Peritonitis
Other namesSurgical abdomen, acute abdomen[1]
Peritonitis from tuberculosis
Pronunciation
SpecialtyEmergency medicine, general surgery
SymptomsSevere pain, swelling of the abdomen, fever[2][3]
ComplicationsShock, acute respiratory distress syndrome[4][5]
Usual onsetSudden[1]
TypesPrimary, secondary, tertiary Generalized, localized [1]
CausesPerforation of the intestinal tract, pancreatitis, pelvic inflammatory disease, cirrhosis, ruptured appendix[3]
Risk factorsAscites, peritoneal dialysis[4]
Diagnostic methodExamination, blood tests, medical imaging[6]
TreatmentAntibiotics, intravenous fluids, pain medication, surgery[3][4]
FrequencyRelatively common[1]

Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs.[2] Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss.[2][3] One part or the entire abdomen may be tender.[1] Complications may include shock and acute respiratory distress syndrome.[4][5]

Causes include perforation of the intestinal tract, pancreatitis, pelvic inflammatory disease, stomach ulcer, cirrhosis, or a ruptured appendix.[3] Risk factors include ascites (the abnormal build-up of fluid in the abdomen) and peritoneal dialysis.[4] Diagnosis is generally based on examination, blood tests, and medical imaging.[6]

Treatment often includes antibiotics, intravenous fluids, pain medication, and surgery.[3][4] Other measures may include a nasogastric tube or blood transfusion.[4] Without treatment death may occur within a few days.[4] About 20% of people with cirrhosis who are hospitalized have peritonitis.[1]

Signs and symptoms

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Abdominal pain

The main manifestations of peritonitis are acute abdominal pain, abdominal tenderness, abdominal guarding, rigidity, which are exacerbated by moving the peritoneum, e.g., coughing (forced cough may be used as a test), flexing one's hips, or eliciting the Blumberg sign (meaning that pressing a hand on the abdomen elicits less pain than releasing the hand abruptly, which will aggravate the pain, as the peritoneum snaps back into place). Rigidity is highly specific for diagnosing peritonitis (specificity: 76–100%).[7] The presence of these signs in a person is sometimes referred to as peritonism.[8] The localization of these manifestations depends on whether peritonitis is localized (e.g., appendicitis or diverticulitis before perforation), or generalized to the whole abdomen. In either case, pain typically starts as a generalized abdominal pain (with involvement of poorly localizing visceral innervation of the visceral peritoneal layer), and may become localized later (with involvement of the somatic innervation of the parietal peritoneal layer). Peritonitis is an example of an acute abdomen.

Other symptoms

Complications

Causes

Infection

Non-infection

Risk factors

Diagnosis

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A diagnosis of peritonitis is based primarily on the clinical manifestations described above. Rigidity (involuntary contraction of the abdominal muscles) is the most specific exam finding for diagnosing peritonitis.[12] If focal peritonitis is detected, further work-up should be done. If diffuse peritonitis is detected, then urgent surgical consultation should be obtained, and may warrant surgery without further investigations. Leukocytosis, hypokalemia, hypernatremia, and acidosis may be present, but they are not specific findings. Abdominal X-rays may reveal dilated, edematous intestines, although such X-rays are mainly useful to look for pneumoperitoneum, an indicator of gastrointestinal perforation. The role of whole-abdomen ultrasound examination is under study and is likely to expand in the future. Computed tomography (CT or CAT scanning) may be useful in differentiating causes of abdominal pain. If reasonable doubt still persists, an exploratory peritoneal lavage or laparoscopy may be performed. In people with ascites, a diagnosis of peritonitis is made via paracentesis (abdominal tap): More than 250 polymorphonuclear cells per μL is considered diagnostic. In addition, Gram stain is almost always negative, whereas culture of the peritoneal fluid can determine the microorganism responsible and determine their sensitivity to antimicrobial agents.

Pathology

In normal conditions, the peritoneum 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 people who are dehydrated, 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.

Treatment

Depending on the severity of the person'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 people. The mortality rate rises to 35% in peritonitis patients who develop sepsis, and patients who have underlying renal insufficiency and complications have a higher mortality rate.[17]

Etymology

The term "peritonitis" comes from Greek περιτόναιον peritonaion "peritoneum, abdominal membrane" and -itis "inflammation".[18]

References

  1. ^ a b c d e f Ferri, Fred F. (2017). Ferri's Clinical Advisor 2018 E-Book: 5 Books in 1. Elsevier Health Sciences. pp. 979–980. ISBN 9780323529570. Archived from the original on 2020-10-08. Retrieved 2020-08-24.
  2. ^ a b c "Peritonitis - National Library of Medicine". PubMed Health. Archived from the original on 2016-01-24. Retrieved 22 December 2017.
  3. ^ a b c d e f "Peritonitis". NHS. 28 September 2017. Archived from the original on 31 December 2017. Retrieved 31 December 2017.
  4. ^ a b c d e f g h "Acute Abdominal Pain". Merck Manuals Professional Edition. Archived from the original on 13 July 2018. Retrieved 31 December 2017.
  5. ^ a b "Acute Abdominal Pain". Merck Manuals Consumer Version. Archived from the original on 13 July 2018. Retrieved 31 December 2017.
  6. ^ a b "Encyclopaedia : Peritonitis". NHS Direct Wales. 25 April 2015. Archived from the original on 31 December 2017. Retrieved 31 December 2017.
  7. ^ McGee, Steven R. (2018). "Abdominal Pain and Tenderness". Evidence-based physical diagnosis (4th ed.). Philadelphia, PA: Elsevier. ISBN 9780323508711. OCLC 959371826.
  8. ^ "Biology Online's definition of peritonism". Archived from the original on 2018-06-12. Retrieved 2008-08-14.
  9. ^ "Peritonitis - Symptoms and causes". Mayo Clinic. Archived from the original on September 22, 2017. Retrieved July 2, 2016.
  10. ^ Arfania D, Everett ED, Nolph KD, Rubin J (1981). "Uncommon causes of peritonitis in patients undergoing peritoneal dialysis". Archives of Internal Medicine. 141 (1): 61–64. doi:10.1001/archinte.141.1.61. PMID 7004371.
  11. ^ Ljubin-Sternak, Suncanica; Mestrovic, Tomislav (2014). "Review: Chlamydia trachonmatis and Genital Mycoplasmias: Pathogens with an Impact on Human Reproductive Health". Journal of Pathogens. 2014 (183167): 183167. doi:10.1155/2014/183167. PMC 4295611. PMID 25614838.
  12. ^ Nishijima, D. K., Simel, D. L., Wisner, D. H., & Holmes, J. F. (2012). Does this adult patient have a blunt intra-abdominal injury?. JAMA, 307(14), 1517–1527. https://doi.org/10.1001/jama.2012.422
  13. ^ "Peritoneal Dialysis". Brenner and Rector's The Kidney (11th ed.). Philadelphia, PA: Elsevier. 2020. pp. 2094–2118. ISBN 9780323759335.
  14. ^ Holten, Keith B.; Onusko, Edward M. (August 1, 2000). "Appropriate Prescribing of Oral Beta-Lactam Antibiotics". American Family Physician. 62 (3): 611–620. PMID 10950216. Archived from the original on June 22, 2018. Retrieved July 22, 2019.
  15. ^ Li, Philip Kam-Tao; Szeto, Cheuk Chun; Piraino, Beth; de Arteaga, Javier; Fan, Stanley; Figueiredo, Ana E.; Fish, Douglas N.; Goffin, Eric; Kim, Yong-Lim; Salzer, William; Struijk, Dirk G. (September 2016). "ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment". Peritoneal Dialysis International: Journal of the International Society for Peritoneal Dialysis. 36 (5): 481–508. doi:10.3747/pdi.2016.00078. ISSN 0896-8608. PMC 5033625. PMID 27282851.
  16. ^ "Peritonitis: Emergencies: Merck Manual Home Edition". Archived from the original on 2010-10-18. Retrieved 2007-11-25.
  17. ^ "Peritonitis and Abdominal Sepsis: Background, Anatomy, Pathophysiology". 2021-07-14. Cite journal requires |journal= (help)
  18. ^ "peritonitis - Online Etymology Dictionary". Archived from the original on 2011-09-16. Retrieved 2017-05-09.
Classification
External resources