Peritonitis, Secondary 951

• Pelvic/abdominal ultrasound: abscess forma-

BASIC INFORMATION DIAGNOSIS tion, abdominal mass, intrauterine versus
P
ectopic pregnancy, identify free fluid sugges-
DEFINITION DIFFERENTIAL DIAGNOSIS tive of hemorrhage or ascites
Peritonitis refers to the acute onset of severe • Postoperative: abscess, sepsis, bowel • CT: mass, ascites
abdominal pain caused by peritoneal inflam- obstruction, injury to internal organs
mation. • Gastrointestinal: perforated viscus, appen-
Secondary peritonitis is a localized (abscess) dicitis, inflammatory bowel disease, infec-
TREATMENT
or diffuse peritonitis originating from a defect in tious colitis, diverticulitis, acute cholecystitis, NONPHARMACOLOGIC THERAPY
abdominal viscus. peptic ulcer perforation, pancreatitis, bowel
• IV hydration to correct dehydration, hypovole-
obstruction
SYNONYMS mia
• Gynecologic: ruptured ectopic pregnan-
• Blood transfusion to correct anemia from
Acute abdomen cy, pelvic inflammatory disease, ruptured

Surgical abdomen
ICD-9CM CODES
567.2 Peritonitis
ICD-10CM CODES
K65.0  Generalized (acute) peritonitis
K65.8  Other peritonitis
K65.9  Peritonitis, unspecified
EPIDEMIOLOGY &
DEMOGRAPHICS
Common presentation as a result of diverse
etiologies; for example, 5% to 10% of the
population has acute appendicitis at some point
in their lives.
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
• Acute abdominal pain
• Abdominal distention and ascites
• Abdominal rigidity, rebound, and guarding
• Fever, chills
• Exacerbation with movement
• Anorexia, nausea, and vomiting
• Constipation
• Decreased bowel sounds
• Hypotension and tachycardia
• Tachypnea, dyspnea
ETIOLOGY
• Microbiology: most common is gram-­negative
bacteria (Escherichia coli, Enterobacter,
Klebsiella, Proteus), gram-positive bacteria
(enterococci, streptococci, staphylococci),
anaerobic bacteria (Bacteroides, Clostridium),
and fungi
• Acute perforation peritonitis: gastrointestinal
perforation, intestinal ischemia, pelvic perito-
nitis, and other forms
• Postoperative peritonitis: anastomotic leak,
accidental perforation, and devascularization
• Posttraumatic peritonitis: after blunt or pen-
etrating abdominal trauma
and Disorders
Diseases
hemorrhage
hemorrhagic ovarian cyst, ovarian torsion,
• Nasogastric decompression, especially if
degenerating leiomyoma
obstruction is present
• Urologic: nephrolithiasis, interstitial cystitis
• Oxygen: intubation if necessary
• Miscellaneous: abdominal trauma, penetrat-
• Bed rest
ing wounds, infections caused by intraperito-
neal dialysis ACUTE GENERAL Rx
• Surgery to correct underlying pathology, such
I
WORKUP
as controlling hemorrhage, correcting perfo-
• Acute peritonitis is mainly a clinical diagnosis
ration, draining abscess
based on patient history and physical exami-
• Broad-spectrum antibiotics to cover both
nation.
gram-negative aerobic and gram-negative
• Laboratory and imaging studies (see
anaerobic bacteria:
“Laboratory Tests”) assist in determining the
1.  Mild-moderate disease: piperacillin-­
need for and type of intervention.
tazobactam 3.375 g IV q6h or 4.5 g IV
• If patient is hemodynamically unstable,
q8h or ticarcillin-clavulanate 3.1 g IV q6h.
immediate diagnostic laparotomy should be
Alternative agents are ciprofloxacin 400
performed in lieu of adjuvant diagnostic stud-
mg IV q12h or levofloxacin 750 mg IV
ies.
q24h plus metronidazole 1 g IV q12h.
LABORATORY TESTS 2.  Severe life-threatening disease: imipe-
nem 500 mg IV q6h or meropenem 1 g IV
• Complete blood count: leukocytosis, left shift,
q8h. Alternative agents are ampicillin plus
anemia
metronidazole plus ciprofloxacin.
• SMA7: electrolyte imbalances, kidney dys-
• Pain control: morphine or meperidine as
function
needed (hold until diagnosis confirmed)
• Liver function tests: ascites from liver dis-
ease, cholelithiasis
DISPOSITION
• Amylase: pancreatitis
Depends on etiology of peritonitis, age of
• Blood cultures: bacteremia, sepsis
patient, coexisting medical disease, and dura-
• Peritoneal cultures: infectious etiology
tion of process before presentation
• Blood gas: respiratory versus metabolic
acidosis REFERRAL
• Ascitic fluid analysis: exudate versus transu-
Surgical consultation is required in all cases of
date
acute peritonitis.
• Urinalysis and culture: urinary tract infection
• Cervical cultures for gonorrhea and
Chlamydia
SUGGESTED READINGS
• Urine/serum human chorionic gonadotropin
Available at www.expertconsult.com
IMAGING STUDIES
AUTHOR: RUBEN ALVERO, M.D.
• Abdominal series: free air from perforation,
small or large bowel dilation from obstruc-
tion, identification of fecalith
• Chest x-ray examination: elevated dia-
phragm, pneumonia
Peritonitis, Secondary 951.e1

SUGGESTED READINGS
Bosscha K et al.: Surgical management of severe secondary peritonitis, Br J Surg
86(11):1371, 1999.
Marshall JC, Innes M: Intensive care management of intra-abdominal infection,
Crit Care Med 31(8):2228, 2003.
Wittmann DH et al.: Management of secondary peritonitis, Ann Surg 224(1):10,
1996.