The main manifestations of peritonitis are acuteabdominal pain,abdominal tenderness,abdominal guarding, rigidity, which are exacerbated by moving theperitoneum, e.g., coughing (forced cough may be used as a test), flexing one's hips, or eliciting theBlumberg's sign (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). Rigidity is highlyspecific for diagnosing peritonitis (specificity: 76–100%).[7] The presence of these signs in a person is sometimes referred to as peritonism.[8] The localization of these manifestations depends on whether peritonitis is localized (e.g.,appendicitis ordiverticulitis before perforation), or generalized to the wholeabdomen. In either case, pain typically starts as a generalized abdominal pain (with involvement of poorly localizingvisceral innervation of thevisceral peritoneal layer), and may become localized later (with involvement of thesomatic innervation of the parietal peritoneal layer). Peritonitis is an example of anacute abdomen.[9]
Spontaneous bacterial peritonitis (SBP) is a peculiar form of peritonitis occurring in the absence of an obvious source of contamination. It occurs in people withascites, including children.
Intra-peritoneal dialysis predisposes to peritoneal infection (sometimes named "primary peritonitis" in this context).
Systemic infections (such astuberculosis) may rarely have a peritoneal localisation.
Sterile abdominal surgery, under normal circumstances, causes localised or minimal generalised peritonitis, which may leave behind aforeign body reaction or fibroticadhesions. However, peritonitis may also be caused by the rare case of asterile foreign body inadvertently left in the abdomen aftersurgery (e.g.,gauze,sponge).
A diagnosis of peritonitis is based primarily on the clinical manifestations described above. Rigidity (involuntary contraction of the abdominal muscles) is the most specific exam finding for diagnosing peritonitis.[14] If focal peritonitis is detected, further work-up should be done. If diffuse peritonitis is detected, then urgent surgical consultation should be obtained, and may warrant surgery without further investigations.Leukocytosis,hypokalemia,hypernatremia, andacidosis may be present, but they are not specific findings. AbdominalX-rays may reveal dilated, edematous intestines, although such X-rays are mainly useful to look forpneumoperitoneum, an indicator ofgastrointestinal perforation. The role of whole-abdomenultrasound 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 exploratoryperitoneal lavage orlaparoscopy may be performed. In people withascites, a diagnosis of peritonitis is made viaparacentesis (abdominal tap): More than 250polymorphonuclear cells per μL 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.[15][16]
In normal conditions, the peritoneum appears greyish and glistening; it becomes dull 2–4 hours after the onset of peritonitis, initially with scarceserous or slightlyturbid fluid. Later on, theexudate becomes creamy and evidentlysuppurative; in people who are dehydrated, 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 theomentum andviscera.Inflammation features infiltration byneutrophils with fibrino-purulent exudation.[17]
Depending on the severity of the person's state, the management of peritonitis may include:
Antibiotics are usually administered intravenously, but they may also be infused directly into the peritoneum. The empiric choice ofbroad-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 grow in cultures isolated, therapy will be targeted against them.[18]
Gram-positive and Gram-negative organisms must be covered. Out of thecephalosporins,cefoxitin andcefotetan 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 includeampicillin/sulbactam,piperacillin/tazobactam, andticarcillin/clavulanate.[19]Carbapenems are also an option when treating primary peritonitis as all of the carbapenems cover Gram-positives, Gram-negatives, and anaerobes except forertapenem. The only fluoroquinolone that can be used is moxifloxacin because this is the only fluoroquinolone that covers anaerobes.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.[20]
Surgery (laparotomy) is needed to perform a full exploration and lavage of theperitoneum, as well as to correct any gross anatomical damage that may have caused peritonitis.[21] The exception isspontaneous bacterial peritonitis, which does not always benefit from surgery and may be treated with antibiotics in the first instance.
If properly treated, typical cases of surgically correctable peritonitis (e.g., perforated peptic ulcer, appendicitis, and diverticulitis) have amortality rate of about <10% in otherwise healthy people. The mortality rate rises to 35% in peritonitis patients who develop sepsis, and patients who have underlying renal insufficiency and complications have a higher mortality rate.[22]
^McGee, Steven R. (2018). "Abdominal Pain and Tenderness".Evidence-based physical diagnosis (4th ed.). Philadelphia, PA: Elsevier.ISBN978-0-323-50871-1.OCLC959371826.
^Ragetly, G. R.; Bennett, R. A.; Ragetly, C. A. (2012). "Therapie und Prognose der septischen Peritonitis".Tierärztliche Praxis Ausgabe K: Kleintiere / Heimtiere.40 (5):372–378.doi:10.1055/s-0038-1623666.ISSN1434-1239.S2CID73133175.
^Nishijima, D. K., Simel, D. L., Wisner, D. H., & Holmes, J. F. (2012). Does this adult patient have a blunt intra-abdominal injury?. JAMA, 307(14), 1517–1527.https://doi.org/10.1001/jama.2012.422
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