Peritonitis

Introduction: Peritonitis is an inflammation of the peritoneum, the thin membrane that lines the abdominal wall and covers the organs within. The inflammation is caused by a bacterial or fungal infection of this membrane. There are two major types of peritonitis. Primary peritonitis is caused by the spread of an infection from the blood and lymph nodes to the peritoneum. This type of peritonitis is rare -- less than 1% of all cases of peritonitis are primary. The more common type of peritonitis, called secondary peritonitis, is caused when the infection comes into the peritoneum from the gastrointestinal or biliary tract. Both cases of peritonitis are very serious and can be life threatening if not treated quickly.

Causes

By Mayo Clinic staff

Infection of the peritoneum can happen for a variety of reasons. Here are the most common causes of peritonitis: Peritoneal dialysis. Dialysis removes waste products and extra fluid from your blood when your kidneys can no longer adequately do so. With peritoneal dialysis, the network of tiny blood vessels in your abdomen (peritoneal cavity) is used to filter your blood. Peritonitis is the most common complication associated with peritoneal dialysis. An infection may occur during peritoneal dialysis due to unclean surroundings, poor hygiene or contaminated equipment. Fluid buildup. Diseases that cause liver damage, such as cirrhosis, can result in a large amount of fluid buildup in your abdominal cavity (ascites). That fluid buildup is susceptible to bacterial infection. This type of peritonitis is called spontaneous peritonitis.

Secondary peritonitis When other medical conditions result in an infection that causes peritonitis, it's referred to as secondary peritonitis. These causes include:

A ruptured appendix, stomach ulcer or perforated colon. Any of these conditions can allow bacteria to get into the peritoneum through a hole in your gastrointestinal tract. Pancreatitis. Inflammation of your pancreas (pancreatitis) complicated by infection may lead to peritonitis if the bacteria spread outside the pancreas. Diverticulitis. Infection of small, bulging pouches in your digestive tract (diverticulitis) may cause peritonitis if one of the pouches ruptures, spilling intestinal waste into your abdomen. Trauma. Injury or trauma may cause peritonitis by allowing bacteria or chemicals from other parts of your body to enter the peritoneum.

Risk factors
By Mayo Clinic staff
Factors that increase your risk of peritonitis include:

Peritoneal dialysis. Peritonitis is common among people undergoing peritoneal dialysis. Other medical conditions. The following medical conditions increase your risk of developing peritonitis: cirrhosis, appendicitis, Crohn's disease, stomach ulcers, diverticulitis and pancreatitis. History of peritonitis. Once you've had peritonitis, your risk of developing it again is higher than it is for someone who has never had peritonitis.

Tests and diagnosis

By Mayo Clinic staff
To diagnose peritonitis, your doctor will talk with you about your medical history and perform a physical exam. When peritonitis is associated with peritoneal dialysis, your signs and symptoms, particularly cloudy dialysis fluid, may be enough for your doctor to diagnose the condition. In cases of peritonitis in which the infection may be a result of other medical conditions (secondary peritonitis) or in which the infection arises from fluid buildup in your abdominal cavity (spontaneous peritonitis), your doctor may recommend the following tests to confirm a diagnosis:

Peritoneal fluid analysis. Using a thin needle, your doctor may take a sample of the fluid in your peritoneum (paracentesis). If you have peritonitis, examination of this fluid may show an increased white blood cell count, which typically indicates an infection or inflammation. A culture of the fluid may also reveal the presence of bacteria. Blood tests. A sample of your blood may be drawn and sent to a lab to check for a high white blood cell count. A blood culture also may be performed to determine if there are bacteria in your blood. Imaging tests. Your doctor may want to use an X-ray to check for holes or other perforations in your gastrointestinal tract. Ultrasound may also be used. In some cases, your doctor may use a computerized tomography (CT) scan instead of an X-ray.

The above tests may also be necessary if you're receiving peritoneal dialysis and a diagnosis of peritonitis is uncertain after a physical exam and examination of the dialysis fluid.

Etiology/Epidemiology A wide variety of disease states give rise to intra-abdominal infection. (4) While varying according to age, gender and geography, the three most common causes of generalized peritonitis in low-income countries are probably appendicitis, perforated duodenal ulcer and typhoid perforations, in no particular order. (5) In a study of Nigerian children 50% of patients had typhoid

perforation. (6) In women, the complications of pelvic inflammatory disease predominate. Abdominal trauma resulting in intestinal injury is also a significant cause of peritonitis, particularly in low-income countries. In the West appendicitis remains the most common cause of peritonitis, followed by colonic perforation, usually as a result of diverticulitis. (7) Iatrogenic causes, resulting from failure of intestinal anastomosis and inadvertent bowel injuries, need to kept in mind. Certain clinical conditions, primary peritonitis and appendicitis, are more common in children. (8) Intra-abdominal infection has its own features in the elderly. (9) Mortality in secondary peritonitis decreased significantly throughout the last century from 90% to about 20%. (10) It varies significantly depending on the specific cause: from 0.25% for appendicitis to 45% for fecal peritonitis. In general it depends very much on the degree of contamination and the ability to achieve control of the source. (11) The APACHE II physiologic measurements correlate best with mortality. (12) Unfortunately many of the required indices are not available in low-income countries. 3. Pathophysiology Peritonitis is an inflammatory response to peritoneal injury. Injury results in an influx of protein rich fluid, activation of the complement cascade, up-regulation of peritoneal mesothelial cell activity and invasion of the peritoneum with polymorphonuclear neutrophils and macrophages. (13) There is stimulation of cytokine and chemokine production. Bacteria are opsonized and killed by white blood cells and cleared through the lymphatics. The anatomic origin of bacterial contamination and microbiological findings are no major predictors of outcome. However, the preoperative physiological derangement, the surgical clearance of the infectious focus and the response to treatment are established prognostic factors. The pathogenesis of intra-abdominal infections is determined by bacterial factors which influence the transition from contamination to infection. Bacterial stimuli, especially endotoxin, lead to an almost uniform activation response which is triggered by reaction of mesothelial cells and interspersed peritoneal macrophages and which also involves plasmatic systems, endothelial cells and extra- and intravascular leukocytes. The local consequences of this activation are the transmigration of granulocytes from peritoneal capillaries to the mesothelial surface and a dilatation of peritoneal blood vessels resulting in enhanced permeability, peritoneal edema and lastly the formation of protein-rich peritoneal exudate.(14) Intra-abdominal adjuvants such as bile, talc, barium and the local host response are additionally important. (15) Sequential metabolic changes occur as a result of induction of the systemic inflammatory response syndrome

by severe sepsis or blunt trauma and result in protein catabolism and weight loss. (16) The first line of defense is clearance of noxious agents via the lymphatics of the parietal peritoneum, diaphragm and omentum. The formation of fibrin acts to wall off the infection and is associated with abscess formation. (17) The response to intra-abdominal infection depends on 5 key factors: (a) inoculum size; (b) virulence of the contaminating organisms; (c) the presences of adjuvants within the peritoneal cavity; (d) adequacy of local, regional, and systemic host defenses; and (e) the adequacy of initial treatment. (11) The specific microbial characteristics of different regions of the gut determine the types of infecting organisms found with specific diseases. Secondary peritonitis typically results in polymicrobial infections with gram-negative aerobes and anaerobes. Inflammation within the peritoneal cavity evokes a series of secondary changes that produce the clinical syndrome of peritonitis. These features are part of the Systemic Inflammatory Response Syndrome, whose characteristics include two or more of the following: Temperature >38 C or <36 C; Heart rate >90 beats/min; Respiratory rate <20 breaths/min, or Paco2 <32 mm Hg; WBC >12,000 cells/mm3 or <4000 cells/mm3, or <10% immature (band) forms. While SIRS is caused by a wide variety of conditions, when seen in peritonitis it is called sepsis. Severe sepsis denotes organ dysfunction distant from the site of infection (renal, cardiac, respiratory or brain) or hypotension (systolic < 90mm Hg or mean BP < 70). Septic shock is sepsis with hypotension unresponsive to fluid administration and requiring pressor agents. The acute inflammatory process within the abdomen results in sympathetic activation, and suppression of intestinal peristalsis, or ileus. Fluid absorption through the wall of the bowel is impaired, and significant amounts of tissue fluid may be sequestered within the lumen of the gut, resulting in systemic hypovolemia. Moreover reduced intestinal peristalsis promotes microbial overgrowth, leading to translocation of bacteria and their products from the gut lumen into regional nodes, the peritoneal cavity, and the portal circulation. (3) 4. Peritonitis Peritonitis is traditionally classified as a) primary, b) secondary and c) tertiary. The form most commonly encountered by surgeons is secondary peritonitis resulting from perforation of a hollow viscus or other abdominal pathology. Primary peritonitis results from spontaneous bacterial infection of the peritoneum, alone or in association with peritoneal dialysis. Tertiary peritonitis is characterized by a class of very ill patients in whom secondary peritonitis

fails to resolve despite what appear to be appropriate measures and is associated with multi-organ failure. Tertiary Peritonitis Tertiary peritonitis is defined as recurrent infection of the peritoneal cavity after an episode of primary or secondary peritonitis. It occurs when source control, antibiotic therapy or host immunity are inadequate. Enteroccoci, yeast and antibiotic resistant gram-negative aerobes are more common in recurrent peritonitis. Few patients have significant abdominal symptoms although they will exhibit fever and leukocytosis. Thus imaging, particularly with CT scan plays an important role in detection. The majority of patients require surgical intervention but mortality rates are much higher, up to 50%.