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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:  ; 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. 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.	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 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:

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.

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?

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