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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];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Causes

Common causes Less common causes Spontaneous bacterial peritonitis Aerobic gram-negative bacteria, such as Escherichia coli Gram-positive cocci, such as  Streptococcus Enterococcus  Staphylococcus aureus Streptococcus salivarius Poly-microbial infection Secondary peritonitis Gram-negative bacilli (e.g. Escherichia coli),  Anaerobic bacteria (e.g. Bacteroides fragilis) Enterobacter cloacae Staphylococcus epidermidis Propionibacterium species Pseudomonas Enterococcus Candida

Classification

Peritonitis is classified based on the cause of the inflammatory process and the character of microbial contamination as follows:

Peritonitis                                                                                         Primary peritonitis         Secondary peritonitis         Tertiary peritonitis                                             ❑ Spontaneous peritonitis ❑ Peritonitis in patients with CAPD ❑ Tuberculous peritonitis                         ❑ Peritonitis without evidence for pathogens ❑ Peritonitis with fungi ❑ Peritonitis with low-grade pathogenic bacteria                                                                                                                               Acute perforation peritonitis ❑ Gastrointestinal perforation ❑ Intestinal ischemia ❑ Pelviperitonitis and other forms     Postoperative peritonitis ❑ Anastomotic leak ❑ Accidental perforation and devascularization     Post-traumatic peritonitis ❑ After blunt abdominal trauma ❑ After penetrating abdominal trauma

Differential diagnosis

Classification of acute abdomen based on etiology		Presentation	Symptoms			Signs			Diagnosis		Comments
			Fever	Abdominal Pain	Jaundice	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging
Common causes of Peritonitis	Primary Peritonitis	Spontateous Bacterial Peritonitis	+	Diffuse	-	-	-	Hypoactive	Ascitic fluid PMN >250cells/mm³ Culture: Positive for single organism	Ultrasound for evaluation of liver cirrhosis
	Secondary Peritonitis	Perforated gastric and duodenal ulcer	+	Diffuse	-	+	+	N	Glucose < 50mg/dl Ascitic fluid LDH > serum LDH Total Protein > 1g/dl	Air under diaphragm in upright CXR	Upper GI endoscopy for diagnosis
		Acute Cholangitis	+	RUQ	+	-	-	N	Abnormal LFT	Ultrasound shows billiary dilatation	Billiray drainage (ERCP) + IV antibiotics
		Acute Cholecystitis	+	RUQ	+	-	-	Hypoactive	Hyperbilirubinemia Leukocytosis	Ultrasound shows gallstone and evidence of inflammation	Murphy’s sign
		Acute Pancreatitis	+	Epigaster	+/-	-	-	N	Increased Amylase / Lipase	Ultrasound shows evidence of inflammation	Pain radiation to back
		Acute Appendicitis	+	RLQ	-	+	+	Hypoactive	Leukocytosis	Ultrasound shows evidence of inflammation	Nausea & vomiting, decreased appetite
		Acute Diverticulitis	+	LLQ	+/-	+	-	Hypoactive	Leukocytosis	CT scan and ultrasound shows evidence of inflammation
		Acute Salpingitis	+	LLQ/ RLQ	-	+/-	+/-	N	Leukocytosis	Pelvic ultrasound	Vaginal discharge
Hollow Viscous Obstruction		Small Intestine obstruction	-	Diffuse	-	+	+/-	Hyperactive then absent	Leukocytosis	Abdominal X ray	Nausea & vomiting associated with constipation, abdominal distention.
		Volvulus	-	Diffuse	-	+	-	Hypoactive	Leukocytosis	CT scan and abdominal X ray	Nausea & vomiting associated with constipation, abdominal distention.
		Biliary Colic	-	RUQ	+	-	-	N	Increased bilirubin and alkaline phosphatase	Ultrasound	Nausea & vomiting
		Renal Colic	-	Flank Pain	-	-	-	N	Hematuria	CT scan and ultrasound	Colicky abdominal pain associated with nausea & vomiting
Vascular Disorders	Ischemic causes	Mesenteric Ischemia	+/-	Periumbilical	-	-	-	Hyperactive	Leukocytosis and lactic acidosis	CT scan	Nausea & vomiting, normal physical examination
		Acute Ischemic Colitis	+/-	Diffuse	-	+	+	Hyperactive then absent	Leukocytosis	CT scan	Nausea & vomiting
	Hemorrhagic causes	Ruptured Abdominal Aortic Aneurysm	-	Diffuse	-	-	-	N	Normal	CT scan	Unstable hemodynamics
		Intraabdominal or Retroperitoneal Hemorrhage	-	Diffuse	-	-	-	N	Anemia	CT scan	History of trauma
Gynaecological Causes	Ovarian Cyst Complications	Torsion of the Cyst	-	RLQ / LLQ	-	+/-	+/-	N	Increased ESR and CRP	Ultrasound	Sudden onset sever pain with nausea and vomiting
		Cyst Rupture	-	RLQ / LLQ	-	+/-	+/-	N	Increased ESR and CRP	Ultrasound	Sudden onset sever pain with nausea and vomiting
	Pregnancy	Ruptured Ectopic Pregnancy	-	RLQ / LLQ	-	-	-	N	Positive pregnancy test	Ultrasound	History of missed period and vaginal bleeding