Secondary peritonitis overview

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Differentiating Secondary peritonitis from other Diseases
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Natural History, Complications and Prognosis
Diagnosis
History & Symptoms
Physical Examination
Laboratory Findings
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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]
Synonyms and keywords:: Surgical peritonitis, Perforation peritonitis, Acute peritonitis, Acute bacterial peritonitis, Acute generalized peritonitis, Abscess of suppurative peritonitis, Purulent peritonitis, Chemical peritonitis, Peritoneal abscess.

Overview

Secondary peritonitis is the most common cause of peritonitis, seen in 80-90% of patients, as a result of inflammation, perforation, or gangrene of an intra-abdominal or retroperitoneal organ. Surgical intervention is typically required to treat these processes. Antibiotics play an adjunctive role in severe intra-abdominal infection. If left untreated, patients with secondary peritonitis usually die due to life-threatening sepsis and shock.

Definition

Secondary peritonitis is defined as the 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.

Historical perspective

• Mikulicz 1889; Krönlein 1885; Körte 1892 reported the surgical treatment of peritonitis.
• Kirschner in 1926 was the first to demonstrate a reduction in mortality rate by surgical treatment from 80–100% to about 60% in 1926.

Classification

Secondary peritonitis is classified based on the etiology and extension of inflammation.

Secondary peritonitis

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

Pathophysiology

Disturbances in the intestinal mucosal barrier as a result of spontaneous disease, trauma, or surgical operations permit the escape of indigenous bacteria causing infection of the peritoneum.

Causes

Causes by source

Infected Secondary Peritonitis		Non-infected Secondary Peritonitis
Perforation of a hollow viscus organ	Disruption of the peritoneum	Leakage of sterile body fluids into the peritoneum	Sterile abdominal surgery	Rarer non-infectious causes
Perforation of a hollow viscus (most common cause of peritonitis) Perforation of the distal esophagus (Boerhaave syndrome) Perforation of the stomach (peptic ulcer, Gastric carcinoma) Perforation of the duodenum (peptic ulcer) Perforations of the remaining intestine (e.g. Appendicitis, Diverticulitis, Meckel diverticulum, IBD, Intestinal infarction, Intestinal strangulation, Colorectal carcinoma, Meconium peritonitis) Perforation of the gallbladder (cholecystitis) Other possible causes for perforation Trauma Ingestion of a sharp foreign body (such as a fish bone) Perforation by an endoscope or catheter Most common organisms: mixed bacteria Gram-negative bacilli (e.g. Escherichia coli), Anaerobic bacteria (e.g. Bacteroides fragilis)	Trauma Surgical wound Peritoneal dialysis Chemotherapy Most common organisms Mixed bacteria Staphylococcus aureus Coagulase-negative staphylococci Fungi such as Candida	Sterile body fluids such as 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), These body fluids are sterile at first, they frequently become infected once they leak out of their organ, leading to infectious peritonitis within 24-48h.	Due to sterile foreign body inadvertently left in the abdomen after surgery (e.g. gauze, sponge)	Familial Mediterranean fever Porphyria Systemic lupus erythematosus

Differentiating Secondary peritonitis from other conditions

Differentiating secondary peritonitis from spontaneous bacterial peritonitis

Characteristic	Spontaneous bacterial peritonitis	Secondary peritonitis
Presentaion	Main manifestations of peritonitis are acute abdominal pain, tenderness, and guarding, which are exacerbated by moving the peritoneum, e.g. coughing, flexing the hips,or Blumberg sign (a.k.a. rebound tenderness)	Similar presentation but insidious onset unlike rapid onset in SBP
Microorganism	Monomicrobial involvement is common No identifiable source of intra-abdominal infection	Polymicrobial involvement is common Identifiable source of intra-abdominal infection, with or without perforation (surgically treatable source)
Diagnostic Criteria	SBP is diagnosed in the presence of: Ascitic fluid PMN count of  ≥250/mm3 No evident intra-abdominal source of infection Positive ascitic fluid bacterial culture	Diagnosed in the presence of Positive ascitic fluid bacterial culture Ascitic fluid PMN count of ≥250/mm3 Evidence of a source of infection (demonstrated at surgery or autopsy], either intra-abdominal or contiguous with the peritoneal cavity
Follow-up paracentesis	Ascitic fluid usually became sterile after one dose of antibiotic	Failure of the ascitic fluid to become culture-negative despite of initial antibiotic treatment, appears to be typical of secondary peritonitis due to continuous spillage of organisms into abdominal cavity which requires surgery.

Risk Factors

Risk factors of Secondary peritonitis are numerous intraabdominal disorders involving the gastrointestinal or genitourinary tract with spillage of material into the peritoneal space.

Natural History, Complications and Prognosis

The prognosis and outcome of patients with postoperative peritonitis is directly related to early diagnosis and stringent treatment interventions along with the complex interaction of factors related to: patient, disease and intervention and the chronic health status. Septicemia, shock and renal failure account for life threatening complications of peritonitis.The mortality of generalized postoperative peritonitis is high at 22-55%. Inability to clear the abdominal infection or to control the septic source, older age, and unconsciousness were significant factors related to mortality. Failure to control the peritoneal infection (15%) increases fatality and correlates with failed septic source control, high Acute Physiology and Chronic Health Evaluation (APACHE) II score, and male gender. Failure to control the septic source (8%) also was always fatal and correlated with high APACHE II score and therapeutic delay. In patients with immediate source control, residual peritonitis occurred in 9% after purulent or biliary peritonitis and in 41% after fecal peritonitis. In patients without immediate control of the septic source, delayed control was still achieved in 100% after a planned relaparotomy (PR) strategy versus 43% after an on-demand relaparotomy (ODR).

Diagnosis

Diagnostic criteria for peritonitis associated with perforation on the basis of the initial ascitic fluid analysis include fulfilling at least two of the following criteria:[8]

• Total protein > 1 g/dl
• Glucose < 50 mg/dl
• Lactate dehydrogenase (LDH) greater than the upper limit of normal for serum.

Non perforated secondary peritonitis such as perinephric abscess, cannot be readily apparent on the basis of the initial ascitic fluid analysis, but the response of the ascitic fluid cell count and cultures to treatment can raise suspicion of this form of secondary peritonitis.

History and Symptoms

The clinical picture of peritonitis is determined by the nature of the causative lesion, duration and extension of the inflammatory process, and stage of the disease.

Physical Examination

The main manifestations of peritonitis are acute abdominal pain, tenderness, and guarding, which are exacerbated by moving the peritoneum, e.g. coughing, flexing the hips, or eliciting the Blumberg sign (a.k.a. rebound tenderness, meaning that pressing a hand on the abdomen elicits pain, but releasing the hand abruptly will aggravate the pain, as the peritoneum snaps back into place). Abdominal rigidity, generalized peritonitis (versus localized), hypotension, tachycardia and anemia were significantly associated with mortality.

Laboratory Findings

As the clinical signs and symptoms are not a good representation for the diagnosis of secondary peritonitis, initial ascitic fluid analysis and the response of ascitic fluid parameters to treatment have been found to be of great value in differentiating secondary peritonitis from spontaneous bacterial peritonitis.

Chest X Ray

An upright and supine plain films of the chest and abdomen should be performed in patients with abdominal pain to exclude free air under the diaphragm (most often on the right), which signals a bowel perforation and associated peritonitis.

CT Scan

CT may be positive in unto 82%. Indicated in all patients with acute abdomen. However, CT can be omitted when a diagnosis is made according to the results of precedent examinations such as Ultrasound. Radiation exposure should be considered with the use of CT.

Ultrasound

Ultrasound may be positive in unto 72%. It is recommended as a screening test for acute abdomen and strongly recommended particularly when abdominal aortic aneurysm rupture or acute cholecystitis is suspected. Ultrasound is recommended in pregnant women, young women or children in whom radioactive exposure is not desirable.

Diagnostic Evaluation of Secondary Peritonitis

Ascitic fluid with PMN ≥250 cells/mm3

Bile stained ascitic fluid

Ascitic fluid biluribin >6 mg/dl and ascitic fluid/serum bilurin >1

IF NO →

IF YES "BILIARY PERFORATION"

Fulfilment of atleast 2 of the following diagnostic criteria: ❑ Total protein >1g/dl ❑ Glucose <60 mg/dl ❑ LDH >upper limit of normal

IF NO Ascitic PMN < baseline. After 48 hours of therapy with antibiotics

IF YES Free air or extravasation of contrast medium

IF YES "SPONTANEOUS BACTERIAL PERITONITIS"

IF NO

IF NO

IF YES "PERFORATION PERITONITIS"

"NON-PERFORATIONAL SECONDARY PERITONITIS"

No evidence for loculated infection

Evidence for loculated infection with U/S or Barium enema etc.

"SPONTANEOUS BACTERIAL PERITONITIS" ❑ Continue antibiotic

LAPAROTOMY

Treatment

Medical Therapy

Medical management of secondary peritonitis includes hydration, prevention of septicemia, and correction of electrolytes. Empiric coverage for gram positive, gram negative, and anaerobic bacteria should be initiated promptly while awaiting culture results. Either open abdominal surgery or an exploratory laparotomy is recommended.

Surgery

The surgical treatment of postoperative peritonitis is primarily aimed at defining source control, followed by debridement of fibrin bedding and abdominal lavage of contaminants and infectious fluids. In cases of suspected diffuse secondary peritonitis, indication for relaparotomy after positive findings in CT were based on the following citeria: Evidence of leakage, intraabdomnal air after more than five days postoperatively, and/or massive collection of intraabdominal fluid. Re-laparotomy has to be performed immediately following positive radiological examination and/or clinical/laboratory signs. In postoperative peritonitis, negative radiological findings and persistent symptoms of sepsis for longer than 24 hours were also indications for relaparotomy.