Secondary peritonitis natural history
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shivani Chaparala M.B.B.S [2]
Overview
Overview
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
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.[1][2]. 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, generalized peritonitis is almost always fatal.
Complications
- Tertiary peritonitis usually follows operative attempts to treat secondary peritonitis and is almost always associated with a systemic inflammatory response. It is a persistent/recurrent infection with organisms of low virulence.
- 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.
- Intraperitoneal adhesions, leading to bowel obstruction
- Sequestration of fluid and electrolytes, as revealed by decreased central venous pressure, may cause electrolyte disturbances, 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.
- 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.
- Tertiary peritonitis: the incidence of tertiary peritonitis in patients requiring ICU admission for severe abdominal infections may be as high as 50-74%.
Prognosis
Factors affecting prognosis are:
- Age
- Blood pressure
- Cause of infection
- Site of origin of peritonitis
- Number of organs involved in multi-organ-failure (MOF)
- Pre-operative organ failure
- Presence of metabolic acidosis
- Serum albumin
- New York Heart Association cardiac function status
- Malnutrition
- Malignoma
- Fecal peritonitis
- Immunosuppression
References
- ↑ Wong PF, Gilliam AD, Kumar S, Shenfine J, O'Dair GN, Leaper DJ (2005). "Antibiotic regimens for secondary peritonitis of gastrointestinal origin in adults". Cochrane Database Syst Rev (2): CD004539. doi:10.1002/14651858.CD004539.pub2. PMID 15846719.
- ↑ Berne TV, Yellin AW, Appleman MD, Heseltine PN (1982). "Antibiotic management of surgically treated gangrenous or perforated appendicitis. Comparison of gentamicin and clindamycin versus cefamandole versus cefoperazone". Am J Surg. 144 (1): 8–13. PMID 6211996.