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Asymptinatuc - diffyse peritonitis: life threatening illness

Pain on lower abdomen & pelviss


-

most frequent sign of acute PHD


short duration (<7 days)
constant and dull
accentuated by sexual activity

Assoicuated endocervical infection or coexistent purulent vaginal discharge


Abnormal uterine bleeding
- spotting or menorrhagia
FITS-HUGH-CURTIS SYNDROME
perihepatic inflammation found in 5-10% of woemnt with acute PID
condition is often mistakenly diagnosed as either pnuemonia or acute cholecytiti
s
persistent symptons and signs
- right upper quadrant pain - may radiate to the shoulder on into the back
- pleuritic pain
- tenderness in the right upper quadrant when theliver is palpated
- elevated liver transaminases.
develops from transperitoneal or vascualar dissemination of either the gonococcu
s or Chlamdia organism to produce the perihepatic inflammation
Chalamydia produces the majority of cases
Other organisms:
- Neisserua gonorrhea
- anaerobic streptococci
- coxsackievirus
Diagnosis: Laparoscopy
][IMAGE]
liver capsule will apear inflamed, with classic "violin string" adhensions to th
e parietal peritoneum beneath the diaphragm.
ACUTE SALPINGITIS
Critiera
[All 3 necessary for diagnosis]
Abdominal direct tenderness, with or without rebound tenderness
Tenderness with motion of cervix and uterus
Adnexal tenderness
[plus] [ 1 or more necessary for diagnosis]

Gram stain of endocervix - positive for gram-negative intracellular diplococci


Temperature (<38C)
Leukocytosis (> 10,000)
Purulent material ( white blood cells present) from peritoneal cavity by culdoce
ntesis or laparoscopy
Pevic abscess or inflammatory complex on bimanual examination or on sonography
Diagnosis of PID
CDC Guidelines for Daiagnosis of Acite PID Clinical Criteria for Initiating Ther
apy
Minimum Critera
Empriric treatment of PID should not be initiated in sexually active young women
and others at risk for STDs if all the following minimum criteria are present a
nd no other cause(s) for the illness can be identified:
Lower abdominal tenderness or
Adnexal tenderness or
Cervical motion tenderness
Routine Criteria for Diagnosing PID
Oral temperature >38C
Abnormal cervical or vaginal discharge ( mucopurulent)
Presence of abundant WBCs on microscopy of vaginal secretions
Elevated erythrocyte sedimentation rate
Elevated C-reactive protein
Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachom
atis
Definitive Criteria for Diagnosing PID
Histopathologic evidence of endometritis on endometrial biopsy
Transvaginal sonography or magnetic resonance imagig techniques showing thickene
d fluid-filled tubes with or without free pelvic or tuboovarian complex
Laparascopic abnormalities consistent with PID
Although initial treatment can be made before bacteriologic diagnosis of C. trac
homatis or N. gonorrhoeae infection, such diagnosis emphasizes the need to treat
sex partners.
PID, pelvic inflammatory disease; STD, sexually transmitted disease; WBC, white

blood cells.

Direct visualization via the laparoscope


- GOld standard
- most accurate method of diagnosisng acute PID
- women who undergo laparascopy to confirm the diagnosis of acute PID have the a
dditional advantage of concurrent operative procedures such as lysis of adhesion
s, potential drainage of an abscess, and irrigation of the pelvic cavity.

Severity of Disease by Laparascopic Examination


Severity
MILD - Erythema, edema, no spontaneous purulent exudates; tubes freely movable
MODERATE - Gross purulent material evident; erythema and edema, more marked; tub
es may not be freelt movable, and fimbria stoma may not be patent
SEVERE - Pyosalpinx or inflammatory complex Abscess
Laboratory findings
- not a relaiable indicator of acute PID nor does it correlate with the need for
hospitalization or the severity of tubal inflammation
- <50% of women with PID: white blood cell count of greater than 10,000 cells pe
r milliliter
- in approximately 75% of woment with laparoscopically confirmed acute pelvic in
fection: elevated ESR (>15 mm/hr)
- C-reactive proteins
- hCG - since 3 - 4 of every 100 women who are admitted to a hospital with a dia
gnosis of acute pelvic infection have an ectopic pregnancy

Gram staining
- First: obtain edocervical mucus for inflammatory cells and perform NAAT for b
oth N. gonorrhoeae and C. trachomatis
- C. trachomatis has surpassed N. gonorrhea as the most prevalent sexually tran
smitted bacteria-producing upper tract infection in the developed world

Endometrial biopsy
- for evidence of endometritis
- primarily used to help confirm a clinical suspicion

Ultrasonography
- of limited value for patients with mild or moderate PID due to its low sensiti
vity
- helpful in documentaing an adnexal mass and differentiating between a tuboovar
ian abscess and tuboovarian complex
- also a noninvasive diagnostic aid for patients who are so tender during pelvic
examination that the pysician cannot determine the presence or absence of a pel
vic mass
Magnetic Resonance Imaging
- is sensitive but its expense and limited acute availability in some locations
have restrected its role in PID diagnosis.
MANAGEMENT
Two ost important goals of the medical therapy of acute PID:
1. resolution of symptoms
2. preservation of tubal function
Indications for Hospitalizing Patients with Acute Pelvic Inflammatory Disease
1.
2.
3.
4.
5.
6.

Surgical emergencies (e.g. appendicitis) cannot be excluded


The patient is pregnant
The patient does not respond clinically to oral antimicrobial therapy
The patient is unable to follow or tolerate an outpatient oral regimen
The patient has severe illness, nausea and vommiting, or high fever
The patient has a tuboovarian abscess

Centers for Disease Contral Ambulatory Management of ACUTE PID


Regimen A
Levofloxacin 500mg PO once daily for 14 days
or
Ofloaxcin 400mg PO once daily for 14 days
with or without
Metrondazole 500mg PO bid for 14 days
Regimen B
Ceftriaxone 250mg IM in a single dose
or
Cefoxitin 2 g IM in a single does and probenecid 1 g PO adminstered concurrently
in a single dose
or

Other parental third-generation cephalosporin (e.g. ceftizoxime or cefotaxime)


plus
Doxycycline 100mg PO bid for 14 days
with or without
Metronidazole 500mg PO bid for 14days

Centers for Disease Control Inpatient Mangement of Acute PID


Parenteral Regimen A
Cefotetan 2 g IV every 12 hours
or
Cefoxitin 2 g IV every 6 hours
PLUS
Doxycycline 100 mg PO or IV every 12 hours
Note: Becayse of pain associated with infusion, doxycycline should be administer
ed orally when possible, even when the patient is hospitalized. Both PO and IV a
dmistration of doxycycline provide similar bioavailability.
* a combination of doxycycline oand IV cefoxitin (cefotetan is as effective as c
efoxitin)

Advantage
* excellent for community- acquired infection because it treats bith gonorrhea
and chlamydial infection
* doxycycline and cefoxitin provide excellent coverage for N. gonorrhoeae, C, t
rachomatis, and also penicillinase-producing N. gonorrhoeae
* cefoxitin is an excellent antibiotic against Peptococcus, Peptostreptococcus,
and E. colli
Disadvantage
* combination is that the two drugs are less than ideal for a pelvic abscess or
for anaerobic infections
Parenteral Regimen B
Clindamycin 900 mg IV every 8 hours
PLUS
Gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by a maintena
nce dose (1.5 mg/kd) every 8 hours.
Singe daily dosing may be substituted.

* combination of clindamycin and an aminoglycoside (gentamicin)

Advanatage
* provides excellent coverage for anaerobic infections and facultative gram-neg
ative rods -> preferred for patients with
- an abscess
- IUD- related infections
- pelvic infections after a diagnostic or operative procedure
Alternative Parenteral Regimens
Levofloxacin 500 mg IV once daily
or
Ofloxacin 400 mg IV every 12 hours
WITH OR WITHOUT
Metronidazole 500 mg IV every 8 hours
OR
Ampicillin/Sulbactam 3 g IV every 6 hours
PLUS
Doxycycline 100 mg PO or IV every 12 hours
IV ofloxacin has veen investigated as a single agent; however, because of concer
ns regarding its spectrum, metronidazole may be included in the regimen. Prelimi
nary data suggest that levoflaxicn is as effective as ofloxacin and may be submi
tted; its single daily dosing makes it advantageous.

OPERATIVE TREATMENT
- life-threatening infections
- ruptured tuboovarian abscesses
- laparoscopic drainange of a pelvic abscess
- persistent masses in some older women for whom future childbearing is not a co
nsideration
- removal of a persistent symptomatic mass
Abscess
- is a collection of pus within a newly created space
Tuboovarian complex
- a collection of pus within an anatomic space created by adherence of adjacent

organs
- mixture of anaerobes and facultative or aerobic organisms
- environment of an abscess cavity results in a low level of oxygen tenstion ->
anaerobic organisms predominate
Treatment
- combinatio of clindamycin and an aminoglycoside (combination does not treat th
e enterococcus, and ampicillin should be added if there is suspicion that this o
rganism is involved)
- metronidazole alone is an effective alternative to clindamycin for anaerobic i
nfections but does not provide gram-negative coverage
- if abscesses do not respond to parenteral broad-spectrum antibiotics, drainage
is imperative

Sequelae
-

rupture of tuboovarian abscesses


involuntary infertility
chronic pelvic pain
hydrosalpinx
a collection of sterile, watery fluid in the fallopian tube
end-stage development of a pyosalpinx
pelvic inflammatory disease after index episode
ectopic pregnancy

ACTINOMYCES INFECTION
- a rare cause of upper genital tract infection
- caused by Actinomyces israelii
- gram positive anaerobic bacterium that is difficult to culture
- to sucessfully culture this organism, an anaerobic enviroment must be
maintained for 2 to 3 weeks
- discovered either by histologic examination or culture from women with
tuboovarian abscesses
- may produce a chronic endometritis with an associated foul-smelling discharge
- Manisfestations:
- widespread adhesions
- induration
- fibrosis
- Diagnosis of Actinomyces infection
- classic "sulfur granules" are observed histologically along with grampositive filaments.
- Treatment
* oral penicillin
* doxycycline

* fluoroquinolones
TUBERCULOSIS
- may be produced by either Mycobacterium tuberculosis or M. bovis
- primary site of infection for tuberculosis: lungs
- early in the course of pulmonary infection the bacteria spread hematogenously
-> infection becomes located in the oviduct -> bacilli usually spread to the en
dometrium and less commonly to the ovaries
- primary and predominant site of pelvic tuberculosis: oviducts
- clinical symptoms and signs of pelvic tuberculosis are similar to the chronic
sequelae of nontuberculous acute PID
- predominant presentations of this chronic infection:
- infertility
- abnormal uterine bleeding
- mild to moderate chronic abdominal and pelvic pain occur in 35% of women with
disease
- advanced cases are often accompanied by ascites
- some women may be asymptomatic
- finding at pelvic examination are normal in approximately 50% of cases (remain
ing patients have mild adnexal tenderness and bilateral adnexal masses, with an
inability to manipulate the adnexa because of scarring and fixation.

TUBERCULOSIS SALPINGITIS
- may be suspected when a patient is not responding to conventional antibiotic t
herapy for acute bacterial PID
- results of a tuberculin skin test will be positive
- Diagnosis: performing an endometrial biopsy late in the secretory phase of the
cycle
* findings of classic giant cells, granulomas, and caseous necrosis conf
irm the diagnosis
- laparotomy or celiotomy
- distal ends of the oviduct remain everted, producing a "tobacco pouch" appeara
nce
- chest radiographic examination
- IV pyelogram
- serial gastric washings
- urine cultures for tuberculosis
- Treatment:
- Medical: initial therapy in a patient with newly diagnosed tuberculos
is usually will include five drugs because of the emergence of multidrug-resista
nt organisms
-Operative (reserved for):

women with persistent pelvic masses


some women with resistant organisms
women older than 40
women whose endmetrial cultures remain positive