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| __NOTOC__
| | ==Classification== |
| {{Spontaneous bacterial peritonitis}}
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| {{CMG}} ; {{AE}}{{SCh}}
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| ==Overview== | | Secondary peritonitis can be classified according to the origin and extent of inflammation into:<ref name="pmid8678610">{{cite journal| author=Wittmann DH, Schein M, Condon RE| title=Management of secondary peritonitis. | journal=Ann Surg | year= 1996 | volume= 224 | issue= 1 | pages= 10-8 | pmid=8678610 | doi= | pmc=1235241 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8678610 }} </ref> |
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| | ===Acute perforation peritonitis=== |
| | *Gastrointestinal perforation |
| | *Intestinal ischemia |
| | *Pelviperitonitis and other forms |
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| | ===Postoperative peritonitis=== |
| | *Anastomotic leak |
| | *Accidental perforation and devascularization |
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| ==Natural history== | | ===Post-traumatic peritonitis=== |
| *SBP is treatable with antibiotics but early diagnosis and intiation of empiric antibiotics is the most important factor for survival.
| | *After blunt abdominal trauma |
| *In a study performed in 2006, Each hour of delay of administration of empiric antibiotics was associated with increased mortality by 7.6% while administration of antibiotics at the first hour of hypotension increased overall survival to 79%.(3)
| | *After penetrating abdominal trauma |
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| ==Complications==
| | {{familytree/start}} |
| The physician should have a high index of suspicion to diagnose SBP early and start empiric antibiotic therapy. The earlier the stage of diagnosis, the better the survival.
| | {{familytree | | | | | | | | | C02 | | | | | | |C02='''Secondary peritonitis'''<ref name="pmid8678610">{{cite journal| author=Wittmann DH, Schein M, Condon RE| title=Management of secondary peritonitis. | journal=Ann Surg | year= 1996 | volume= 224 | issue= 1 | pages= 10-8 | pmid=8678610 | doi= | pmc=1235241 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8678610 }} </ref>}} |
| ===Hypotension, hypothermia and shock:===
| | {{familytree | | | | |,|-|-|-|-|+|-|-|-|-|.| | | | | }} |
| *With the progression of infection, septicaemia ensues with its classic symptoms and signs. Septicaemia and shock are associated with very bad prognosis. | | {{familytree |boxstyle=text-align: left; | | | | D02 | | | D03 | | | D04 | | |D02='''Acute perforation peritonitis'''<br>❑ Gastrointestinal perforation<br>❑ Intestinal ischemia<br>❑ Pelviperitonitis and other forms|D03='''Postoperative peritonitis'''<br>❑ Anastomotic leak<br>❑ Accidental perforation and devascularization|D04='''Post-traumatic peritonitis'''<br>❑ After blunt abdominal trauma<br>❑ After penetrating abdominal trauma}} |
| ===Altered mental status:===
| | {{familytree/end}} |
| *Hepatic decompensation in association with the progression of infection make altered mental status more likely to happen. Ammonia levels can be within normal limits or slightly elevated as hepatic decompensation is not the only element leading to the altered mental status. | |
| ===Paralytic ileus:===
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| *Peritoneal inflammation can be complicated with paralytiv=c ileus. Paralytic ileus is a very poor prognostic sign with increased mortality rate.
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| ===Diarrhea:===
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| *Diarrhea is common due to associated intestinal bacterial overgrowth.(4)
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| ==Prognosis==
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| *Mortality of SBP remains high. 1-year mortality rate is 30-90 (1), probably due to the advanced liver disease present in the first place.
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| *Early admission and prophylactic cephalosporins might have a role in decreasing mortality rate.(2)
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| {| border="2" cellpadding="4" cellspacing="0" style="margin: 1em 1em 1em 0; background: #f9f9f9; border: 1px #aaa solid; border-collapse: collapse;
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| ! colspan="2" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Disease'''}}
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| ! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Prominent clinical findings'''}}
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| ! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Lab tests'''}}
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| ! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Tratment'''}}
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| | rowspan="3" |'''[[Primary peritonitis]]''' | |
| |'''[[Primary peritonitis|Spontaneous bacterial peritonitis]]''' | |
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| * Absence of GI [[perforation]], most closely associated with [[cirrhosis]] and advanced liver disease.
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| * Presents with abrupt onset of [[fever]], [[abdominal pain]], [[distension]], and [[rebound tenderness]].
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| * Most have clinical and biochemical manifestations of advanced [[cirrhosis]] or [[nephrosis]] like [[leukocytosis]],[[hypoalbuminemia]],
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| * a prolonged [[prothrombin]] time. SAAG >1.1 g/dL, ↑s.lactic acid level, or a ↓ascitic fluid pH (< 7.31) supports the diagnosis. Gram staining reveals bacteria in only 25% of cases.
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| * Diagnosed by analysis of the ascitic fluid which reveals [[WBC]] > 500/ML, and [[PMN]] >250cells/ml.
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| * Culture of ascitic fluid inoculated immediately into [[blood culture]] media at the bedside usually reveals a single [[enteric]] organism, most commonly ''[[Escherichia coli]]'', ''[[Klebsiella]]'', or [[streptococci]].
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| * Once diagnosed,it is treated with [[Ceftriaxone]].
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| |'''[[Tuberculous peritonitis]]''' | |
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| * Seen in 0.5% of new cases of [[tuberculosis]] particularly in young women in endemic areas as a primary infection.
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| * Presents with [[abdominal pain]] and [[distension]], [[fever]], [[night sweats]], [[weight loss]], and altered bowel habits.
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| * [[Ascites]] is present in about half of cases. Abdominal mass may be felt in a third of cases. The peritoneal fluid is characterized by a [[protein]] concentration > 3 g/dL with < 1.1 g/dL SAAG and [[lymphocyte]] predominance of [[WBC]].
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| * Definitive diagnosis in 80% of cases is by culture. Most patients presenting acutely are diagnosed only by [[laparotomy]].
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| * Combination antituberculosis chemotherapy is preferred in chronic cases.
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| |'''Continuous Ambulatory Peritoneal Dialysis''' ('''CAPD peritonitis)''' | |
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| * Peritonitis is one of the major complications of [[peritoneal dialysis]] & 72.6% occurred within the first six months of peritoneal dialysis.
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| * Historically, [[coagulase-negative staphylococci]] were the most common cause of peritonitis in CAPD, presumably due to touch contamination or infection via the pericatheter route.
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| * Treatment for [[peritoneal dialysis]]-associated peritonitis consists of antimicrobial therapy, in some cases catheter removal is also warranted.
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| * Additional therapies for relapsing or recurrent peritonitis may include fibrinolytic agents and peritoneal lavage. Most episodes of peritoneal dialysis-associated peritonitis resolve with outpatient antibiotic treatment.
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| * Majority of peritonitis cases are caused by bacteria(50%-due to [[Gram-positive bacteria|gram positive]] organisms, 15% to [[gram negative]] organisms,20% were culture negative.2% of cases are caused by fungi, mostly [[Candida]] species. Polymicrobial infection in 4%.Exit-site infection was present in 13% and a peritoneal fluid leak in 3 % and M.tuberculosis 0.1%.
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| * Initial empiric antibiotic coverage for peritoneal dialysis-associated peritonitis consists of coverage for [[gram-positive]] organisms (by [[vancomycin]] or a first-generation [[cephalosporin]]) and [[gram-negative]] organisms (by a third-generation [[cephalosporin]] or an [[aminoglycoside]]). Subsequently, the regimen should be adjusted based on culture and sensitivity data. Cure rates are approximately 75%.
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| | rowspan="2" |'''[[Acute bacterial secondary peritonitis|Secondary peritonitis]]''' | |
| |'''[[Acute bacterial secondary peritonitis]]'''
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| * Occurs after perforating, penetrating, inflammatory, infectious, or [[ischemic]] injuries of the GI or GU tracts. Most often follows disruption of a hollow viscus→chemical peritonitis→bacterial peritonitis(polymicrobial, includes [[aerobic]] [[gram negative]] {[[E coli]], [[Klebsiella]], [[Enterobacter]], [[Proteus mirabilis]]} and gram positive { [[Enterococcus]], [[Streptococcus]]} and [[anaerobes]] {[[Bacteroides]], [[clostridia]]}).
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| * Presents with [[abdominal pain]], [[tenderness]], [[guarding]] or rigidity, [[distension]], free peritoneal air, and diminished [[bowel sounds]]. Signs that reflect irritation of the parietal peritoneum resulting [[ileus]]. Systemic findings include [[fever]], [[chills]] or [[rigors]], [[tachycardia]], [[sweating]], [[tachypnea]], [[restlessness]], [[dehydration]], [[oliguria]], [[disorientation]], and, ultimately, refractory [[shock]].
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| * [[Peritoneal lavage]], [[Laparoscopy]] are the treatment of choice.
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| |'''[[Biliary peritonitis]]''' | |
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| * Most often seen in cases of rupture of pathological [[gallbladder]] or [[bile duct]] or [[cholangitic abscess]] or secondary to obstruction of the biliary tract.
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| * Seen in alcoholic patients with [[ascites]].
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| | colspan="2" |'''[[Tertiary peritonitis]]''' | |
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| * Persistence or recurrence of [[Infection|intraabdominal infection]] following apparently adequate therapy of [[Peritonitis|primary or secondary peritonitis]].
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| * Associated with [[Mortality|high mortality]] due to multi organ dysfunction. It presents in a similar way as other [[peritonitis]] but is recognized as an adverse outcome with poor prognosis.
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| * [[Enterococcus]], [[Candida]], [[Staphylococcus epidermidis]], and [[Enterobacter]] being the most common organisms.
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| * Characterized by lack of response to appropriate surgical and [[antibiotic therapy]] due to disturbance in the hosts [[immune response]].
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| | colspan="2" |'''[[Familial Mediterranean fever (periodic peritonitis, familial paroxysmal polyserositis)]]''' | |
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| * Rare genetic condition which affects individuals of Mediterranean genetic background.
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| * Etiology is unclear.
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| * Presents with recurrent bouts of [[abdominal pain]] and [[tenderness]] along with [[pleuritic]] or [[joint pain]]. [[Fever]] and [[leukocytosis]] are common.
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| * [[Colchicine]] prevents but does not treat acute attacks.
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| | colspan="2" |'''[[Granulomatous peritonitis]]''' | |
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| * A rare condition caused by disposable surgical fabrics or food particles from a [[perforated ulcer]], eliciting a vigorous [[granulomatous]] ([[delayed hypersensitivity]]) response in some patients 2-6 weeks after [[laparotomy]].
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| * Presents with [[abdominal pain]], [[fever]], [[nausea and vomiting]], [[ileus]], and systemic complaints, mild and diffuse [[abdominal tenderness]].
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| * Diagnosed by the demonstration of diagnostic Maltese cross pattern of starch particles.
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| * The disease is self-limiting.
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| * Treated with [[corticosteroids]] or [[Anti inflammatory medications|anti-inflammatory agents]].
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| | colspan="2" |'''[[Sclerosing encapsulating peritonitis]]''' | |
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| * Seen in conditions associated with long term [[peritoneal dialysis]], shunts like VP & PV, history of abdominal surgeries, [[liver transplantation]].
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| * Symptoms include [[nausea]], [[abdominal pain]], [[diarrhea]], [[anorexia]], bloody [[ascites]].
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| | colspan="2" |'''[[Intraperitoneal abscesses]]''' | |
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| * Most common etiologies being Gastrointestinal perforations, postoperative complications, and penetrating injuries.
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| * Signs and symptoms depend on the location of the abscess within the peritoneal cavity and the extent of involvement of the surrounding structures.
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| * Diagnosis is suspected in any patient with a predisposing condition. In a third of cases it occurs as a sequela of generalized peritonitis.
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| * The pathogenic organisms are similar to those responsible for peritonitis, but [[anaerobic]] organisms occupy an important role.
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| * The mortality rate of serious intra-abdominal abscesses is about 30%.
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| * Diagnosed best by [[CT-scans|CT]] scan of the abdomen.
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| * Treatment consists of prompt and complete [[CT]] or US guided drainage of the [[abscess]], control of the primary cause, and adjunctive use of effective antibiotics. Open drainage is reserved for abscesses for which percutaneous drainage is inappropriate or unsuccessful.
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| | colspan="2" |'''[[Peritoneal mesothelioma]]'''
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| * Arises from the [[mesothelium]] lining the [[peritoneal cavity]].
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| * Its incidence is approximately 300-500 new cases being diagnosed in the United States each year. As with [[pleural mesothelioma]], there is an association with an asbestos exposure.
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| * Most commonly affects men at the age of 50-69 years. Patients most often present with [[abdominal pain]] and later increased abdominal girth and ascites along with [[anorexia]], [[weight loss]] and [[abdominal pain]].
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| * Mean time from diagnosis to death is less than 1 year without treatment.
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| * [[Computed tomography|CT]] with intravenous contrast typically demonstrates the thickening of the peritoneum. [[Laparoscopy]] with tissue biopsy or CT guided tissue biopsy with immunohistochemical staining for [[calretinin]], [[cytokeratin]] 5/6, [[mesothelin]], and Wilms tumor 1 antigen remain the gold standard for diagnosis.
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| * At [[laparotomy]] the goal is [[cytoreduction]] with [[excision]]. Debulking surgery and intraperitoneal [[chemotherapy]] improves survival in some cases.
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| | colspan="2" |'''[[peritoneal carcinomatosis]]''' | |
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| * Associated with a history of [[ovarian]] or GI tract malignancy.
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| * Symptoms include [[ascites]], [[abdominal pain]], [[nausea]], [[vomiting]].
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| |}
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| ==References==
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| {{reflist|2}} | |
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| [[Category:Gastroenterology]]
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| [[Category:Emergency medicine]]
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| [[Category:Infectious disease]]
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