4.
3
Karlos Noel R. Aleta, MD
Schwartz and Sabiston
Ang trans na ito ay based sa Schwartz at Sabiston. Ang laman
ay peritonitis at super short na abdominal abscess (kasi yun
lang talaga ang laman ng 2 books). Hindi nilagay yung 2014
old trans dahil ibang lecturer yun (si Dr. Enriquez at iba-ibang
books ang gamit niya noon). Better na i-review pa din yung
lecture ni Dr. Aleta.
SCHWARTZ
PERITONITIS
 intra-abdominal infection
 microbial contamination of the peritoneal cavity
 classified according etiology
PRIMARY MICROBIAL PERITONITIS
 occurs when microbes invade the normally sterile
confines of the peritoneal cavity via hematogenous
dissemination from a distant source of infection or direct
inoculation
o this process is more common among patients who retain
large amounts of peritoneal fluid due to ascites, and in
those individuals who are being treated for renal failure
via peritoneal dialysis
 these infections invariably are monomicrobial and rarely
require surgical intervention
DIAGNOSIS
 diagnosis is established based on:
o patient who has ascites for medical reasons
o physical examination that reveals diffuse tenderness
and guarding without localized findings
o absence of pneumoperitoneum on abdominal flat plate
and upright roentgenograms
o presence of more than 100 WBCs/mL
o microbes with a single morphology on Gram's stain
performed on fluid obtained via paracentesis
 subsequent cultures will typically demonstrate the
presence of gram-positive organisms in patients
receiving peritoneal dialysis
TREATMENT
 treatment consists of administration of an antibiotic to
which the organism is sensitive; often 14 to 21 days of
therapy are required
 removal of indwelling devices (e.g., peritoneal dialysis
catheter or peritoneovenous shunt) may be required for
effective therapy of recurrent infections
SECONDARY MICROBIAL PERITONITIS
 occurs subsequent to contamination of the peritoneal
cavity due to perforation or severe inflammation and
infection of an intra-abdominal organ
 examples include:
o appendicitis
o perforation of any portion of the GI tract
o diverticulitis
Agatep, Dela Fuente, Detera, Leynes, Rodriguez, Tejano
10 February 2014
Peritonitis
DIAGNOSIS
 the vast majority of intra-abdominal abscesses can be
effectively diagnosed via abdominal computed
tomographic (CT) imaging techniques and drained
percutaneously
TREATMENT
 effective therapy requires:
o source control to resect or repair the diseased organ
o deridement of necrotic, infected tissue and debris
o administration of antimicrobial agents directed against
aerobes and anaerobes
 this type of antibiotic regimen should be chosen
because in most patients the precise diagnosis
cannot be established until exploratory laparotomy is
performed, and the most morbid form of this disease
process is colonic perforation, due to the large
number of microbes present
 a combination of agents or single agents with a
broad spectrum of activity can be used for this
purpose; conversion of a parenteral to an oral
regimen when the patient's ileus resolves will provide
results similar to those achieved with IV antibiotics
 effective source control and antibiotic therapy is associated
with low failure rates and a mortality rate of approximately
5 to 6%
 inability to control the source of infection leads to mortality
greater than 40%
 the response rate to effective source control and use of
appropriate antibiotics has remained approximately 70 to
90% over the past several decades
 Patients in whom standard therapy fails develop an intra-
abdominal abscess, leakage from a GI anastomosis leading
to postoperative peritonitis, or tertiary (persistent)
peritonitis
 Microbes such as E. faecalis and faecium , S. epidermidis ,
C. albicans , and P. aeruginosa can be identified, typically in
combination, and may be selected based on their lack of
responsiveness to the initial antibiotic regimen, coupled
with diminished activity of host defenses
 Unfortunately, even with effective antimicrobial agent
therapy, this disease process is associated with mortality
rates in excess of 50%
 surgical intervention is reserved for:
o those who harbor multiple abscesses
o those with abscesses in proximity to vital structures
such that percutaneous drainage would be hazardous
o those in whom an ongoing source of contamination
(e.g., enteric leak) is identified
 A short course (3 to 7 days) of antibiotics that possess
aerobic and anaerobic activity seems reasonable, and most
practitioners leave the drainage catheter in situ until it is
clear that cavity collapse has occurred, output is less than
10 to 20 mL/d, no evidence of an ongoing source of
contamination is present, and the patient's clinical condition
has improved.
Page 1 of 3
 Peritonitis

SABISTON PROGNOSIS
 The immediate mortality risk due to SBP is low, particularly
PERITONITIS if recognized and treated expeditiously.
 inflammation of the peritoneum and peritoneal cavity o However, the development of other complications of
 is most commonly due to a localized or generalized hepatic failure, including gastrointestinal hemorrhage or
infection hepatorenal syndrome, contributes to the death of many
PRIMARY  results from bacterial, chlamydial, fungal, of these patients during the hospitalization in which SBP
PERITONITIS or mycobacterial infection in the absence is detected.
of perforation of the gastrointestinal tract
SECONDARY  occurs in the setting of gastrointestinal TUBERCULOUS PERITONITIS
PERITONITIS perforation  Peritoneal tuberculosis is the sixth most common site of
 frequent causes of secondary bacterial extrapulmonary tuberculosis after lymphatic, genitourinary,
peritonitis include: bone and joint, miliary, and meningeal
o peptic ulcer disease  Most cases of tuberculous peritonitis result from
o acute appendicitis reactivation of latent peritoneal disease that had been
o colonic diverticulitis previously established hematogenously from a primary
o pelvic inflammatory disease pulmonary focus
 About one-sixth of cases are associated with active
SPONTANEOUS BACTERIAL PERITONITIS (SBP) pulmonary disease
 defined as a bacterial infection of ascitic fluid in the  The illness often presents insidiously, with patients having
absence of an intra-abdominal, surgically treatable had symptoms for several weeks to months at the time
source of infection of presentation
 although most commonly associated with cirrhosis, SBP  MOST COMMON SYMPTOM: Abdominal swelling due to
may also occur in patients with nephrotic syndrome and, ascites formation occurring in >80% of instances
less commonly, congestive heart failure  Similarly, most patients complain of a nonlocalized,
 it is extremely rare for patients with ascitic fluid containing vague abdominal pain
a high protein concentration to develop SBP, such as those  Constitutional symptoms reported in about 60% of
with peritoneal carcinomatosis patients:
 most common pathogens in adults with SBP: o low-grade fever and night sweats
o Escherichia coli o weight loss
o Klebsiella pneumonia o anorexia
 in children with nephrogenic or hepatogenic ascites: o malaise
o group A streptococcus  Abdominal tenderness is present upon palpation in about
o Staphylococcus aureus half of patients with peritoneal tuberculosis
o Streptococcus pneumonia  A positive tuberculin skin test is present in most cases,
whereas only about half of these patients will have an
DIAGNOSIS abnormal chest radiograph.
 The ascitic fluid SAAG is <1.1 g/dL, consistent with a high
 made initially by demonstrating more than 250
protein concentration within the ascitic fluid.
neutrophils/mm3 of ascitic fluid in a clinical setting
 Microscopic examination of the ascites shows:
consistent with this diagnosis (abdominal pain, fever, or
o erythrocytes
leukocytosis in a patient with low-protein ascites)
o increased number of leukocytes, most of which are
lymphocytes
TREATMENT
 Broad-spectrum antibiotics, such as a third-generation DIAGNOSIS
cephalosporin
o are started immediately in patients suspected of having
ULTRASOUND CT
ascitic fluid infection
 may demonstrate the  will demonstrate the
o these agents cover about 95% of the flora most
presence of echogenic thickened and nodular
commonly associated with SBP material within the ascitic mesentery with
o the spectrum of the antibiotic coverage may be fluid, seen as fine mobile mesenteric
narrowed once the results of antibiotic sensitivity tests strands or particulate lymphadenopathy and
are known matter omental thickening.
 Repeat paracentesis with ascitic fluid analysis is not needed  may suggest the diagnosis but lacks the sensitivity and
in the usual case in which there is rapid improvement in specificity to be diagnostic
response to antibiotic therapy.  The diagnosis is made by laparoscopy with directed
 If the setting, symptoms, ascitic fluid analysis, or response biopsy of the peritoneum.
to therapy are atypical, repeat paracentesis may be helpful o in more than 90% of cases, laparoscopy demonstrates
in detecting secondary peritonitis. multiple whitish nodules (<5 mm) scattered over
 Multiple bacterial isolates, particularly of gram-negative the visceral and parietal peritoneum; histologic
enteric organisms, combined with a poor response to examination of these nodules demonstrates caseating
antibiotic therapy, suggests the presence of secondary granulomas
peritonitis.

Agatep, Dela Fuente, Detera, Leynes, Rodriguez, Tejano Page 2 of 3

 Peritonitis

 Multiple adhesions are commonly present between the ABDOMINAL ABSCESSES

abdominal organs and the parietal peritoneum.
 The gross appearance of the peritoneal cavity is similar to
that of peritoneal carcinomatosis, sarcoidosis, and Crohn's
disease, thus reiterating the importance of biopsy
 Blind percutaneous peritoneal biopsy
o has a much lower yield than directed biopsy
 Laparotomy with peritoneal biopsy
o is reserved for those cases in which laparoscopy has
been nondiagnostic or cannot be safely performed.
 Microscopic examination of ascitic fluid for acid-fast
bacilli:
o identifies the organism in less than 3% of cases
o culture results are positive in less than 20% of cases
 Diagnostic usefulness of mycobacterial cultures
o further limited by the time it may take for the cultures
to yield definitive information (up to 8 weeks)
 Treatment
o includes antituberculous drugs
o drug regimens useful in treating pulmonary tuberculosis
are also effective for peritoneal disease, with isoniazid
and rifampin daily for 9 months being a commonly
used and effective regimen
PERITONITIS ASSOCIATED WITH CHRONIC
AMBULATORY PERITONEAL DIALYSIS (CAPD)
 Peritonitis is one of the most common complications of
chronic ambulatory peritoneal dialysis, occurring with an
incidence of about one episode every 1 to 3 years.
 Refractory or recurrent peritonitis was the most
common cause of technical failure, accounting for 43% of
all cases of technique failure
 Patients present with:
o abdominal pain
o fever
o cloudy peritoneal dialysate containing more than 100
leukocytes/mm3, with more than 50% of the cells being
neutrophils
 Postsurgical intra-abdominal abscesses can present with
vague complaints of:
o intermittent abdominal pain
o fever
o leucocytosis
o change in bowel habits
 Depending on the type and timing of the original procedure,
the clinical assessment of these complaints is sometimes
difficult, and a CT scan is usually required.
 When a fluid collection within the peritoneal cavity is found
on CT scan, antibiotics and percutaneous drainage of
the collection is the treatment of choice.
 There should still be a determination as to what the cause
of the infection was, so tailored antibiotic therapy can be
initiated
 Initial antibiotic treatment is usually with broad-spectrum
antibiotics such as piperacillin-tazobactam or imipenem
 Should the patient exhibit signs of peritonitis and/or have
free air on x-ray or CT scan, then re-exploration should be
considered.
 For patients who present primarily (i.e., not
postoperatively) with the clinical and radiologic findings of
an abscess but are clinically stable, the etiology of the
abscess must be determined.
o A plan for drainage of the abscess and decisions about
further diagnostic studies with consideration of the
timing of any definitive surgery all need to be balanced.
 This can be a complex set of decisions, depending on
the etiology (e.g., appendicitis or diverticulitis); but if
the patient exhibits signs of peritonitis, urgent
surgical exploration should be performed.

DIAGNOSIS
 Gram stain detects organisms in only about 10% to 40%
of cases
 About 75% of infections are due to gram-positive
organisms, with Staphylococcus epidermidis
accounting for 30% to 50% of cases
o S. aureus, gram-negative bacilli, and fungi are also
important causes of dialysis-associated peritonitis

TREATMENT
 Peritoneal dialysis–associated peritonitis is treated by the
intraperitoneal administration of antibiotics, most
commonly a first-generation cephalosporin
 75% of infections are cured by culture-directed
antibiotic therapy
 The cure rate for peritonitis due to coagulase-negative
staphylococcus is nearly 90%, compared with the rates for
peritonitis due to S. aureus, gram-negative bacilli, or fungi
of 66%, 56%, and 0%, respectively
 Recurrent or persistent peritonitis requires removal
of the dialysis catheter and resumption of
hemodialysis.

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