Signs and symptoms[edit]

Abdominal pain and tenderness[edit]

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).
The presence of these signs in a patient is sometimes referred to as peritonism.[1] 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.

Collateral manifestations[edit]

Diffuse abdominal rigidity ("washboard stomach") 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[edit]

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 renal 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[edit]
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Infected peritonitis[edit]

Perforation of part of the gastrointestinal tract is the most common cause of peritonitis.
Examples include perforation of the distal esophagus (Boerhaave syndrome), of
thestomach (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, andanastomotic 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.[2]
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 fungisuch as Candida.[3]
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, in particular, in 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[4]
Non-infected peritonitis[edit]

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 and/or fibroticadhesions. 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[edit]

Previous history of peritonitis

History of alcoholism
Liver disease
Fluid accumulation in the abdomen
Weakened immune system
Pelvic inflammatory disease

Diagnosis[edit]
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A diagnosis of peritonitis is based primarily on the clinical manifestations described above. 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 polymorphonucleate cells per L 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[edit]
In normal conditions, the peritoneum appears greyish and glistening; it becomes dull 24 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[edit]
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 are actually isolated, therapy will of course be targeted
on 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,
andticarcillin/clavulanate.[5] 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 atetracycline 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.[6] The
exception is spontaneous bacterial peritonitis, which does not always benefit from surgery and
may be treated with antibiotics in the first instance.

Prognosis[edit]
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 otherwisehealthy patient.
The mortality rate rises to about 40% in the elderly, and/or in those with significant underlying illness,
as well as in cases that present late (after 48 hours).

If untreated, generalised peritonitis is almost always fatal.

Notable cases[edit]
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On May 13, 1864, 21-year-old Private William Christman of Pennsylvania, who had died of
peritonitis, became the first military man buried at Arlington.[citation needed]
American poet Henry Wadsworth Longfellow also died due to peritonitis on Friday March 24,
1882.
The Swiss Freudian psychiatrist and psychoanalyst Hermann Rorschach, best known for
developing a projective test known as the Rorschach inkblot test, died of peritonitis in 1922 at
the age of 37.[citation needed]
Artist George Bellows died of peritonitis on January 8, 1925 after failing to tend to a ruptured
appendix.
Actor Rudolph Valentino died of peritonitis on August 23, 1926, after suffering a ruptured
appendix. He also developed pleuritis in his left lung and died several hours after entering into
a comatose state.[7][8]
On October 31, 1926, magician and escape artist Harry Houdini died of peritonitis due to a
surprise stomach punch. Many believe that it was a fan who Houdini willingly asked to punch
him (as this was indeed part of his act), but in reality, it was a surprise by a man named Jocelyn
Gordon Whitehead. It is possible, however, that the punch was only the tipping point, and the
stomach punches over the years weakened his stomach muscles more and more.[9][10]
On November 3, 1931, three days after the premiere of Platinum Blonde,[11] Robert Williams died
of peritonitis at Hollywood Hospital after undergoing two operations for acute appendicitis the
previous week.[12][13]
In 1947, drummer Ringo Starr of the Beatles contracted peritonitis, falling into a coma for
three[disputed discuss] days as a result.[14] He contracted it again on April 28, 1979.[15]
Rhythm and blues singer Chuck Willis died from peritonitis in 1958 at the peak of his
popularity.[citation needed]
Japanese professional wrestling legend Rikidzan died of peritonitis on 15 December 1963 after
being stabbed in the abdomen by a urine soaked knife by a member of theYakuza a week prior.
Actress Gloria Grahame contracted peritonitis and died in 1981 after a doctor accidentally
punctured her bowel during a procedure to drain excess fluid from her abdomen.[16]
Kenneth Pinyan, age 45, died in 2005 in what became known as the Enumclaw horse sex case.
Pinyan had engaged in receptive anal sex with a horse, leading to his death due to acute
peritonitis.
 Henry Worsley died on 24 January 2016 while attempting to be the first person to cross the
Antarctic unaided due to bacterial peritonitis, and died of "complete organ failure" after he had
covered 913 miles and only had 30 miles to go. He had spent 71 days travelling out of an
expected 75.[17]

References[edit]
1. Jump up^ "Biology Online's definition of peritonism". Retrieved 2008-08-14.
2. Jump up^ "Causes". Mayo Clinic. Retrieved July 2, 2016.
3. Jump up^ 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.
4. Jump up^ 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.
5. Jump up^ Appropriate Prescribing of Oral Beta-Lactam Antibiotics
6. Jump up^ "Peritonitis: Emergencies: Merck Manual Home Edition". Retrieved 2007-11-25.
7. Jump up^ "Valentino Loses Battle With Death: Greatest of Screen Lovers Fought Valiantly For
Life" (PDF). The Plattsburgh Sentinel. Associated Press. August 24, 1926. p. 1. Retrieved 2010-05-15.
8. Jump up^ Gilbert King (13 June 2012). "The "Latin Lover" and His Enemies". Smithsonian.com.
Smithsonian Institution. Retrieved 30 May 2014.
9. Jump up^ Kalush, William; Sloman, Larry (October 2006). The Secret Life of Houdini: The Making of
America's First Superhero. Simon & Schuster. ISBN 978-0-7432-7207-0.
10. Jump up^ SmarterEveryDay (26 December 2013). "How Houdini DIED (in Slow Motion) - Smarter
Every Day 108" (Video upload). SmarterEveryDay on YouTube. Google, Inc. Retrieved 30 May 2014.
11. Jump up^ Burr, Ty (July 2, 1992). "Platinum Blonde". ew.com. Retrieved June 3, 2009.
12. Jump up^ "Death Claims Robert Williams; Film Actor". Reading Eagle. November 4, 1931. p. 22.
Retrieved February 4, 2013.
13. Jump up^ "Robert Williams, Movie Actor, Dies". Schenectady Gazette. November 4, 1931. p. 1.
Retrieved May 11, 2014.
14. Jump up^ Womack, Kenneth. Beatles Encyclopedia, The: Everything Fab Four: Everything Fab Four.
15. Jump up^ Harry, Bill. The Ringo Starr Encyclopedia.
16. Jump up^ Lentz, Robert J. (2011). Gloria Grahame, Bad Girl of Film Noir: The Complete Career.
Mcfarland. ISBN 0-786-43483-X.
17. Jump up^ Worsley, Henry. BBC News: Explorer Henry Worsley dies in Antarctic crossing.

External links[edit]
Peritonitis disease causes, treatment treatment basis
Article on peritonitis at AllRefer.com
Genuit T and Napolitano L. 2004. Peritonitis and Abdominal Sepsis at Emedicine.com
Peritonitis at HealthCentral.com
openabdomen.org - Peritonitis, Medical and Surgical Therapy Reviewed
Microbiology for Surgical Infections. Diagnosis, Prognosis and Treatment (Eds Kateryna Kon
and Mahendra Rai). Elsevier, 2014.http://www.sciencedirect.com/science/book/9780124116290