Peritonitis

From Wikipedia, the free encyclopedia
  (Redirected from Acute peritonitis)
Jump to: navigation, search
Peritonitis
Classification and external resources
ICD-10 K65
ICD-9 567
MedlinePlus 001335
eMedicine med/2737
MeSH D010538

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 (often due to rupture of a hollow organ as may occur in abdominal trauma or appendicitis) or from a non-infectious process.

Signs and symptoms[edit]

Abdominal pain and tenderness[edit]

The main manifestations of peritonitis are acute abdominal pain, abdominal tenderness, and abdominal guarding, 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 (a.k.a. rebound tenderness, 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). The presence of these signs in a patient is sometimes referred to as peritonism.[1] 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 innervation of the visceral peritoneal layer), and may become localized later (with the involvement of the somatically innervated parietal peritoneal layer). Peritonitis is an example of an acute abdomen.

Collateral manifestations[edit]

Complications[edit]

Causes[edit]

Infected peritonitis[edit]

Non-infected peritonitis[edit]

Diagnosis[edit]

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 (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 patients with ascites, a diagnosis of peritonitis is made via paracentesis (abdominal tap): More than 250 polymorphonucleate cells per μL is considered diagnostic. In addition, Gram stain and culture of the peritoneal fluid can determine the microorganism responsible and determine their sensibility to antimicrobial agents.

Pathology[edit]

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[edit]

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 (see above); 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.[2] 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 (laparotomy) 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.[3] The exception is spontaneous bacterial peritonitis, which does not always benefit from surgery and may be treated with antibiotics in the first instance.

Prognosis[edit]

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 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 (after 48 hours).

If untreated, generalised peritonitis is almost always fatal.

Famous Cases[edit]

Famous magician and escape artist Harry Houdini died of peritonitis after a fan asked to punch him in the stomach. At the time Houdini had been suffering from appendicitis, rupturing his already weakened appendix and eventual infection of his peritoneum. Refusing to get medical help he died two days later.

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.

References[edit]

  1. ^ "Biology Online's definition of peritonism". Retrieved 2008-08-14. 
  2. ^ Appropriate Prescribing of Oral Beta-Lactam Antibiotics
  3. ^ "Peritonitis: Emergencies: Merck Manual Home Edition". Retrieved 2007-11-25. 

External links[edit]