Secondary peritonitis natural history: Difference between revisions

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{{CMG}} {{AE}} {{SCh}}
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==Overview==
==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.
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><ref name="pmid6211996">{{cite journal| author=Berne TV, Yellin AW, Appleman MD, Heseltine PN| title=Antibiotic management of surgically treated gangrenous or perforated appendicitis. Comparison of gentamicin and clindamycin versus cefamandole versus cefoperazone. | journal=Am J Surg | year= 1982 | volume= 144 | issue= 1 | pages= 8-13 | pmid=6211996 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6211996  }} </ref>. 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, which rises to about 40% in the elderly, and/or in those with significant underlying illness, as well as in cases that present late (after 48h). If untreated, generalized peritonitis is almost always fatal.
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==
===Complications related to surgery===
===Hypotension, hypothermia and shock:===
* '''Tertiary peritonitis''' usually follows operative attempts to treat secondary peritonitis and is almost always associated with a systemic inflammatory response. It is a persistent/recurrent infection with organisms of low virulence.
*With the progression of [[infection]], [[septicaemia]] ensues with its classic symptoms and signs. [[Septicaemia]] and [[shock]] are associated with very bad prognosis.
* '''Surgical site infection''' and delayed wound healing- Depends on the degree of contamination. Measures taken to prevent postoperative infections such as peri-operative, systemic antibiotics, and lavage of the wound would not help to prevent this complication. In such instances, the wound should be kept open, and treated with wet-to-dry dressing several times a day. It occurs in 5-15% of patients.
===Altered mental status:===
===Complications related to peritonitis===
*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.
*Intraperitoneal adhesions, leading to bowel obstruction
===Paralytic ileus:===
* Sequestration of [[fluid]] and [[electrolyte]]s, as revealed by decreased [[central venous pressure]], may cause [[electrolyte disturbance]]s, as well as significant [[hypovolaemia]], possibly leading to [[shock]] and [[acute renal failure]].
*[[Peritonitis|Peritoneal inflammation]] can be complicated with [[paralytic ileus]]. [[Paralytic ileus]] is a very poor prognostic sign with increased [[mortality rate]].
* A peritoneal abscess may form (e.g. above or below the [[liver]], or in the lesser [[omentum]]).
===Diarrhea:===
* [[Sepsis]] may develop, so blood cultures should be obtained.
*[[Diarrhea]] occurs due to [[Peritonitis|peritoneal inflammation]] and secondary irritation of the [[intestines]].
* The fluid may push on the diaphragm and cause breathing difficulties
===Renal failure===
* Development of abscess is the leading cause of persistent infection and development of tertiary peritonitis.
*[[Shock]] and [[septicemia]] can develop into [[renal failure]]. [[Renal failure]] can be reversible if proper management is done at timeproper .
* The majority of abscess formation occurs subsequent to secondary peritonitis.The risk of abscess increases to 10-30% in cases of preoperative perforation of the hollow viscus, significant fecal contamination of the peritoneal cavity, bowel ischemia, delayed diagnosis and therapy of the initial peritonitis, and the need for reoperation, as well as in the setting of immunosuppression.
* Tertiary peritonitis: the incidence of tertiary peritonitis in patients requiring ICU admission for severe abdominal infections may be as high as 50-74%.


==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:
Factors affecting prognosis are:
* Age
* Age
* Blood pressure
* [[Blood pressure]]
* Cause of infection
* Cause of infection
* Site of origin of peritonitis
* Site of origin of peritonitis
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* Pre-operative organ failure
* Pre-operative organ failure
* Presence of metabolic acidosis
* Presence of metabolic acidosis
* Serum albumin
* Serum [[Serum albumin|albumin]]
* New York Heart Association cardiac function status
* [[New york heart association functional classification|New York Heart Association]] cardiac function status
* Malnutrition
* [[Malnutrition]]
* Malignoma
* Malignoma
* Fecal peritonitis
* Fecal peritonitis
* Immunosuppression
* 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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