Peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall
of the abdomen and covers most of the abdominal organs. Peritonitis may be localized or generalized,
and may result from infection or from a non-infectious process.
Signs and symptoms Abdominal pain and tenderness
The main manifestations of peritonitis are acute abdominal pain, abdominal tenderness
and abdominal guarding, which are exacerbated by moving the peritoneum, e.g., coughing,
flexing one's hips, or eliciting the Blumberg sign. The presence of these signs in a patient
is sometimes referred to as peritonism. The localization of these manifestations depends
on whether peritonitis is localized, or generalized to the whole abdomen. In either case, pain
typically starts as a generalized abdominal pain, and may become localized later. Peritonitis
is an example of an acute abdomen. Collateral manifestations
Diffuse abdominal rigidity is often present, especially in generalized peritonitis
Fever Sinus tachycardia
Development of ileus paralyticus, which also causes nausea, vomiting and bloating.
Complications Sequestration of fluid and electrolytes, as
revealed by decreased central venous pressure, may cause electrolyte disturbances, as well
as significant hypovolemia, 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.
Causes Infected peritonitis
Perforation of part of the gastrointestinal tract is the most common cause of peritonitis.
Examples include perforation of the distal esophagus, of the stomach, of the duodenum,
of the remaining intestine, intestinal infarction, intestinal strangulation, colorectal carcinoma,
meconium peritonitis), or of the gallbladder. Other possible reasons for perforation include
abdominal trauma, ingestion of a sharp foreign body, perforation by an endoscope or catheter,
and anastomotic leakage. The latter occurrence is particularly difficult to diagnose early,
as abdominal pain and ileus paralyticus are considered normal in patients who have just
undergone abdominal surgery. In most cases of perforation of a hollow viscus, mixed bacteria
are isolated; the most common agents include Gram-negative bacilli and anaerobic bacteria.
Fecal peritonitis results from the presence of faeces in the peritoneal cavity. It can
result from abdominal trauma and occurs if the large bowel is perforated during surgery.
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 trauma, surgical wound, continuous ambulatory peritoneal dialysis, and 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 is a peculiar form of peritonitis occurring in the absence
of an obvious source of contamination. It occurs in patients with ascites, in particular,
in children. Intra-peritoneal dialysis predisposes to peritoneal
infection. Systemic infections may rarely have a peritoneal
localisation. Non-infected peritonitis
Leakage of sterile body fluids into the peritoneum, such as blood, gastric juice, bile, urine,
menstruum, pancreatic juice, 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 to 48
hours. Sterile abdominal surgery, under normal circumstances,
causes localised or minimal generalised peritonitis, which may leave behind a foreign body reaction
and/or fibrotic adhesions. However, peritonitis may also be caused by the rare case of a sterile
foreign body inadvertently left in the abdomen after surgery.
Much rarer non-infectious causes may include familial Mediterranean fever, TNF receptor
associated periodic syndrome, porphyria, and systemic lupus erythematosus.
Diagnosis A diagnosis of peritonitis is based primarily
on the clinical manifestations described above. If peritonitis is strongly suspected, then
surgery is performed without further delay for other 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 may be useful in differentiating causes of abdominal pain. If reasonable doubt
still persists, an exploratory peritoneal lavage or laparoscopy may be performed. In
patients with ascites, a diagnosis of peritonitis is made via paracentesis: More than 250 polymorphonucleate
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 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. Treatment
Depending on the severity of the patient's state, the management of peritonitis may include:
General supportive measures such as vigorous intravenous rehydration and correction of
electrolyte disturbances. Antibiotics are usually administered intravenously,
but they may also be infused directly into the peritoneum. The empiric choice of broad-spectrum
antibiotics often consist of multiple drugs, and should be targeted against the most likely
agents, depending on the cause of peritonitis; once one or more agents are actually isolated,
therapy will of course be targeted on them. Gram positive and gram negative organisms
must be covered. Out of the Cephalosporins, cefoxitin and cefotetan can be used to cover
gram positives, gram negatives, and anaerobes. Beta-lactams with beta lactamase inhibitors
can also be used, examples include ampicillin/sulbactam, piperacillin/tazobactam, and ticarcillin/clavulanate.
Carbapenems are also an option when treating primary peritonitis as all of the carbapenems
cover gram positives, gram negatives, and anaerobes except for ertapenem. The only fluoroquinolone
that can be used is moxifloxacin because this is the only fluoroquinolone that covers anaerobes.
Finally, tigecycline is a tetracycline that can be used due to its coverage of gram positives
and gram negatives. Empiric therapy will often require multiple drugs from different classes.
Surgery is needed to perform a full exploration and lavage of the peritoneum, as well as to
correct any gross anatomical damage that may have caused peritonitis. The exception is
spontaneous bacterial peritonitis, which does not always benefit from surgery and may be
treated with antibiotics in the first instance. Prognosis
If properly treated, typical cases of surgically correctable peritonitis have a mortality rate
of about <10% in otherwise healthy patient. The mortality rate rises to about 40% in the
elderly, and/or in those with significant underlying illness, as well as in cases that
present late. If untreated, generalised peritonitis is almost
always fatal. Famous cases
On May 13, 1864, 21-year-old Private William Christman of Pennsylvania, who had died of
peritonitis, became the first military man buried at Arlington. The Swiss Freudian psychiatrist
and psychoanalyst Hermann Rorschach, best known for developing a projective test known
as the Rorschach inkblot test, died of peritonitis in 1922 at the age of 37.
Famous magician and escape artist Harry Houdini died of peritonitis after a fan asked to punch
him in the stomach, a practice that had become a part of Houdini's repertoire. Speculation
remains in regard to the exact reason for the performer's death, but one medical professional
has suggested that the punch caused a rupture in Houdini's intestine. Following Houdini's
initial refusal of surgical treatment—four physicians tried to persuade him to undergo
surgery—he died two days later on October 31, 1926, even though he eventually agreed
to undergo surgery. Actor Rudolph Valentino died of peritonitis
on August 23, 1926, after suffering a ruptured appendix. He also developed pleuritis in his
left lung and died several hours after entering into a comatose state.
Rhythm and blues singer Chuck Willis died from peritonitis in 1958 at the peak of his
popularity. References
^ "Biology Online's definition of peritonism". Retrieved 2008-08-14.
^ Appropriate Prescribing of Oral Beta-Lactam Antibiotics
^ "Peritonitis: Emergencies: Merck Manual Home Edition". Retrieved 2007-11-25.
^ Kalush, William; Sloman, Larry. The Secret Life of Houdini: The Making of America's First
Superhero. Simon & Schuster. ISBN 978-0-7432-7207-0. ^ SmarterEveryDay. "How Houdini DIED - Smarter
Every Day 108". SmarterEveryDay on YouTube. Google, Inc. Retrieved 30 May 2014.
^ "Valentino Loses Battle With Death: Greatest of Screen Lovers Fought Valiantly For Life".
The Plattsburgh Sentinel. Associated Press. August 24, 1926. p. 1. Retrieved 2010-05-15.
^ Gilbert King. "The "Latin Lover" and His Enemies". Smithsonian.com. Smithsonian Institution.
Retrieved 30 May 2014. External links
Peritonitis disease causes, treatment treatment basis
Article on peritonitis at AllRefer.com Genuit T and Napolitano L. 2004. Peritonitis
and Abdominal Sepsis at Emedicine.com Peritonitis at HealthCentral.com
openabdomen.org - Peritonitis, Medical and Surgical Therapy Reviewed