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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 (result of alcoholism), 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 is a emergency medical/surgical condition requiring prompt medical attention and treatment.

Causes

Common causes Less common causes Spontaneous bacterial peritonitis Aerobic gram-negative bacteria, such as Escherichia coli Gram-positive cocci, such as  Streptococcus Enterococcus  Staphylococcus aureus Streptococcus salivarius Poly-microbial infection Secondary peritonitis Gram-negative bacilli (e.g. Escherichia coli),  Anaerobic bacteria (e.g. Bacteroides fragilis) Enterobacter cloacae Staphylococcus epidermidis Propionibacterium species Pseudomonas Enterococcus Candida

Classification

Peritonitis is classified based on the cause of the inflammatory process and the character of microbial contamination as follows:

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 >250cells/mm³ Culture: Positive for single organism Ultrasound for evaluation of liver cirrhosis - Secondary Peritonitis Perforated gastric and duodenal ulcer + Diffuse - + + N Glucose < 50mg/dl Ascitic fluid LDH > serum LDH 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 Hyperbilirubinemia Leukocytosis 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 |}