[pregnancy test]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |History of missed period and [[vaginal bleeding]]
|-
|}


==References==
==References==
{{reflist|2}}
{{reflist|2}}|}|}

Latest revision as of 14:48, 9 May 2017

Peritonitis Main Page

Patient Information

Overview

Causes

Classification

Spontaneous Bacterial Peritonitis
Secondary Peritonitis

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

Peritonitis defined as inflammation of peritoneum (serosal membrane lining the abdominal cavity and abdominal viscera) and is associated with high mortality rate secondary to bacteremia and sepsis syndrome. Most common cause of peritonitis in approximately 80% adults is perforation of the gastrointestinal or biliary tract. Other less common causes include liver cirrhosis, and peritoneal dialysis associated peritonitis. Peritonitis can also result from injury, contamination with microorganisms, chemicals or both. It may be localized or generalized, and can have an acute course in infection secondary to rupture of a hollow viscus or follows a chronic course as seen in tuberculous peritonitis. Patients present with severe abdominal pain associated with fever, chills, nausea and vomiting. Peritonitis must be differentiated from other diseases affecting the peritoneum such as peritoneal abscess, peritoneal mesothelioma and peritoneal carcinomatosis which presents with ascites and abdominal pain. Peritonitis is a emergency medical condition requiring prompt medical attention and treatment.

Causes


Common causes Less common causes Comment
Spontaneous bacterial peritonitis To see a complete list of causes, click here.
Secondary peritonitis To see a complete list of causes, click here.


Classification

Peritonitis is classified based on the cause of the inflammatory process and the character of microbial contamination as follows:[1][2][3]

 
 
 
 
 
 
 
 
Peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary peritonitis
 
 
 
 
Secondary peritonitis
 
 
 
 
Tertiary peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Spontaneous peritonitis
❑ Peritonitis in patients with CAPD
❑ Tuberculous peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
❑ Peritonitis without evidence for pathogens
❑ Peritonitis with fungi
❑ Peritonitis with low-grade pathogenic bacteria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute perforation peritonitis
❑ Gastrointestinal perforation
❑ Intestinal ischemia
❑ Pelviperitonitis and other forms
 
 
Postoperative peritonitis
❑ Anastomotic leak
❑ Accidental perforation and devascularization
 
 
Post-traumatic peritonitis
❑ After blunt abdominal trauma
❑ After penetrating abdominal trauma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Differential diagnosis

Classification of acute abdomen based on etiology Presentation Symptoms Signs Diagnosis Comments
Fever Abdominal Pain Jaundice Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Common causes of Peritonitis Primary Peritonitis Spontaneous bacterial peritonitis + Diffuse - - - Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
Ultrasound for evaluation of liver cirrhosis -
Secondary Peritonitis Perforated gastric and duodenal ulcer + Diffuse - + + N
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis
Acute cholangitis + RUQ + - - N Abnormal LFT Ultrasound shows biliary dilatation Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis + RUQ + - - Hypoactive Ultrasound shows gallstone and evidence of inflammation Murphy’s sign
Acute pancreatitis + Epigastric +/- - - N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back
Acute appendicitis + RLQ - + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite
Acute diverticulitis + LLQ +/- + - Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation
Acute salpingitis + LLQ/ RLQ - +/- +/- N Leukocytosis Pelvic ultrasound Vaginal discharge
Hollow Viscous Obstruction Small intestine obstruction - Diffuse - + +/- Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Volvulus - Diffuse - + - Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Biliary colic - RUQ + - - N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting
Renal colic - Flank pain - - - N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting
Vascular Disorders Ischemic causes Mesenteric ischemia +/- Periumbilical - - - Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination
Acute ischemic colitis +/- Diffuse - + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting
Hemorrhagic causes Ruptured abdominal aortic aneurysm - Diffuse - - - N Normal CT scan Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage - Diffuse - - - N Anemia CT scan History of trauma
Gynaecological Causes Ovarian Cyst Complications Torsion of the cyst - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Cyst rupture - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Pregnancy Ruptured ectopic pregnancy - RLQ / LLQ - - - N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding

References

  1. Wittmann DH, Schein M, Condon RE (1996). "Management of secondary peritonitis". Ann Surg. 224 (1): 10–8. PMC 1235241. PMID 8678610.
  2. Nathens AB, Rotstein OD, Marshall JC (1998) Tertiary peritonitis: clinical features of a complex nosocomial infection. World J Surg 22 (2):158-63. PMID: 9451931
  3. Mishra SP, Tiwary SK, Mishra M, Gupta SK (2014) An introduction of Tertiary Peritonitis. J Emerg Trauma Shock 7 (2):121-3. DOI:10.4103/0974-2700.130883 PMID: 24812458
|}|}