|
|
| Line 263: |
Line 263: |
| |style="padding: 5px 5px; background: #F5F5F5;" align="left" |History of missed period and [[vaginal bleeding]] | | |style="padding: 5px 5px; background: #F5F5F5;" align="left" |History of missed period and [[vaginal bleeding]] |
| |- | | |- |
| |}
| |
|
| |
| {| style="margin: 1em 1em 1em 0; background: #f9f9f9; border: 1px #aaa solid; border-collapse: collapse;" cellspacing="0" cellpadding="4" border="2"
| |
| |+'''Differentiating the different causes of peritonitis'''
| |
| ! colspan="2" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Disease'''}}
| |
| ! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Prominent clinical findings'''}}
| |
| ! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Lab tests'''}}
| |
| ! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Tratment'''}}
| |
| |-
| |
| | rowspan="3" |'''Primary peritonitis'''
| |
| |'''[[Primary peritonitis|Spontaneous bacterial peritonitis]]'''
| |
| |
| |
| * Absence of GI [[perforation]], most closely associated with [[cirrhosis]] and [[Liver disease|advanced liver disease]].
| |
| * Presents with abrupt onset of [[fever]], [[abdominal pain]], [[distension]], and [[rebound tenderness]].
| |
| |
| |
| * Most have clinical and biochemical manifestations of advanced [[cirrhosis]] or [[nephrosis]] like [[leukocytosis]],[[hypoalbuminemia]],
| |
| * Prolonged [[prothrombin]] time. SAAG >1.1 g/dL, increased serum [[lactic acid]] level, or a decreased [[Ascites|ascitic fluid]] pH (< 7.31) supports the diagnosis. [[Gram staining]] reveals bacteria in only 25% of cases.
| |
| * Diagnosed by analysis of the [[Ascitic|ascitic fluid]] which reveals [[WBC]] > 500/ML, and [[PMN]] >250cells/ml.
| |
| * [[Culture medium|Culture]] of ascitic fluid inoculated immediately into [[blood culture]] media at the bedside usually reveals a single [[Enteric Bacilli|enteric organism]], most commonly ''[[Escherichia coli]]'', ''[[Klebsiella]]'', or [[streptococci]].
| |
| |
| |
| * Once diagnosed,it is treated with [[Ceftriaxone]].
| |
| |-
| |
| |'''[[Tuberculous peritonitis]]'''
| |
| |
| |
| * Seen in 0.5% of new cases of [[tuberculosis]] particularly in young women in endemic areas as a primary infection.
| |
| * Presents with [[abdominal pain]] and [[distension]], [[fever]], [[night sweats]], [[weight loss]], and altered bowel habits.
| |
| |
| |
| * [[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|lymphocyte predominance]] of [[WBC]].
| |
| * Definitive diagnosis in 80% of cases is by culture. Most patients presenting acutely are diagnosed only by [[laparotomy]].
| |
| |
| |
| * Combination [[Antituberculosis|antituberculosis chemotherapy]] is preferred in chronic cases.
| |
| |-
| |
| |'''[[Continuous ambulatory peritoneal dialysis|Continuous Ambulatory Peritoneal Dialysis]]''' [[Continuous ambulatory peritoneal dialysis|('''CAPD peritonitis)''']]
| |
| |
| |
| * [[Peritonitis]] is one of the major complications of [[peritoneal dialysis]] & 72.6% occurred within the first six months of [[peritoneal dialysis]].
| |
| * Historically, [[coagulase-negative staphylococci]] were the most common cause of peritonitis in [[Continuous ambulatory peritoneal dialysis|CAPD]], presumably due to touch contamination or infection via the pericatheter route.
| |
| * Treatment for [[peritoneal dialysis]]-associated peritonitis consists of [[Antimicrobial drug|antimicrobial therapy]], in some cases catheter removal is also warranted.
| |
| * Additional therapies for [[Peritonitis|relapsing or recurrent peritonitis]] may include [[Fibrinolytic agent|fibrinolytic agents]] and [[peritoneal lavage]]. Most episodes of peritoneal dialysis-associated peritonitis resolve with outpatient [[Antibiotic|antibiotic treatment]].
| |
| |
| |
| * 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%.
| |
| |
| |
| * [[Antibiotic|Initial empiric antibiotic coverage]] for peritoneal dialysis-associated peritonitis consists of coverage for [[gram-positive]] organisms (by [[vancomycin]] or a [[Cephalosporins|first-generation cephalosporin]]) and [[gram-negative]] organisms (by a [[cephalosporin|third-generation cephalosporin]] or an [[aminoglycoside]]). Subsequently, the regimen should be adjusted based on [[Culture medium|culture]] and [[sensitivity]] data. Cure rates are approximately 75%.
| |
| |-
| |
| | rowspan="2" |'''[[Secondary peritonitis]]'''
| |
| |'''Acute [[bacterial]] [[secondary peritonitis]]'''
| |
| |
| |
| * 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]]}).
| |
| * 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]].
| |
| |
| |
| |
| |
| * [[Peritoneal lavage]], [[Laparoscopy]] are the treatment of choice.
| |
| |-
| |
| |'''[[Biliary]] [[Secondary peritonitis|peritonitis]]'''
| |
| |
| |
| * Most often seen in cases of rupture of pathological [[gallbladder]] or [[bile duct]] or [[Cholangitis|cholangitic abscess]] or secondary to obstruction of the [[biliary tract]].
| |
| * Seen in alcoholic patients with [[ascites]].
| |
| |
| |
| |
| |
| |-
| |
| | colspan="2" |'''[[Peritonitis|Tertiary peritonitis]]'''
| |
| |
| |
| * Persistence or recurrence of [[Infection|intraabdominal infection]] following apparently adequate therapy of [[Peritonitis|primary or secondary peritonitis]].
| |
| * 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.
| |
| |
| |
| * [[Enterococcus]], [[Candida]], [[Staphylococcus epidermidis]], and [[Enterobacter]] being the most common organisms.
| |
| |
| |
| * Characterized by lack of response to appropriate surgical and [[antibiotic therapy]] due to disturbance in the hosts [[immune response]].
| |
| |-
| |
| | colspan="2" |'''[[Familial mediterranean fever|Familial Mediterranean fever (periodic peritonitis, familial paroxysmal polyserositis)]]'''
| |
| |
| |
| * Rare [[Genetic disorder|genetic condition]] which affects individuals of Mediterranean genetic background.
| |
| * Etiology is unclear.
| |
| * Presents with recurrent bouts of [[abdominal pain]] and [[tenderness]] along with [[pleuritic]] or [[joint pain]]. [[Fever]] and [[leukocytosis]] are common.
| |
| |
| |
| |
| |
| * [[Colchicine]] prevents but does not treat acute attacks.
| |
| |-
| |
| | colspan="2" |'''[[Granulomatous peritonitis]]'''
| |
| |
| |
| * A rare condition caused by disposable surgical fabrics or food particles from a [[perforated ulcer]], eliciting a vigorous [[granulomatous]] ([[Hypersensitivity|delayed hypersensitivity]]) response in some patients 2-6 weeks after [[laparotomy]].
| |
| * Presents with [[abdominal pain]], [[fever]], [[nausea and vomiting]], [[ileus]], and systemic complaints, mild and diffuse [[abdominal tenderness]].
| |
| |
| |
| * Diagnosed by the demonstration of diagnostic Maltese cross pattern of starch particles.
| |
| |
| |
| * The disease is self-limiting.
| |
| * Treated with [[corticosteroids]] or [[Anti inflammatory medications|anti-inflammatory agents]].
| |
| |-
| |
| | colspan="2" |'''[[Sclerosing encapsulating peritonitis]]'''
| |
| |
| |
| * Seen in conditions associated with long term [[peritoneal dialysis]], shunts like [[Ventriculoperitoneal shunt|VP shunts]], history of [[Abdominal surgery|abdominal surgeries]], [[liver transplantation]].
| |
| * Symptoms include [[nausea]], [[abdominal pain]], [[diarrhea]], [[anorexia]], bloody [[ascites]].
| |
| |
| |
| |
| |
| |-
| |
| | colspan="2" |'''[[Abscess|Intraperitoneal abscesses]]'''
| |
| |
| |
| * Most common etiologies being [[Perforation|Gastrointestinal perforations]], postoperative complications, and penetrating injuries.
| |
| * Signs and symptoms depend on the location of the [[abscess]] within the [[peritoneal cavity]] and the extent of involvement of the surrounding structures.
| |
| * Diagnosis is suspected in any patient with a predisposing condition. In a third of cases it occurs as a sequela of [[Peritonitis|generalized peritonitis]].
| |
| * The pathogenic organisms are similar to those responsible for [[peritonitis]], but [[anaerobic]] organisms occupy an important role.
| |
| * The [[mortality rate]] of serious [[Abscesses|intra-abdominal abscesses]] is about 30%.
| |
| |
| |
| * Diagnosed best by [[CT-scans|CT]] scan of the abdomen.
| |
| |
| |
| * Treatment consists of prompt and complete [[CT]] or [[Ultrasound|US]] guided drainage of the [[abscess]], control of the primary cause, and adjunctive use of effective [[Antibiotics|antibiotics.]] Open drainage is reserved for [[abscesses]] for which percutaneous drainage is inappropriate or unsuccessful.
| |
| |-
| |
| | colspan="2" |'''[[Peritoneal mesothelioma]]'''
| |
| |
| |
| * Arises from the [[mesothelium]] lining the [[peritoneal cavity]].
| |
| * 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|asbestos exposure]].
| |
| * 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]].
| |
| * Mean time from diagnosis to death is less than 1 year without treatment.
| |
| |
| |
| * [[Computed tomography|CT]] with [[Contrast|intravenous contrast]] typically demonstrates the thickening of the [[peritoneum]]. [[Laparoscopy]] with tissue biopsy or CT guided tissue biopsy with [[immunohistochemical staining]] for [[calretinin]], [[cytokeratin|cytokeratin 5/6]], [[mesothelin]], and [[WT1|Wilms tumor 1 antigen]] remain the [[Gold standard (test)|gold standard]] for diagnosis.
| |
| |
| |
| * At [[laparotomy]] the goal is cytoreduction with [[excision]]. Debulking surgery and intraperitoneal [[chemotherapy]] improves survival in some cases.
| |
| |-
| |
| | colspan="2" |'''[[peritoneal carcinomatosis]]'''
| |
| |
| |
| * Associated with a history of [[ovarian]] or [[Malignancy|GI tract malignancy]].
| |
| * Symptoms include [[ascites]], [[abdominal pain]], [[nausea]], [[vomiting]].
| |
| |
| |
| |
| |
| |}
| |
|
| |
| {| border="1"
| |
| |+
| |
| '''Differentiating secondary peritonitis from spontaneous bacterial peritonitis'''
| |
| ! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Characteristic}}
| |
| ! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Spontaneous bacterial peritonitis}}
| |
| ! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Secondary peritonitis}}
| |
| |-
| |
| !Presentaion
| |
| |
| |
| * Main manifestations of [[peritonitis]] are acute abdominal [[Abdominal pain|pain]], [[Abdominal tenderness|tenderness]], and [[Abdominal guarding|guarding]], which are exacerbated by moving the peritoneum, e.g. coughing, flexing the hips, or elicitingthe [[Blumberg sign]] (a.k.a. [[rebound tenderness]])
| |
| |
| |
| * Similar presentation but insidious onset unlike rapid onset in [[SBP]]
| |
| |-
| |
| ![[Microorganism]]
| |
| |
| |
| * Monomicrobial involvement is common
| |
| * No identifiable source of [[intra-abdominal infection]]
| |
| |
| |
| * Polymicrobial involvement is common
| |
| * Identifiable source of [[intra-abdominal infection]], with or without perforation (surgically treatable source)<ref name="pmid6724512">{{cite journal| author=Runyon BA, Hoefs JC| title=Ascitic fluid analysis in the differentiation of spontaneous bacterial peritonitis from gastrointestinal tract perforation into ascitic fluid. | journal=Hepatology | year= 1984 | volume= 4 | issue= 3 | pages= 447-50 | pmid=6724512 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6724512 }} </ref>
| |
| |-
| |
| ![[Diagnostic criteria]]
| |
| | valign="top" |[[SBP]] is diagnosed in the presence of:<ref name="pmid3729637">{{cite journal| author=Runyon BA, Hoefs JC| title=Spontaneous vs secondary bacterial peritonitis. Differentiation by response of ascitic fluid neutrophil count to antimicrobial therapy. | journal=Arch Intern Med | year= 1986 | volume= 146 | issue= 8 | pages= 1563-5 | pmid=3729637 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3729637 }} </ref>
| |
| * [[Ascitic|Ascitic fluid]] [[PMN]] count of =250/mm3
| |
| * No evident [[Intra-abdominal infection|intra-abdominal source of infection]]
| |
| * Positive [[Bacterial cultures|ascitic fluid bacterial culture]]
| |
| |Diagnosed in the presence of
| |
| * Positive [[Bacterial cultures|ascitic fluid bacterial culture]]
| |
| * Ascitic fluid [[PMN]] count of =250/mm3
| |
| * Evidence of a source of infection (demonstrated at surgery or autopsy], either intra-abdominal or contiguous with the [[peritoneal cavity]]
| |
| |-
| |
| !Follow-up paracentesis
| |
| |
| |
| * [[Ascitic|Ascitic fluid]] usually became sterile after one dose of [[antibiotic]]
| |
| |
| |
| * Failure of the [[Ascites|ascitic fluid]] to become culture-negative despite of initial [[Antibiotic|antibiotic treatment]], appears to be typical of secondary peritonitis due to continuous spillage of [[organisms]] into [[abdominal cavity]] which requires surgery.<ref name="pmid3518442">{{cite journal| author=Runyon BA| title=Bacterial peritonitis secondary to a perinephric abscess. Case report and differentiation from spontaneous bacterial peritonitis. | journal=Am J Med | year= 1986 | volume= 80 | issue= 5 | pages= 997-8 | pmid=3518442 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3518442 }} </ref><ref name="pmid2293571">{{cite journal| author=Akriviadis EA, Runyon BA| title=Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. | journal=Gastroenterology | year= 1990 | volume= 98 | issue= 1 | pages= 127-33 | pmid=2293571 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2293571 }} </ref>
| |
| |} | | |} |