Abdominal pain

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). Rigidity (involuntary contraction of the abdominal
muscles) is the most specific exam finding for diagnosing peritonitis (+ likelihood ratio: 3.9). The
presence of these signs in a patient is sometimes referred to as peritonism.[7] 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.

Other symptoms

Diffuse abdominal rigidity ("abdominal guarding") is often present, especially in generalized peritonitis

Fever

Sinus tachycardia

Development of ileus paralyticus (i.e., intestinal paralysis), 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 kidney
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.

Complicated peritonitis typically involves multiple organs.

Causes

Infection

Perforation of part of the gastrointestinal tract is the most common cause of peritonitis. Examples
include perforation of the distal esophagus (Boerhaave syndrome), of the stomach (peptic ulcer, gastric
carcinoma), of the duodenum (peptic ulcer), of the remaining intestine (e.g., appendicitis, diverticulitis,
Meckel diverticulum, inflammatory bowel disease (IBD), intestinal infarction, intestinal strangulation,
colorectal carcinoma, meconium peritonitis), or of the gallbladder (cholecystitis). Other possible reasons
for perforation include abdominal trauma, ingestion of a sharp foreign body (such as a fish bone,
toothpick or glass shard), 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
(e.g., Escherichia coli) and anaerobic bacteria (e.g., Bacteroides fragilis). 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.[8]

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.[9]

Spontaneous bacterial peritonitis (SBP) is a peculiar form of peritonitis occurring in the absence of an
obvious source of contamination. It occurs in patients with ascites, including children.

Intra-peritoneal dialysis predisposes to peritoneal infection (sometimes named "primary peritonitis" in

this context).

Systemic infections (such as tuberculosis) may rarely have a peritoneal localisation.

Pelvic inflammatory disease[10]

Non-infection

Leakage of sterile body fluids into the peritoneum, such as blood (e.g., endometriosis, blunt abdominal
trauma), gastric juice (e.g., peptic ulcer, gastric carcinoma), bile (e.g., liver biopsy), urine (pelvic trauma),
menstruum (e.g., salpingitis), pancreatic juice (pancreatitis), 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 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 (e.g., gauze, sponge).

Much rarer non-infectious causes may include familial Mediterranean fever, TNF receptor associated
periodic syndrome, porphyria, and systemic lupus erythematosus.

Risk factors
Previous history of peritonitis

History of alcoholism

Liver disease

Fluid accumulation in the abdomen

Weakened immune system

Pelvic inflammatory disease

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 (+ likelihood ratio: 3.9). 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 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 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 (see above);
once one or more agents grow in cultures isolated, therapy will be target against them.

Gram positive and gram negative organisms must be covered. Out of the cephalosporins, cefoxitin and
cefotetan can be used to cover gram positive bacteria, gram negative bacteria, and anaerobic bacteria.
Beta-lactams with beta lactamase inhibitors can also be used, examples include ampicillin/sulbactam,
piperacillin/tazobactam, and ticarcillin/clavulanate.[11] 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.[12] 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 (e.g., perforated peptic ulcer,
appendicitis, and diverticulitis) have a mortality rate of about <10% in otherwise healthy patients. The
mortality rate rises to about 40% in the elderly, or in those with significant underlying illness, as well as
cases that present late (after 48 hours).

Without being treated, generalised peritonitis almost always causes death. The stage magician Harry
Houdini died this way, having contracted streptococcus peritonitis after his appendix ruptured and was
removed too late to prevent spread of the infection.

Etymology
The term "peritonitis" comes from Greek περιτόναιον peritonaion "peritoneum, abdominal membrane"
and -itis "inflammation".[13]

References

Ferri, Fred F. (2017). Ferri's Clinical Advisor 2018 E-Book: 5 Books in 1. Elsevier Health Sciences. pp. 979–
980. ISBN 9780323529570.

"Peritonitis - National Library of Medicine". PubMed Health. Retrieved 22 December 2017.

"Peritonitis". NHS. 28 September 2017. Retrieved 31 December 2017.

"Acute Abdominal Pain". Merck Manuals Professional Edition. Retrieved 31 December 2017.

"Acute Abdominal Pain". Merck Manuals Consumer Version. Retrieved 31 December 2017.

"Encyclopaedia : Peritonitis". NHS Direct Wales. 25 April 2015. Retrieved 31 December 2017.

"Biology Online's definition of peritonism". Retrieved 2008-08-14.

"Causes". Mayo Clinic. Retrieved July 2, 2016.

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.

Ljubin-Sternak, Suncanica; Mestrovic, Tomislav (2014). "Review: Clamydia trachonmatis and Genital
Mycoplasmias: Pathogens with an Impact on Human Reproductive Health". Journal of Pathogens. 2014
(183167): 1. doi:10.1155/2014/183167. PMC 4295611. PMID 25614838.

Appropriate Prescribing of Oral Beta-Lactam Antibiotics

"Peritonitis: Emergencies: Merck Manual Home Edition". Retrieved 2007-11-25.

peritonitis - Online Etymology Dictionary