History

Fact Explanation
Usually occurs due to an infection This is a common emergency. peritoneum is the serosal memebrane which lines the abdominal cavity. When this serosal membrane gets inflamed, it's known as Peritonitis. It is either infectious or sterile or either primary or secondary. Infective microorganisms can cause infectious peritonitis. Perforation of a viscus which releases blood, bile acid, feces is another method in which peritonitis occurs. There's usually no underlying pathology for primary or spontaneous peritonitis but secondary is due to an underlying secondary cause. [1] [2] [3]
Fever with chills [5] Underlying sepsis is the cause. Micro-organisms, white blood cells release interleukins which act on the thermo regulatory centre in the hypothalamus anc causes high temperature. [5]
Abdominal pain or discomfort [3] [4] Pain is diffuse when visceral peritoneum is inflamed but rather sharp and localized when it involves the parietal peritoneum. Diagnosis of peritonitis is usually clinical. Patient usually lies still as the movement exacerbates the pain. In the history previous abdominal surgery, previous history of peritonitis, Immunosuppressive agents, and history of pepitc ulcer disease, diverticlulits, inflammatory bowel disease need to be inquired. [3] [4]
Anorexia, nausea, vomiting [6] Intestinal obstruction due to underlying pathology Ex: obstruction of the proximal intestine can cause nausea and vomiting. [6]
Diarrhea [6] Due to underlying ileus/ paralysis of intestines. The intestinal paralysis that follows peritonitis is explained as the result of local inflammation of the overlying serosa (Stokes's law). When peritonitis was achieved, all motor activity ceased in the intracavitary loops. [6]
Ascites [7] This is due to transudation of fluid through serosal membranes when these are inflamed. [7]
Inability to pass urine, confusion [7] These symptoms usually indicate the presence of acute renal failure. Because of fluid transduation and causes hypovolemia. This leads to inadequate perfusion of the kidney and acute renal failure. [7]
References
  1. GUPTA SANJAY, KAUSHIK ROBIN. . World J Emerg Surg [online] 2006 December [viewed 21 July 2014] Available from: doi:10.1186/1749-7922-1-13
  2. WIEST R., KRAG A., GERBES A.. Spontaneous bacterial peritonitis: recent guidelines and beyond. Gut [online] December, 61(2):297-310 [viewed 21 July 2014] Available from: doi:10.1136/gutjnl-2011-300779
  3. CHOW KAI MING, CHOW VIOLA CHI YING, HUNG LAWRENCE CHEUNG TSUI, WONG SHIU MAN, SZETO CHEUK CHUN. Tuberculous Peritonitis–Associated Mortality Is High among Patients Waiting for the Results of Mycobacterial Cultures of Ascitic Fluid Samples. CLIN INFECT DIS [online] 2002 August, 35(4):409-413 [viewed 21 July 2014] Available from: doi:10.1086/341898
  4. WOO P. C. Y., WONG S. S. Y., LAU S. K. P., YUEN K.-Y.. Continuous Ambulatory Peritoneal Dialysis-Related Peritonitis Associated with Lancefield Group G Beta-Hemolytic Streptococcus: Report of Two Cases Requiring Tenckhoff Catheter Removal. Journal of Clinical Microbiology [online] December, 42(9):4399-4402 [viewed 21 July 2014] Available from: doi:10.1128/JCM.42.9.4399-4402.2004
  5. CONE L. A., LEUNG M. M.. Culture-Negative Spontaneous Bacterial Peritonitis: An Ambiguous Diagnosis without Peritoneal Biopsy. Clinical Infectious Diseases [online] 1999 December, 29(6):1582-1583 [viewed 21 July 2014] Available from: doi:10.1086/313560
  6. SHAH RS, GOUDA BP, KOCHAR RT. Retained portion of the appendix following laparosocpic appendicectomy causing peritonitis and ileus. J Min Access Surg [online] 2011 December [viewed 21 July 2014] Available from: doi:10.4103/0972-9941.78353
  7. SARTELLI MASSIMO, et al. 2013 WSES guidelines for management of intra-abdominal infections. Array [online] 2013 December [viewed 21 July 2014] Available from: doi:10.1186/1749-7922-8-3

Examination

Fact Explanation
Fever/ Hypothermia [1] [6] Most of the patients are febrile and Elevated temperature is due to release of inflammatory mediators from micro-organisms which act on the thermo-regulatory centre in the hypothalamus. Septicemia can sometimes present with hypothermia [1] [6]
Toxic/ ill looking [1] [5] Patient maybe severely septic and appear ill looking. [1] [5]
Tachycardia [1] [2] [5] Tachycardia is also due to release of inflammatory mediators [1] [2] [5]
Signs of dehydration [1] [5] Vomiting, increased fluid transduation into the peritoneal cavity can cause intravascular hypovolemia therefore signs of dehydration may appear. [1] [5]
Hypotension [1] [5] Intravascular hypovolemia can result in hypotension. [1] [5]
Guarding/ Rigidity [1] [5] Abdominal wall rigidity is a phenomenon that is observed during abdominal examination in which is the patient voluntarily increases the muscle tone when anticipating palpation of the abdomen due to pain. Guarding is involuntary increase in the tone. [1] [5]
Tenderness on abdominal palpation [1] [5] Tenderness to palpation is common usually indicates the underlying pathology. [1] [5]
Distension of the abdomen/ Abdominal mass [1] [5] The abdomen is often distended due to ascitis. Occasionally a mass can be present such as inflammatory mass like inflamed appendix. [1] [5]
Absent bowel sounds [1] [5] Stokes's law implies the intestinal paralysis which follows peritonitis as a result of local inflammation of the overlying serosa. Therefore all motor activity ceased in the intracavitary loops and ileus results, bowel sounds maybe absent. [1] [5]
pain during digital rectal examination (DRE) [1] [4] [5] Inflamed pelvic appendix may cause pain only during a DRE due to it's location. [1] [4] [5]
Pain during vaginal examination (VE) [3] If the cause for peritonitis is endometritis, salpingo-oophoritis, tubo-ovarian abscess there will be pain in VE [3]
References
  1. GUPTA SANJAY, KAUSHIK ROBIN. . World J Emerg Surg [online] 2006 December [viewed 21 July 2014] Available from: doi:10.1186/1749-7922-1-13
  2. CHOW KAI MING, CHOW VIOLA CHI YING, HUNG LAWRENCE CHEUNG TSUI, WONG SHIU MAN, SZETO CHEUK CHUN. Tuberculous Peritonitis–Associated Mortality Is High among Patients Waiting for the Results of Mycobacterial Cultures of Ascitic Fluid Samples. CLIN INFECT DIS [online] 2002 August, 35(4):409-413 [viewed 21 July 2014] Available from: doi:10.1086/341898
  3. EGGERT JAN, SUNDQUIST KRISTINA, VAN VUUREN CAROLINE, FIANU-JONASSON AINO. . BMC Women's Health [online] 2006 December [viewed 05 September 2014] Available from: doi:10.1186/1472-6874-6-16
  4. SHAH RS, GOUDA BP, KOCHAR RT. Retained portion of the appendix following laparosocpic appendicectomy causing peritonitis and ileus. J Min Access Surg [online] 2011 December [viewed 21 July 2014] Available from: doi:10.4103/0972-9941.78353
  5. SARTELLI MASSIMO, et al. 2013 WSES guidelines for management of intra-abdominal infections. Array [online] 2013 December [viewed 21 July 2014] Available from: doi:10.1186/1749-7922-8-3
  6. MALLET M.L.. Pathophysiology of accidental hypothermia. [online] 2002 December, 95(12):775-785 [viewed 05 September 2014] Available from: doi:10.1093/qjmed/95.12.775

Differential Diagnoses

Fact Explanation
Abdominal aneurysm [1] A ruptured abdominal aneurysm causes blood to leak into the peritoneal cavity and might give rise to hemoperitoneum and resultant peritonitis. A typical patient is an elderly male presenting with acute abdomen with hypotension, shock [1] [2]
Acute Appendicitis [3] [4] Typical presentation is initial peri-umbilical pain which later migrates to the right iliac fossa (RIF). Other symptoms are fever, nausea, vomiting. Ruptured inflamed appendix can cause peritonitis as well. [3] [4]
Mesenteric Ischemia [5] When the blood supply is inadequate to the intestines via mesenteric vessels, results in bowel ischemia and eventual gangrene of the bowel wall and presents as acute abdomen. [5]
Pyelonephritis [6] Infection of the kidney is called pyelonephritis and can present as acute abdomen. Also infection of the kidney, it self can cause peritonitis. [6]
Whipple Disease [7] This is a rare multisystem disorder characterized in which patient has malabsorption, mesenteric lymph node enlargement, arthritis, and skin pigmentation and considered as a differential diagnosis. [7]
Familial Mediterranean fever [8] Recurrent episodes of fever, peritonitis, pleuritis, synovitis are observed and mainly affects Jews and Arabs. Abdominal pain that may progress to peritonitis is seen and resembles a surgical abdomen. [8]
Granulomatous peritonitis [9] This occurs in parasitic infestations, sarcoidosis, tumors, Crohn's disease, And symptoms due to peritoneal irritation could occur. [9]
Gynecologic disorders [10] Pelvic inflammatory disease, Rupture of a ovarian cyst, ectopic pregnancy can give rise to acute abdomen. These may be the cause for peritonitis as well [10]
Perforated viscus [3] Gastrointestinal perforation is one of the most common cause of peritonitis. Release of blood, bile acid, gastirc acid, feces can inflame peritoneum and cause secondary peritonitis. [3]
References
  1. O'GARA P. T.. Aortic Aneurysm. [online] 2003 February, 107(6):43e-45 [viewed 24 July 2014] Available from: doi:10.1161/​01.CIR.0000054210.62588.ED
  2. YAP D. Y. H., YIP T. P. S., LUI S. L., LO W. K.. Ruptured Abdominal Aortic Aneurysm As a Cause of Spontaneous Hemoperitoneum in a Patient on Peritoneal Dialysis. Peritoneal Dialysis International [online] December, 31(5):600-602 [viewed 24 July 2014] Available from: doi:10.3747/pdi.2011.00006
  3. MALANGONI MARK A, INUI TAZO. . World J Emerg Surg [online] 2006 December [viewed 24 July 2014] Available from: doi:10.1186/1749-7922-1-25
  4. NSHUTI R, KRUGER D, LUVHENGO TE. Clinical presentation of acute appendicitis in adults at the Chris Hani Baragwanath academic hospital Int J Emerg Med [online] :12 [viewed 24 July 2014] Available from: doi:10.1186/1865-1380-7-12
  5. BRENER ZACHARY Z, WINCHESTER JAMES F, OHM HYUNSOOK K, BERGMAN MICHAEL. Acute non-occlusive mesenteric ischemia of the small bowel in a patient started on hemodialysis: a case report. Array [online] 2008 December [viewed 24 July 2014] Available from: doi:10.1186/1757-1626-1-217
  6. SUN JEN‐TANG, TSAI KUANG‐CHAU, WANG HSIU‐PO, LIEN WAN‐CHING. A Diabetic Man with Abdominal Pain. CLIN INFECT DIS [online] 2008 July, 47(2):286-287 [viewed 24 July 2014] Available from: doi:10.1086/589285
  7. MISBAH S A. Whipple's disease revisited. [online] 2000 October, 53(10):750-755 [viewed 24 July 2014] Available from: doi:10.1136/jcp.53.10.750
  8. BEN-CHETRIT E. Amyloidosis induced, end stage renal disease in patients with familial Mediterranean fever is highly associated with point mutations in the MEFV gene. [online] 2001 February, 60(2):146-149 [viewed 24 July 2014] Available from: doi:10.1136/ard.60.2.146
  9. K RATAN SIMMI. Peritoneal ascariasis presenting as granulomatous peritonitis and omental cyst. TG [online] 2014 December, 34(4):265-267 [viewed 24 July 2014] Available from: doi:10.7869/tg.146
  10. MAZZEI MARIA, GUERRINI SUSANNA, CIOFFI SQUITIERI NEVADA, CAGINI LUCIO, MACARINI LUCA, COPPOLINO FRANCESCO, GIGANTI MELCHIORE, VOLTERRANI LUCA. The role of US examination in the management of acute abdomen. Array [online] 2013 December [viewed 24 July 2014] Available from: doi:10.1186/2036-7902-5-S1-S6

Investigations - for Diagnosis

Fact Explanation
Full blood count [1] [5] Mostly a high white blood cell count is obeserved. But severe sepsis may even cause a leukopenia. Hypersplenism in spontaneous bacterial peritonitis, may reduce the white cell count. [1] [5] [6]
Liver function tests [5] Spontaneous bacterial peritonitis (SBP) may occur in the presence of liver cirrhosis, therefore to assess liver function, this is done. [5]
Amylase and lipase [5] may be done if pancreatitis is suspected as a differential diagnosis for acute abdomen. [5]
Blood culture [5] When a patient is in sepsis, this can be postive and may help guide antibiotic therapy as well. [5]
serum albumin [2] [4] [5] This measurement of the serum-to-ascites albumin gradient (SAAG) more than 1.1 is noted in SBP. [2] [4] [5]
Arterial blood gas analysis [5] Patient may be in an acidotic state due to intravascular hypovolaemia and hypoxemia. [5]
Urineanalysis [5] To rule out pyelonephritis. [5]
Peritoneal fluid analysis [2] [4] [5] An ascitic fluid neutrophil count of greater than 500 cells/µL points towards the diagnosis of spontaneous bacterial peritonitis and the fluid should be evaluated for glucose, lactate dehydrogenase (LDH), protein, cell count, Gram stain, and aerobic and anaerobic cultures and also for AFB as well. Amylase analysis is helpful if pancreatitis is suspected [2] [4] [5]
Bedside reagent strips [2] [5] A portable spectrophotometric device is used to for diagnosis [2] [5]
Abdominal x-ray [1] [3] [5] Perforated viscus may show air under the diaphragm. [1] [3] [5]
Abdominal ultrasound [1] [3] [5] Intra-abdominal abscesses, ascitis, can be assessed [1] [3] [5]
CT-abdomen [1] [3] This also shows ascitis with a high sensitivity and can also detect abscesses [1] [3]
MRI- abdomen [5] Intra-abdominal abscesses are diagnosed with a high sensitivity due to increased soft tissue resolution. [5]
Contrast studies [5] Upper GI follow through with gastrograffin, colorectal enema with contrast, fistulogram are done when peritoneal abscess are suspected. [5]
Peritoneal biopsy [2] To diagnose tuberculous peritonitis, or any malignancies which cause ascitis. [2]
References
  1. MALANGONI MARK A, INUI TAZO. . World J Emerg Surg [online] 2006 December [viewed 25 July 2014] Available from: doi:10.1186/1749-7922-1-25
  2. CONE L. A., LEUNG M. M.. Culture-Negative Spontaneous Bacterial Peritonitis: An Ambiguous Diagnosis without Peritoneal Biopsy. Clinical Infectious Diseases [online] 1999 December, 29(6):1582-1583 [viewed 25 July 2014] Available from: doi:10.1086/313560
  3. WILMORE STEPHANIE MS, REYNOLDS CARL J. Gonococcal peritonitis diagnosed post laparotomy in a 38-year-old woman: a case report. Array [online] 2009 December [viewed 25 July 2014] Available from: doi:10.4076/1757-1626-2-8080
  4. CHOW KAI MING, CHOW VIOLA CHI YING, HUNG LAWRENCE CHEUNG TSUI, WONG SHIU MAN, SZETO CHEUK CHUN. Tuberculous Peritonitis–Associated Mortality Is High among Patients Waiting for the Results of Mycobacterial Cultures of Ascitic Fluid Samples. CLIN INFECT DIS [online] 2002 August, 35(4):409-413 [viewed 25 July 2014] Available from: doi:10.1086/341898
  5. SARTELLI MASSIMO, et al, . 2013 WSES guidelines for management of intra-abdominal infections. Array [online] 2013 December [viewed 25 July 2014] Available from: doi:10.1186/1749-7922-8-3
  6. AL-BUSAFI SAID A., MCNABB-BALTAR JULIA, FARAG AMANDA, HILZENRAT NIR. Clinical Manifestations of Portal Hypertension. International Journal of Hepatology [online] 2012 December, 2012:1-10 [viewed 05 September 2014] Available from: doi:10.1155/2012/203794

Investigations - Fitness for Management

Fact Explanation
Coagulation profile [1] In spontaneous bacterial peritonitis (SBP), associated with liver cirrhosis, a diagnostic paracentesis is done to diagnose SBP. Prior to that a coagulation profile is needed to exclude any bleeding tendency. [1]
References
  1. MALANGONI MARK A, INUI TAZO. . World J Emerg Surg [online] 2006 December [viewed 25 July 2014] Available from: doi:10.1186/1749-7922-1-25

Investigations - Followup

Fact Explanation
Blood culture [1] To follow up a patient with sepsis with treatment, blood cultures are done. [1]
Peritoneal fluid analysis [1] To see the drop in polymorphonuclear count in response to therapy [1]
USS abdomen [2] [3] To detect whether abscesses are fully drained after drainage procedures. [3] [2]
CT abdomen To detect whether abscesses are fully drained after drainage procedures. [3] [2]
MRI abdomen To detect whether abscesses are fully drained after drainage procedures. [3] [2]
References
  1. SARTELLI MASSIMO, et al, . 2013 WSES guidelines for management of intra-abdominal infections. Array [online] 2013 December [viewed 25 July 2014] Available from: doi:10.1186/1749-7922-8-3
  2. MALANGONI MARK A, INUI TAZO. . World J Emerg Surg [online] 2006 December [viewed 25 July 2014] Available from: doi:10.1186/1749-7922-1-25
  3. WILMORE STEPHANIE MS, REYNOLDS CARL J. Gonococcal peritonitis diagnosed post laparotomy in a 38-year-old woman: a case report. Array [online] 2009 December [viewed 25 July 2014] Available from: doi:10.4076/1757-1626-2-8080

Management - General Measures

Fact Explanation
Fluid resuscitation [1] As there's hypovolemia, fluid replacement is done and regular monitoring of vital parameters such as blood pressure, pulse, urine output are done and blood gas analysis, hemoglobin and hematocrit, serum electrolytes and renal function tests are done to detect any complications. [1]
Nutrition [1] [2] [3] Enteral nutrition is considered better thatn parenteral nutrition as it has a low complications rate . However parenteral nutrition is used if there are any contraindications for enteral nutrition. Sepsis leads to increased catabolism therefore high calorie diet may be required [1] [2] [3]
Patient education [1] Patient should be education the aetiology of the disease, nature and course, importance of treatment and the options available for treatment. [1]
References
  1. MALANGONI MARK A, INUI TAZO. . World J Emerg Surg [online] 2006 December [viewed 25 July 2014] Available from: doi:10.1186/1749-7922-1-25
  2. PEARCE C B. Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations. [online] 2002 April, 78(918):198-204 [viewed 25 July 2014] Available from: doi:10.1136/pmj.78.918.198
  3. GRIFFITHS R D. Nutrition support for patients in the intensive care unit. Postgraduate Medical Journal [online] 2005 October, 81(960):629-636 [viewed 25 July 2014] Available from: doi:10.1136/pgmj.2005.033399

Management - Specific Treatments

Fact Explanation
Antibiotic therapy [1] [2] [6] Many antibiotic regimes are available for the treatment of intra-abdominal infections mainly with broad spectrum antibiotics. Gram-positive, gram-negative bacteria and anaerobic coverage is essential. Agents which are commonly used are cefotaxime, aminoglycoside, ampicillin, and sulfamethoxazole.Carbapenems such as Meropenem, Fluroquinolones are also used. [1] [2] [6]
No operative drainage (Percutaneous drainage) [2] Percutaneous drainage under ultrasound or CT guidance for abscesses is carried out. [2]
Surgical drainage [2] [3] Open drainage or laparoscopic drainage is carried out in deep seated abscesses. [2] [3]
Therapeutic paracentesis [4] Sometimes in patients with ascitis, serial paracentesis are needed when fluid is keep on accumulating. This is done as a supportive management.[4]
Antibiotic prophylaxis [1] [6] Prophylaxis is indicated for patients with a history of SBP, Presenting with an upper GI hemorrhage, Low total protein level in ascitic fluid and antibiotics used are Norfloxacin , Ciprofloxacin, trimethoprim-sulfamethoxazole [6]
References
  1. MALANGONI MARK A, INUI TAZO. . World J Emerg Surg [online] 2006 December [viewed 25 July 2014] Available from: doi:10.1186/1749-7922-1-25
  2. SARTELLI MASSIMO. A focus on intra-abdominal infections. Array [online] 2010 December [viewed 25 July 2014] Available from: doi:10.1186/1749-7922-5-9
  3. KORUMILLI RAMESHK, MAHESH SRINIVASA, GINJALA GAUTHAMR. Pyogenic liver abscesses in adults: A 3-year study. Arch Int Surg [online] 2014 December [viewed 25 July 2014] Available from: doi:10.4103/2278-9596.136709
  4. MOORE KP, AITHAL GP. Guidelines on the management of ascites in cirrhosis Gut [online] 2006 Oct, 55(Suppl 6):vi1-vi12 [viewed 25 July 2014] Available from: doi:10.1136/gut.2006.099580
  5. WU HSIN-HSU, LI I-JUNG, WENG CHENG-HAO, LEE CHENG-CHIA, CHEN YUNG-CHANG, CHANG MING-YANG, FANG JI-TSENG, HUNG CHENG-CHIEH, YANG CHIH-WEI, TIAN YA-CHUNG, BURDMANN EMMANUEL A.. Prophylactic Antibiotics for Endoscopy-Associated Peritonitis in Peritoneal Dialysis Patients. PLoS ONE [online] 2013 August [viewed 25 July 2014] Available from: doi:10.1371/journal.pone.0071532
  6. ECKMANN C, DRYDEN M, MONTRAVERS P, KOZLOV R, SGANGA G. Antimicrobial Treatmdent of "Complicated" Intra-Abdominal Infections and The New IDSA Guidelines - A Commentary and an Alternative European Approach According to Clinical Definitions. Array [online] 2011 December [viewed 25 July 2014] Available from: doi:10.1186/2047-783X-16-3-115
  7. ALANIZ C, REGAL RE. Spontaneous Bacterial Peritonitis: A Review of Treatment Options P T [online] 2009 Apr, 34(4):204-210 [viewed 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697093