Sandbox: Peritonitis landing page

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]

Synonyms and keywords: Acute bacterial peritonitis, acute generalized peritonitis, acute peritonitis, abscess of suppurative peritonitis, acute suppurative peritonitis, purulent peritonitis, subphrenic peritonitis, pelvic peritonitis, acute serositis, aseptic peritonitis, chronic peritonitis, continuous ambulatory peritoneal dialysis associated peritonitis, fungal peritonitis, granulomatous peritonitis, peritoneal dialysis-associated peritonitis, serositis, chemical peritonitis, neonatal peritonitis, tuberculous peritonitis, peritoneal abscess, spontaneous bacterial peritonitis, benign paroxysmal peritonitis, pyogranulomatous serositis, perforation peritonitis, CAPD peritonitis, primary peritonitis, secondary peritonitis, tertiary peritonitis.

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 can also result from injury and 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.

Definition

Peritonitis is defined as inflammation of the peritoneum (a tissue that lines the inner wall of the abdominal cavity and covers most of the abdominal organs) from any cause. In contrast to peritonitis intrabdominal infection is defined as inflammation of peritoneum due to an infectious cause.

Primary or Spontaneous Peritonitis	Secondary Peritonitis	Tertiary Peritonitis
Primary peritonitis/ spontaneous bacterial peritonitis (SBP) represents a group of diseases with different 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. Primary peritonitis lacks an identifiable anatomical derangement.	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.	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.

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:

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

Classification Based on the clinical view point

Peritonitis may be classified based on the prognosis into the following types:

• Uncomplicated: In uncomplicated peritonitis, the infection only involves a single organ and no anatomical disruption is present. Usually, patients with such infections can be managed with surgical resection alone and no antimicrobial therapy besides peri-operative prophylaxis is necessary.
• Complicated:The infectious process proceeds beyond the organ that is the source of the infection, and causes either localised peritonitis, also referred to as abdominal abscess, or diffuse peritonitis, depending on the ability of the host to contain the process within a part of the abdominal cavity.They are the important cause of morbidity and more frequently associated with poor prognosis.However, an early clinical diagnosis, followed by adequate source control to stop ongoing contamination and restore anatomical structures and physiological function, as well as prompt initiation of appropriate empirical therapy, can limit the associated mortality.

Classification based on the etiological agents

• Peritonitis, caused by enteric organisms such as E.coli, Klebsiella, staphylococci, streptococci, anaerobes.
• Peritonitis, caused by bacteria residing out of GI tract such as gonococci, pneumococci.
• Aseptic peritonitis resulting from irritation of the peritoneal cavity from the extravasation of fluids such as blood, gastric juice.

Classification based on the pathological alterations in the clinical course of peritonitis

• Reactive: In the first 24 hours when there are maximal manifestations of local signs of peritonitis.
• Toxic: In 24-72 hours, when there is increased general intoxication with a gradual reduction in the local signs of peritonitis.
• Terminal: It is often the severe stage of peritonitis, usually after 72 hours characterized by irreversible intoxication in the background of a sharply expressed local manifestations of peritonitis.

Pathophysiology

Peritonitis results from contamination of normal sterile peritoneal cavity with infections or chemical irritants. Release of bile or gastric juices initially causes chemical peritonitis, infection occurs when bacteria enter and contaminate the peritoneal cavity. Bacterial peritonitis is usually caused by normal enteric flora like E.coli, Klebsiella. Inflammatory process causes shift of fluid into the peritoneal cavity(third spacing) which leads to hypovolemia, septicemia and multi-organ failure resulting in death of the patient if not adequately diagnosed and treated early.

• The main causes of peritonitis are the acute inflammation of the abdominal viscera, discontinuity and increased permeability of their walls, open and closed traumas of the abdomen with the damage of viscera followed by microbial contamination of peritoneal cavity.
• Despite the cause of peritonitis, the disease is characterized by a typical bacterial inflammation.
• Chronic peritonitis is caused mainly by extraperitoneal (lungs, lymph nodes) tuberculosis, entering the peritoneal cavity through hematogenous route.

Causes

The most common cause of peritonitis is perforation of a hollow viscus such as perforation of the distal esophagus (Boerhaave syndrome), of the stomach (peptic ulcer, gastric carcinoma), of the duodenum (peptic ulcer), of the remaining intestine (e.g. appendicitis, diverticulitis, Meckel's diverticulum, IBD, intestinal infarction, intestinal strangulation, colorectal carcinoma, meconium peritonitis), or of the gallbladder (cholecystitis). Other causes of infected peritonitis include spontaneous bacterial peritonitis and disruption of the peritoneum, such as in cases of trauma, surgical wounds, continuous peritoneal dialysis, and intra-peritoneal chemotherapy. Causes of non-infected peritonitis include endometriosis, blunt abdominal trauma, gastric carcinoma, peptic ulcer, pelvic trauma, and pancreatitis.

Causes

Causes of peritonitis can be divided into infected and non-infected, which are as follows:

Causes of Infected Peritonitis

Perforation of a hollow viscus organ	Disruption of the peritoneum	Spontaneous bacterial peritonitis (SBP)	Systemic infections
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	Peritonitis occurring in the absence of an obvious source of contamination. It occurs either in children, or in patients with ascites.	e.g. Tuberculosis

Causes of Non-Infected Peritonitis

Leakage of sterile body fluids into the peritoneum	Sterile abdominal surgery	Rarer non-infectious causes
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

Causes by Organ System

Cardiovascular	No underlying causes
Chemical/Poisoning	No underlying causes
Dental	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	Appendicitis, Ascites, Boerhaave syndrome, Cholecystitis, Cholelithiasis, Chronic liver disease, Diverticulitis, Gall bladder rupture, Gastrointestinal perforation, IBD, Intestinal strangulation, Mallory-Weiss syndrome, Meckel diverticulitis, Meconium peritonitis, Neonatal necrotizing enterocolitis, Pancreatitis, Peptic ulcer, Perihepatitis, Recurrent hereditary polyserositis, Toxic megacolon, Typhlitis
Genetic	No underlying causes
Hematologic	No underlying causes
Iatrogenic	Continuous ambulatory peritoneal dialysis, Intra-peritoneal chemotherapy, Surgical wounds
Infectious Disease	Bacteroides fragilis, E. coli, Enterobacteriaceae, Escherichia coli, Fitz-Hugh Curtis syndrome, Klebsiella pneumoniae, Pseudomonas, Staphylococcus, Streptococcus pneumoniae, Streptococcus pyogenes, Miliary tuberculosis
Musculoskeletal/Orthopedic	No underlying causes
Neurologic	No underlying causes
Nutritional/Metabolic	No underlying causes
Obstetric/Gynecologic	Endometriosis, Fitz-Hugh Curtis syndrome, Pelvic inflammatory disease
Oncologic	Colorectal carcinoma
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal/Electrolyte	Nephritic syndrome
Rheumatology/Immunology/Allergy	Systemic lupus erythematosus
Sexual	No underlying causes
Trauma	Trauma
Urologic	No underlying causes
Miscellaneous	Ruptured dermoid cyst, Spontaneous bacterial peritonitis

Causes in Alphabetical Order

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