Secondary peritonitis is the initial phase of infection after intestinal perforation which can progress to [[abscess]], if left untreated. Severe abdominal infections are invariably progress to a high level of [[sepsis]], [[endotoxin]] production and [[systemic inflammatory response syndrome]] (SIRS), which often results in [[multiple organ failure]].<ref name="pmid15846719">{{cite journal| author=Wong PF, Gilliam AD, Kumar S, Shenfine J, O'Dair GN, Leaper DJ| title=Antibiotic regimens for secondary peritonitis of gastrointestinal origin in adults. | journal=Cochrane Database Syst Rev | year= 2005 | volume= | issue= 2 | pages= CD004539 | pmid=15846719 | doi=10.1002/14651858.CD004539.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15846719 }} </ref><ref name="pmid6211996">{{cite journal| author=Berne TV, Yellin AW, Appleman MD, Heseltine PN| title=Antibiotic management of surgically treated gangrenous or perforated appendicitis. Comparison of gentamicin and clindamycin versus cefamandole versus cefoperazone. | journal=Am J Surg | year= 1982 | volume= 144 | issue= 1 | pages= 8-13 | pmid=6211996 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6211996 }} </ref>. If properly treated, typical cases of surgically correctable peritonitis (e.g. [[perforated peptic ulcer]], [[appendicitis]], and [[diverticulitis]]) have a mortality rate of about <10% in otherwise healthy patients, which rises to about 40% in the elderly, and/or in those with significant underlying illness, as well as in cases that present late (after 48h). If left untreated, generalized peritonitis is almost always fatal.
==Complications==
===Complications related to surgery===
* '''Tertiary peritonitis''' usually follows operative attempts to treat secondary peritonitis and is almost always associated with a [[Systemic inflammatory response syndrome|systemic inflammatory response]]. It is a persistent/recurrent infection with organisms of low virulence. The incidence of tertiary peritonitis in patients requiring ICU admission for severe abdominal infections may be as high as 50-74%.
* '''Surgical site infection''' and delayed wound healing- Depends on the degree of contamination. Measures taken to prevent postoperative infections such as peri-operative, systemic antibiotics, and lavage of the wound would not help to prevent this complication. In such instances, the wound should be kept open, and treated with wet-to-dry dressing several times a day. It occurs in 5-15% of patients.
* Laparotomy increases the risk of small Bowel obstruction due to post-operative adhesions.<ref name="pmid14978440">{{cite journal| author=Duron JJ| title=[Post-operative bowel obstruction. Part 2: Mechanical post-operative small bowel obstruction by bands and adhesions]. | journal=J Chir (Paris) | year= 2003 | volume= 140 | issue= 6 | pages= 325-34 | pmid=14978440 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14978440 }} </ref>
===Complications related to peritonitis===
*Intraperitoneal adhesions, leading to bowel obstruction
* Sequestration of [[fluid]] and [[electrolyte]]s, as revealed by decreased [[central venous pressure]], may cause [[electrolyte disturbance]]s, as well as significant [[hypovolaemia]], possibly leading to [[shock]] and [[acute renal failure]].
* A peritoneal abscess may form (e.g. above or below the [[liver]], or in the lesser [[omentum]]).
* [[Sepsis]] may develop, so blood cultures should be obtained.<ref name="Rau2007">{{cite journal|last1=Rau|first1=Bettina M.|title=Evaluation of Procalcitonin for Predicting Septic Multiorgan Failure and Overall Prognosis in Secondary Peritonitis|journal=Archives of Surgery|volume=142|issue=2|year=2007|pages=134|issn=0004-0010|doi=10.1001/archsurg.142.2.134}}</ref>
* The fluid may push on the diaphragm and cause breathing difficulties
* Development of abscess is the leading cause of persistent infection and development of tertiary peritonitis.
* The majority of abscess formation occurs subsequent to secondary peritonitis.The risk of abscess increases to 10-30% in cases of preoperative perforation of the hollow viscus, significant fecal contamination of the peritoneal cavity, bowel ischemia, delayed diagnosis and therapy of the initial peritonitis, and the need for reoperation, as well as in the setting of [[immunosuppression]].
With treatment, patients usually do well. Without treatment, the outcome is usually poor. However, in some cases, patients do poorly even with prompt and appropriate treatment.
Natural History
Prognosis
Peritonitis is a frequent cause of morbidity.The prognosis greatly depends on the degree of intra-abdominal contamination, the severity of underlying disease, the immune response of the host and associated organ dysfunction.[1]
Associated mortality rates vary from < 1% to > 60%
Factors affecting prognosis are:
Assessment of the prognosis of patients with peritonitis using MPI
For a score of 27, the sensitivity was 66.67%, specificity was 100%, and positive predictive value for mortality is 100% at an accuracy of 94%.[2]
Assessment of severity of peritonitis using MPI
Score
Mortality rate
Morbidity rate
<21
0%
13.33%
21-27
27.28%
65.71%
>27
100%
100%
Factors that were found to be independently significant factors in predicting the mortality:
Duration of pain for >24 h
Organ failure on admission
Female sex and
Feculent exudate
Early prognostic evaluation of abdominal sepsis is useful in the assessment of the severity of the disease and to select high-risk patients for early surgical reintervention.
References
↑Mulier, Stefaan; Penninckx, Freddy; Verwaest, Charles; Filez, Ludo; Aerts, Raymond; Fieuws, Steffen; Lauwers, Peter (2003). "Factors Affecting Mortality in Generalized Postoperative Peritonitis: Multivariate Analysis in 96 Patients". World Journal of Surgery. 27 (4): 379–384. doi:10.1007/s00268-002-6705-x. ISSN0364-2313.