Secondary peritonitis natural history: Difference between revisions

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==Overview==
==Overview==
With treatment, patients usually do well. Without treatment, the outcome is usually poor. However, in some cases, patients do poorly even with prompt and appropriate treatment.
==Natural History==
==Natural History==
Secondary peritonitis is the initial phase of infection after intestinal perforation which can progress to abscess, if left untreated. Severe abdominal infections are invariably progress to a high level of sepsis, endotoxin production and systemic inflammatory response syndrome (SIRS), which often results in multiple organ failure.<ref name="pmid15846719">{{cite journal| author=Wong PF, Gilliam AD, Kumar S, Shenfine J, O'Dair GN, Leaper DJ| title=Antibiotic regimens for secondary peritonitis of gastrointestinal origin in adults. | journal=Cochrane Database Syst Rev | year= 2005 | volume=  | issue= 2 | pages= CD004539 | pmid=15846719 | doi=10.1002/14651858.CD004539.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15846719  }} </ref>
With treatment, patients usually do well. Without treatment, the outcome is usually poor. However, in some cases, patients do poorly even with prompt and appropriate treatment.


==Complications==
==Complications==
===Hypotension, hypothermia and shock:===
*With the progression of [[infection]], [[septicaemia]] ensues with its classic symptoms and signs. [[Septicaemia]] and [[shock]] are associated with very bad prognosis.
===Altered mental status:===
*With the progression of [[shock]], blood supply to the [[brain]] might be compromised leading to [[altered mental status]]. Associated [[comorbidities]] and poor general status make the development of [[altered mental status]] more likely.
===Paralytic ileus:===
*[[Peritonitis|Peritoneal inflammation]] can be complicated with [[paralytic ileus]]. [[Paralytic ileus]] is a very poor prognostic sign with increased [[mortality rate]].
===Diarrhea:===
*[[Diarrhea]] occurs due to [[Peritonitis|peritoneal inflammation]] and secondary irritation of the [[intestines]].
===Renal failure===
*[[Shock]] and [[septicemia]] can develop into [[renal failure]]. [[Renal failure]] can be reversible if proper management is done at timeproper .
==Prognosis==
==Prognosis==
Peritonitis is a frequent cause of [[morbidity]].The prognosis greatly depends on the degree of [[Intra-abdominal infection|intra-abdominal contamination]], the severity of underlying disease, the [[immune response]] of the host and associated organ dysfunction.<ref name="MulierPenninckx2003">{{cite journal|last1=Mulier|first1=Stefaan|last2=Penninckx|first2=Freddy|last3=Verwaest|first3=Charles|last4=Filez|first4=Ludo|last5=Aerts|first5=Raymond|last6=Fieuws|first6=Steffen|last7=Lauwers|first7=Peter|title=Factors Affecting Mortality in Generalized Postoperative Peritonitis: Multivariate Analysis in 96 Patients|journal=World Journal of Surgery|volume=27|issue=4|year=2003|pages=379–384|issn=0364-2313|doi=10.1007/s00268-002-6705-x}}</ref>
Associated [[Mortality rate|mortality rates]] vary from less than 1% to more than 60%
Factors affecting prognosis are:
* Age
* [[Blood pressure]]
* Cause of infection
* Site of origin of peritonitis
* Number of organs involved in multi-organ-failure (MOF)
* Pre-operative organ failure
* Presence of metabolic acidosis
* Serum [[Serum albumin|albumin]]
* [[New york heart association functional classification|New York Heart Association]] cardiac function status
* [[Malnutrition]]
* Malignoma
* Fecal peritonitis
* Immunosuppression
''The prognosis risk of [[peritonitis]] may be stratified using the '''[[Mannheim's Peritoneal index score (MPI)|Mannheim's Peritoneal index score (MPI]])''' as shown below'':<ref name="pmid27843277">{{cite journal| author=Sharma S, Singh S, Makkar N, Kumar A, Sandhu MS| title=Assessment of Severity of Peritonitis Using Mannheim Peritonitis Index. | journal=Niger J Surg | year= 2016 | volume= 22 | issue= 2 | pages= 118-122 | pmid=27843277 | doi=10.4103/1117-6806.189009 | pmc=5013738 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27843277  }} </ref><ref name="pmid8645072">{{cite journal| author=Pacelli F, Doglietto GB, Alfieri S, Piccioni E, Sgadari A, Gui D et al.| title=Prognosis in intra-abdominal infections. Multivariate analysis on 604 patients. | journal=Arch Surg | year= 1996 | volume= 131 | issue= 6 | pages= 641-5 | pmid=8645072 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8645072  }} </ref>
{| class="wikitable"
!Riskfactor
!Score
|-
|Age >50 years
|5
|-
|Female sex
|5
|-
|[[Organ failure]]
|7
|-
|[[Malignancy]]
|4
|-
|Origin of [[sepsis]] not colonic
|4
|-
|Diffuse generalized peritonitis
|6
|-
|Preoperative duration of peritonitis >24h
|4
|-
|[[Exudate|Intraperitoneal exudates]]
* Clear
* Cloudy, purulent
* Fecal
|
* 0
* 6
* 12
|-
|}


===Assessment of the prognosis of patients with peritonitis using [[Mannheim's Peritoneal index score (MPI)|Mannheim Peritonitis Index (MPI)]]===
*For a score of 27, the sensitivity was 66.67%, specificity was 100%, and positive predictive value for mortality is 100% at an accuracy of 94%.<ref name="pmid27843277">{{cite journal| author=Sharma S, Singh S, Makkar N, Kumar A, Sandhu MS| title=Assessment of Severity of Peritonitis Using Mannheim Peritonitis Index. | journal=Niger J Surg | year= 2016 | volume= 22 | issue= 2 | pages= 118-122 | pmid=27843277 | doi=10.4103/1117-6806.189009 | pmc=5013738 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27843277  }} </ref>
{| border="1"
| colspan="3" |'''Assessment of severity of peritonitis using MPI'''
|-
!'''Score'''!! Mortality rate !! Morbidity rate
|-
|align=center|<21
|align=center|0%
|align=center|13.33%
|-
|align=center| 21-27
| align= center|27.28%
| align=center|65.71%
|-
|align=center| >27
| align=center|100%
|align=center|100%
|}
''Factors that were found to be independently significant factors in predicting the [[mortality]]'':
* Duration of pain for >24 h
* [[Organ failure]] on admission
* Female sex and
* Feculent exudate
*Early prognostic evaluation of [[Intra-abdominal infection|abdominal sepsis]] is useful in the assessment of the severity of the disease and to select high-risk patients for early surgical reintervention.


==References==
==References==
{{reflist|2}}
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Gastroenterology]]
[[Category:Surgery]]

Latest revision as of 00:07, 30 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shivani Chaparala M.B.B.S [2]

Overview

With treatment, patients usually do well. Without treatment, the outcome is usually poor. However, in some cases, patients do poorly even with prompt and appropriate treatment.

Natural History

With treatment, patients usually do well. Without treatment, the outcome is usually poor. However, in some cases, patients do poorly even with prompt and appropriate treatment.

Complications

Hypotension, hypothermia and shock:

Altered mental status:

Paralytic ileus:

Diarrhea:

Renal failure

Prognosis

Peritonitis is a frequent cause of morbidity.The prognosis greatly depends on the degree of intra-abdominal contamination, the severity of underlying disease, the immune response of the host and associated organ dysfunction.[1] Associated mortality rates vary from less than 1% to more than 60% Factors affecting prognosis are:

  • Age
  • Blood pressure
  • Cause of infection
  • Site of origin of peritonitis
  • Number of organs involved in multi-organ-failure (MOF)
  • Pre-operative organ failure
  • Presence of metabolic acidosis
  • Serum albumin
  • New York Heart Association cardiac function status
  • Malnutrition
  • Malignoma
  • Fecal peritonitis
  • Immunosuppression

The prognosis risk of peritonitis may be stratified using the Mannheim's Peritoneal index score (MPI) as shown below:[2][3]

Riskfactor Score
Age >50 years 5
Female sex 5
Organ failure 7
Malignancy 4
Origin of sepsis not colonic 4
Diffuse generalized peritonitis 6
Preoperative duration of peritonitis >24h 4
Intraperitoneal exudates
  • Clear
  • Cloudy, purulent
  • Fecal
  • 0
  • 6
  • 12

Assessment of the prognosis of patients with peritonitis using Mannheim Peritonitis Index (MPI)

  • For a score of 27, the sensitivity was 66.67%, specificity was 100%, and positive predictive value for mortality is 100% at an accuracy of 94%.[2]
Assessment of severity of peritonitis using MPI
Score Mortality rate Morbidity rate
<21 0% 13.33%
21-27 27.28% 65.71%
>27 100% 100%

Factors that were found to be independently significant factors in predicting the mortality:

  • Duration of pain for >24 h
  • Organ failure on admission
  • Female sex and
  • Feculent exudate
  • Early prognostic evaluation of abdominal sepsis is useful in the assessment of the severity of the disease and to select high-risk patients for early surgical reintervention.

References

  1. ↑ Mulier, Stefaan; Penninckx, Freddy; Verwaest, Charles; Filez, Ludo; Aerts, Raymond; Fieuws, Steffen; Lauwers, Peter (2003). "Factors Affecting Mortality in Generalized Postoperative Peritonitis: Multivariate Analysis in 96 Patients". World Journal of Surgery. 27 (4): 379–384. doi:10.1007/s00268-002-6705-x. ISSN 0364-2313.
  2. ↑ 2.0 2.1 Sharma S, Singh S, Makkar N, Kumar A, Sandhu MS (2016). "Assessment of Severity of Peritonitis Using Mannheim Peritonitis Index". Niger J Surg. 22 (2): 118–122. doi:10.4103/1117-6806.189009. PMC 5013738. PMID 27843277.
  3. ↑ Pacelli F, Doglietto GB, Alfieri S, Piccioni E, Sgadari A, Gui D; et al. (1996). "Prognosis in intra-abdominal infections. Multivariate analysis on 604 patients". Arch Surg. 131 (6): 641–5. PMID 8645072.
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