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==Causes==
==Causes==
===Infected peritonitis===
* '''Perforation of a hollow viscus''' is the most common cause of peritonitis. Examples include perforation of the distal [[oesophagus]] ([[Boerhaave syndrome]]), of the [[stomach]] ([[peptic ulcer]], [[gastric carcinoma]], of the [[duodenum]] ([[peptic ulcer]]), of the remaining [[intestine]] (e.g. [[appendicitis]], [[diverticulitis]], [[Meckel diverticulum]], [[IBD]], intestinal infarction, intestinal strangulation, [[colorectal carcinoma]], [[meconium peritonitis]]), or of the [[gallbladder]] ([[cholecystitis]]). Other possible reasons for perforation include [[physical trauma|trauma]], ingestion of sharp [[foreign body]] (such as a fish bone), perforation by an [[endoscope]] or [[catheter]], and anastomotic leakage. The latter occurrence is particularly difficult to diagnose early, as [[abdominal pain]] and [[ileus|ileus paralyticus]] are considered normal in patients who just underwent [[abdominal surgery]]. In most cases of perforation of a hollow viscus, mixed [[bacteria]] are isolated; the most common agents include [[Gram-negative]] [[bacilli]] (e.g. ''[[Escherichia coli]]'') and [[anaerobic bacteria]] (e.g. ''[[Bacteroides fragilis]]'').
* '''Disruption of the [[peritoneum]]''', even in the absence of perforation of a hollow viscus, may also cause infection simply by letting [[micro-organisms]] into the peritoneal cavity. Examples include [[physical trauma|trauma]], surgical wound, continuous ambulatory [[peritoneal dialysis]], intra-peritoneal [[chemotherapy]]. Again, in most cases mixed [[bacteria]] are isolated; the most common agents include cutaneous species such as ''[[Staphylococcus aureus]]'', and [[coagulase]]-negative [[staphylococci]], but many others are possible, including [[fungi]] such as [[Candida]].
* '''Spontaneous bacterial peritonitis''' (SBP) is a peculiar form of peritonitis occurring in the absence of an obvious source of contamination. It occurs either in [[children]], or in patients with [[ascites]]. See the article on [[spontaneous bacterial peritonitis]] for more information.
* '''Systemic infections''' (such as [[tuberculosis]]) may rarely have a peritoneal localisation.
===Non-infected peritonitis===
* '''Leakage of [[sterilization (microbiology)|sterile]] [[body fluids]] into the peritoneum''', such as [[blood]] (e.g. [[endometriosis]], blunt abdominal [[physical trauma|trauma]]), [[gastric juice]] (e.g. [[peptic ulcer]], [[gastric carcinoma]]), [[bile]] (e.g. [[liver biopsy]]), [[urine]] (pelvic [[physical trauma|trauma]]), [[menstruum]] (e.g. [[salpingitis]]), [[pancreatic juice]] ([[pancreatitis]]), or even the contents of a ruptured [[dermoid cyst]]. It is important to note that, while 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.
* '''Sterile abdominal surgery''' normally causes localised or minimal generalised peritonitis, which may leave behind a foreign body reaction and/or fibrotic [[adhesion (medicine)|adhesion]]s. Obviously, peritonitis may also be caused by the rare, unfortunate case of a [[sterile technique|sterile]] [[foreign body]] inadvertently left in the [[abdomen]] after [[surgery]] (e.g. [[gauze]], [[sponge]]).
* Much rarer non-infectious causes may include [[familial Mediterranean fever]], [[porphyria]], and [[systemic lupus erythematosus]].


==Treatment==
==Treatment==

Revision as of 15:07, 6 February 2012

For patient information click here

Peritonitis
ICD-10 K65
ICD-9 567
DiseasesDB 9860
MeSH D010538

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]

Overview

Mechanisms & manifestations

Abdominal pain & tenderness

The main manifestations of peritonitis are acute abdominal pain, tenderness, and guarding, which are exacerbated by moving the peritoneum, e.g. coughing, flexing the hips, or eliciting the Blumberg sign (a.k.a. rebound tenderness, meaning that pressing a hand on the abdomen elicits pain, but releasing the hand abruptly will aggravate the pain, as the peritoneum snaps back into place). The localisation of these manifestations depends on whether peritonitis is localised (e.g. appendicitis or diverticulitis before perforation), or generalised to the whole abdomen; even in the latter case, pain typically starts at the site of the causing disease. Peritonitis is an example of acute abdomen.

Collateral manifestations

Complications

  • the fluid may push on the diaphragm and cause breathing difficulties

Diagnosis and investigations

A diagnosis of peritonitis is based primarily on clinical grounds, that is on the clinical manifestations described above; if they support a strong suspicion of peritonitis, no further investigation should delay surgery. Leukocytosis and acidosis may be present, but they are not specific findings. Plain abdominal X-rays may reveal dilated, oedematous intestines, although it is mainly useful to look for pneumoperitoneum (free air in the peritoneal cavity), which may also be visible on chest X-rays. If reasonable doubt still persists, an exploratory peritoneal lavage may be performed (e.g. in cause of trauma, in order to look for white blood cells, red blood cells, or bacteria).

Causes

Treatment

Depending on the severity of the patient's state, the management of peritonitis may include:

Prognosis

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 untreated, generalised peritonitis is almost always fatal.

Pathology

The peritoneum normally appears greyish and glistening; it becomes dull 2-4 hours after the onset of peritonitis, initially with scarce serous or slightly turbid fluid. Later on, the exudate becomes creamy and evidently suppurative; in dehydrated patients, it also becomes very inspissated. The quantity of accumulated exudate varies widely. It may be spread to the whole peritoneum, or be walled off by the omentum and viscera. Inflammation features infiltration by neutrophils with fibrino-purulent exudation.

References

  1. "Peritonitis: Emergencies: Merck Manual Home Edition". Retrieved 2007-11-25.

Additional Resources

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