Sandbox: Peritonitis landing page

Jump to navigation Jump to search

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:  ; Shivani Chaparala M.B.B.S [2] For more information related to Primary peritonitis click here
For more information related to Secondary peritonitis click here

Overview

Peritonitis defined as inflammation of peritoneum (a serosal membrane lining the abdominal cavity and abdominal viscera) is associated with a higher 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 (result of alcoholism), and peritoneal dialysis associated peritonitis. Peritonitis is an emergency medical/surgical condition that requires prompt medical attention and treatment.

Primary or Spontaneous bacterial peritonitis Secondary Peritonitis Tertiary Peritonitis
  • Primary peritonitis/ spontaneous bacterial peritonitis (SBP) represents a group of diseases with numerous causes characterized by ascitic fluid infection of the peritoneal cavity without an evident surgically treatable intra-abdominal source of infection. It is usually associated with cirrhosis and ascites in adults.[1] Primary peritonitis lacks an identifiable anatomical derangement.
  • Secondary peritonitis is defined as infection of the peritoneum due to spillage of organisms into the peritoneal cavity resulting from hollow viscus perforation, anastomotic leak, ischemic necrosis, or other injuries of the gastrointestinal tract.[2][3]
  • Tertiary peritonitis is defined as the persistant or recurrent intra-abdominal infection that occur in ≥48 hours following the successful and adequate surgical source control of primary or secondary peritonitis.[2][4][5][6]

Peritonitis may be classified according to the etiology into 3 subtypes: primary, secondary, and tertiary peritonitis.

Classification Based on Etiology

Peritonitis is classified based on the cause of the inflammatory process and the character of microbial contamination as follows:[3][5][6]

 
 
 
 
 
 
 
 
Peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary peritonitis
 
 
 
 
Secondary peritonitis
 
 
 
 
Tertiary peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Spontaneous peritonitis
❑ Peritonitis in patients with continuous ambulatory peritoneal dialysis (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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Causes

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Causes of peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infectious
 
 
 
 
 
 
 
Non-Infectious
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary
 
 
 
 
 
 
Secondary
 
 
 
Chemical
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Common organisms
 
 
Uncommon organisms
 
 
 
 
❑ Gram-negative organisms like E.coli, Klebsiella
❑ Anaerobes
❑ Fungi such as Candida
 
Peritonitis induced by sterile body fluids
 
Uncommon causes of chemical peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ E.Coli
❑ Klebsiella
❑ Streptococcus pneumonia
❑ Enterococcus
 
 
❑ Staphylococcus
❑ Streptococcus salivarias
 
 
 
 
 
 
 
 
Blood(e.g.Endometriosis,Blunt abdominal trauma)
Gastric juice (e.g.Peptic ulcer, Gastric carcinoma)
Bile (e.g. Liver biopsy)
Urine (e.g. Pelvic trauma)
Menstruum (e.g. salpingitis)
Pancreatic juice (pancreatitis)
 
Familial Mediterranean fever
Porphyria
Systemic lupus erythematosus
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Risk Factors

The following factors may increase the risk of peritonitis:

  • Penetrating trauma to the intestine
  • Twisted intestine
  • Inflammation of the hollow viscera of the abdomen
  • Surgical injuries to the abdominal viscera
  • Liver disease (Cirrhosis)
  • Pelvic inflammatory disease
  • Leakage of sterile body fluids into the peritoneum, such as blood (endometriosis), gastric acid (peptic ulcer), bile( liver biopsy), urine(pelvic trauma), menstruum( salpingitis),pancreatic juice (pancreatitis).
  • Peritoneal dialysis
  • Extra peritoneal tuberculous infection

Common risk factors for peritonitis are described as follows:[7]

Primary Peritonitis Secondary Peritonitis Tertiary Peritonitis
  • Cirrhosis with ascitis
  • Portal hypertension with ascitis
  • Patient with continuous ambulatory peritoneal dialysis (CAPD)
  • Ruptured gastric ulcer, appendicular abscess or diverticular abscess
  • Inflamatory bowel diseases such as chron's disease or ulcerative colitis with toxic megacolon
  • Pelvic inflamatory disease
  • Recent surgical procedures
  • Recent trauma to the abdomen (e.g. Stab injury or gun shot injury)
  • Previous history of severe antibiotic use
  • Treatment failure in patients with primary or secondary peritonitis

Approach to peritonitis

Approach to the diagnosis and management of peritonitis.[8]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patent with signs and symptoms suggestive of peritonitis
❑ Abdominal pain ± guarding or rebound
❑ Fever, leukocytosis
❑ Signs of sepsis (hypotension, tachycardia, etc.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diffuse Peritonitis
 
 
 
 
 
 
 
 
 
Localized peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluation for GI pathology and potential secondary peritonitis based on history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If negative Consider Primary Peritonitis
 
 
 
 
 
 
 
 
 
If positive
Suspect Secondary peritonitis
 
 
 
Secondary peritonitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Peritoneal dialysis
 
 
 
 
 
 
 
Ascites
 
 
 
 
 
 
Obtain supine and erect abdominal X-rays
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Drain peritoneal fluid and irrigate 2-3 times
 
 
 
 
 
 
 
Diagnostic paracentesis
 
 
 
 
 
 
Free air?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Send peritoneal fluid for Gram stain and culture, cell count with differential and pH
❑ Initiate general supportive care
Initiate empiric antibiotic coverage according to most likely pathogen
 
 
 
 
 
 
 
 
 
 
 
No free air under the diaphragm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monomicrobial Gram stain or culture
❑ Tailor antibiotics and continue for 7 days
 
 
 
 
 
 
 
 
Polymicrobial Gram stain or culture or presence of bile or fecal material in peritoneal fluid
❑ Broaden antibiotic coverage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Condition resolved
 
 
 
 
 
 
 
Condition does not resolve:
❑ Re-culture,
❑ Adjust antibiotics
❑ Remove indwelling catheters
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continue workup for:
❑ Cholecystitis, pancreatitis
❑ Diverticulitis, colitis, ileitis
❑ Pelvic inflammatory disease or other gynecologic causes
❑ Other non-GI causes
Tests include:
CT-scan
Abdominal ultrasound
Laboratory tests such as: Serum amylase, lipase, bilurubin, alk. phosphotase, lactate, urinalysis and beta-HCG, stool WBC and culture, Clostridium difficile toxin assay and others
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
← ← ← ←
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Peritoneal abscess?
❑ No clear indications for operation?
❑ Drainage possible through percutaneous approach?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Indication for operation?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If YES
 
 
 
 
 
 
 
If NO
 
 
 
 
 
 
 
 
 
If YES
 
 
 
 
 
 
 
If NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Percutaneous drainage of abscess
 
 
 
 
 
 
 
 
 
 
 
 
 
Depending on the severity of the disease, prepare patient for emergent laparotomy
Goals of operative approach
❑ Eliminate pathologic process
❑ Reduce bacterial contamination
❑ Provide adequate drainage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continue conservative therapy and antibiotics until:
❑ Symptoms resolved
❑ Afebrile ≥ 48 hours
❑ Normal WBC count
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Condition resolved
 
 
 
 
 
 
 
 
 
 
 
Condition does not resolve:
❑ Persistent or new pathologic process?
❑ Tertiary peritonitis or abscess?
→ → → →
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



References

  1. Wiest R, Krag A, Gerbes A (2012) Spontaneous bacterial peritonitis: recent guidelines and beyond. Gut 61 (2):297-310. DOI:10.1136/gutjnl-2011-300779 PMID: 22147550
  2. 2.0 2.1 Calandra T, Cohen J, International Sepsis Forum Definition of Infection in the ICU Consensus Conference (2005) The international sepsis forum consensus conference on definitions of infection in the intensive care unit. Crit Care Med 33 (7):1538-48. PMID: 16003060
  3. 3.0 3.1 Wittmann DH, Schein M, Condon RE (1996) Management of secondary peritonitis. Ann Surg 224 (1):10-8. PMID: 8678610
  4. Evans HL, Raymond DP, Pelletier SJ, Crabtree TD, Pruett TL, Sawyer RG (2001) Tertiary peritonitis (recurrent diffuse or localized disease) is not an independent predictor of mortality in surgical patients with intraabdominal infection. Surg Infect (Larchmt) 2 (4):255-63; discussion 264-5. DOI:10.1089/10962960152813296 PMID: 12593701
  5. 5.0 5.1 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
  6. 6.0 6.1 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
  7. Li PK, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE et al. (2016) ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment. Perit Dial Int 36 (5):481-508. DOI:10.3747/pdi.2016.00078 PMID: 27282851
  8. European Association for the Study of the Liver (2010). "EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis". J Hepatol. 53 (3): 397–417. doi:10.1016/j.jhep.2010.05.004. PMID 20633946.