Acute peritonitis is an inflammation of the tissue lining the abdominal cavity that can be caused by infections from a perforated organ or surgery. It leads to decreased movement in the intestines and buildup of fluid and gas. Left untreated, it can cause rapid dehydration and impact multiple organ systems. Treatment involves rehydration, antibiotics, and surgery to address the underlying cause. Prognosis depends on the patient's overall health and how quickly peritonitis is treated.
Acute peritonitis is an inflammation of the tissue lining the abdominal cavity that can be caused by infections from a perforated organ or surgery. It leads to decreased movement in the intestines and buildup of fluid and gas. Left untreated, it can cause rapid dehydration and impact multiple organ systems. Treatment involves rehydration, antibiotics, and surgery to address the underlying cause. Prognosis depends on the patient's overall health and how quickly peritonitis is treated.
Acute peritonitis is an inflammation of the tissue lining the abdominal cavity that can be caused by infections from a perforated organ or surgery. It leads to decreased movement in the intestines and buildup of fluid and gas. Left untreated, it can cause rapid dehydration and impact multiple organ systems. Treatment involves rehydration, antibiotics, and surgery to address the underlying cause. Prognosis depends on the patient's overall health and how quickly peritonitis is treated.
Acute peritonitis is an inflammation of the tissue lining the abdominal cavity that can be caused by infections from a perforated organ or surgery. It leads to decreased movement in the intestines and buildup of fluid and gas. Left untreated, it can cause rapid dehydration and impact multiple organ systems. Treatment involves rehydration, antibiotics, and surgery to address the underlying cause. Prognosis depends on the patient's overall health and how quickly peritonitis is treated.
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Acute Peritonitis
Peritonitis is an inflammation of the peritoneum; it may be localized or diffuse in location, acute
or chronic in natural history, infectious or aseptic in pathogenesis. Acute peritonitis is most often infectious and is usually related to a perforated viscus (and called secondary peritonitis). When no intraabdominal source is identified, infectious peritonitis is called primary or spontaneous. Acute peritonitis is associated with decreased intestinal motor activity, resulting in distention of the intestinal lumen with gas and fluid. The accumulation of fluid in the bowel together with the lack of oral intake leads to rapid intravascular volume depletion with effects on cardiac, renal, and other systems. Etiology Infectious agents gain access to the peritoneal cavity through a perforated viscus, a penetrating wound of the abdominal wall, or external introduction of a foreign object that is or becomes infected (for example, a chronic peritoneal dialysis catheter). In the absence of immune compromise, host defenses are capable of eradicating small contaminations. The conditions that most commonly result in the introduction of bacteria into the peritoneum are ruptured appendix, ruptured diverticulum, perforated peptic ulcer, incarcerated hernia, gangrenous gall bladder, volvulus, bowel infarction, cancer, inflammatory bowel disease, or intestinal obstruction. However, a wide range of mechanisms may play a role (Table 294-2). Bacterial peritonitis can also occur in the apparent absence of an intraperitoneal source of bacteria (primary or spontaneous bacterial peritonitis). This condition occurs in the setting of ascites and liver cirrhosis in 90% of the cases, usually in patients with ascites with low protein concentration (<1 g/L) (Chap. 302). Bacterial peritonitis is discussed in detail in Chap. 121.
Table 294-2 Conditions Leading to Secondary Bacterial Peritonitis
Perforations of bowel Trauma, blunt or penetrating Inflammation Appendicitis Diverticulitis Peptic ulcer disease Inflammatory bowel disease
Pancreaspancreatitis Gall bladdercholecystitis Urinary bladdertrauma, rupture Liverbile leak after biopsy Fallopian tubessalpingitis Bleeding into the peritoneal cavity
Aseptic peritonitis may be due to peritoneal irritation by abnormal presence of physiologic fluids (e.g., gastric juice, bile, pancreatic enzymes, blood, or urine) or sterile foreign bodies (e.g., surgical sponges or instruments, starch from surgical gloves) in the peritoneal cavity or as a complication of rare systemic diseases such as lupus erythematosus, porphyria, or familial Mediterranean fever (Chap. 323). Chemical irritation of the peritoneum is greatest for acidic gastric juice and pancreatic enzymes. In chemical peritonitis, a major risk of secondary bacterial infection exists. Clinical Features The cardinal manifestations of peritonitis are acute abdominal pain and tenderness, usually with fever. The location of the pain depends on the underlying cause and whether the inflammation is localized or generalized. Localized peritonitis is most common in uncomplicated appendicitis and diverticulitis, and physical findings are limited to the area of inflammation. Generalized peritonitis is associated with widespread inflammation and diffuse abdominal tenderness and rebound. Rigidity of the abdominal wall is common in both localized and generalized peritonitis. Bowel sounds are usually absent. Tachycardia, hypotension, and signs of dehydration are common. Leukocytosis and marked acidosis are common laboratory findings. Plain abdominal films may show dilation of large and small bowel with edema of the bowel wall. Free air under the diaphragm is associated with a perforated viscus. CT and/or ultrasonography can identify the presence of free fluid or an abscess. When ascites is present, diagnostic paracentesis with cell count (>250 neutrophils/ L is usual in peritonitis), protein and lactate dehydrogenase
levels, and culture is essential. In elderly and immunosuppressed patients, signs of peritoneal irritation may be more difficult to detect. Therapy and Prognosis
Treatment relies on rehydration, correction of electrolyte abnormalities, antibiotics, and surgical
correction of the underlying defect. Mortality rates are <10% for uncomplicated peritonitis associated with a perforated ulcer or ruptured appendix or diverticulum in an otherwise healthy person. Mortality rates of 40% have been reported for elderly people, those with
underlying illnesses, and when peritonitis has been present for >48 h.
