Peritonitis
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220675885
2008-06-21T00:51:20Z
TwoMightyGods
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[[Category:Peritonitis| ]] create own category so that "deaths from .." can be sensible subcategory
{{Infobox_Disease |
Name = {{PAGENAME}} |
Image = |
Caption = |
DiseasesDB = 9860 |
ICD10 = {{ICD10|K|65||k|65}} |
ICD9 = {{ICD9|567}} |
ICDO = |
OMIM = |
MedlinePlus = |
eMedicineSubj = med |
eMedicineTopic = 2737 |
MeshID = D010538 |
}}
:''This article is concerned with peritonitis in human beings. For a specific cause of peritonitis in cats, see [[feline infectious peritonitis]].''
'''Peritonitis''' is defined as [[inflammation]] of the [[peritoneum]] (the [[serous membrane]] which lines part of the [[abdomen|abdominal cavity]] and some of the [[viscera]] it contains). It may be localised or generalised, generally has an acute course, and may depend on either [[infection]] (often due to rupture of a hollow [[organ (anatomy)|organ]] as may occur in [[abdominal trauma]]) or on a non-infectious process. Peritonitis generally represents a [[surgical emergency]].
==Mechanisms and manifestations==
===Abdominal pain and tenderness===
The main manifestations of peritonitis are acute '''[[abdominal pain]]''', '''[[abdominal tenderness]]''', and '''[[abdominal guarding]]''', which are exacerbated by moving the peritoneum, e.g. coughing, flexing the 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 often referred to as peritonism{{Fact|date=June 2008}}. 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 generalised abdominal pain (with involvement of poorly localising innervation of the visceral [[Peritoneum#Layers|peritoneal layer]]), and may become localised later (with the involvement of the somatically innervated parietal peritoneal layer). Peritonitis is an example of an [[acute abdomen]].
===Collateral manifestations===
* Diffuse abdominal rigidity ("[[washboard abdomen]]") is often present, especially in generalized peritonitis;
* [[Fever]];
* [[Sinus tachycardia]];
* Development of [[ileus|ileus paralyticus]] (i.e. intestinal paralysis), which also causes [[nausea]] and [[vomiting]];
===Complications===
* Sequestration of [[fluid]] and [[electrolyte]]s, as revealed by decreased [[central venous pressure]], may cause [[electrolyte disturbance]]s, as well as significant [[hypovolaemia]], 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.
* the fluid may push on the diaphragm and cause breathing difficulties
==Diagnosis and investigations==
A [[diagnosis]] of peritonitis is based primarily on clinical grounds, that is on the clinical manifestations described above; if they support a strong suspicion of peritonitis, [[surgery]] is performed without further delay from other investigations. [[Leukocytosis]] and [[acidosis]] may be present, but they are not specific findings. Plain [[abdominal X-rays]] may reveal dilated, oedematous intestines, although it is mainly useful to look for [[pneumoperitoneum]] (free air in the peritoneal cavity), which may also be visible on [[chest X-rays]]. If reasonable doubt still persists, an exploratory [[peritoneal lavage]] may be performed (e.g. in cases of [[physical trauma|trauma]], in order to look for [[white blood cells]], [[red blood cells]], or [[bacteria]]).
==Causes==
===Infected peritonitis===
* '''Perforation of a hollow viscus''' is the most common cause of peritonitis. Examples include perforation of the distal [[oesophagus]] ([[Boerhaave syndrome]]), of the [[stomach]] ([[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]], and [[anastomosis|anastomotic]] leakage. The latter occurrence is particularly difficult to diagnose early, as [[abdominal pain]] and [[ileus|ileus paralyticus]] are considered normal in patients who just underwent [[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.
* '''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 [[physical trauma|trauma]], [[surgical wound]], continuous ambulatory [[peritoneal dialysis]], 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 [[fungi]] such as [[Candida]].
* '''Spontaneous bacterial peritonitis''' (SBP) is a peculiar form of peritonitis occurring in the absence of an obvious source of contamination. It occurs either in [[children]], or in patients with [[ascites]]. See the article on [[spontaneous bacterial peritonitis]] for more information.
* '''Systemic infections''' (such as [[tuberculosis]]) may rarely have a peritoneal localisation.
===Non-infected peritonitis===
* '''Leakage of [[sterilization (microbiology)|sterile]] [[body fluids]] into the peritoneum''', such as [[blood]] (e.g. [[endometriosis]], blunt abdominal [[physical trauma|trauma]]), [[gastric juice]] (e.g. [[peptic ulcer]], [[gastric carcinoma]]), [[bile]] (e.g. [[liver biopsy]]), [[urine]] (pelvic [[physical trauma|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 24-48h.
* '''Sterile abdominal surgery''' normally causes localised or minimal generalised peritonitis, which may leave behind a [[foreign body reaction]] and/or fibrotic [[adhesion (medicine)|adhesion]]s. Obviously, peritonitis may also be caused by the rare, unfortunate case of a [[sterile technique|sterile]] [[foreign body]] inadvertently left in the [[abdomen]] after [[surgery]] (e.g. [[gauze]], [[sponge]]).
* Much rarer non-infectious causes may include [[familial Mediterranean fever]], [[porphyria]], and [[systemic lupus erythematosus]].
==Treatment==
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 disturbance]]s.
* '''[[Antibiotics]]''' are usually administered [[intravenous]]ly, 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.
* '''[[Surgery]]''' ([[laparotomy]]) is needed to perform a full exploration and lavage of the [[peritoneum]], as well as to correct any gross anatomical damage which may have caused peritonitis.<ref name="titlePeritonitis: Emergencies: Merck Manual Home Edition">{{cite web |url=http://www.merck.com/mmhe/sec09/ch132/ch132g.html |title=Peritonitis: Emergencies: Merck Manual Home Edition |accessdate=2007-11-25 |format= |work=}}</ref> The exception is [[spontaneous bacterial peritonitis]], which does not benefit from [[surgery]].
==Prognosis==
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 otherwise [[healthy]] [[patient]]s, which rises to about 40% in the [[elderly]], and/or in those with significant underlying [[illness]], as well as in cases that present late (after 48h). If untreated, generalised peritonitis is almost always fatal.
==Pathology==
The [[peritoneum]] normally appears greyish and glistening; it becomes dull 2-4 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.
==References==
<references/>
* [http://www.peritonitis-disease.com Peritonitis disease causes, treatment ..].
* [http://health.allrefer.com/health/peritonitis-symptoms.html All Refer Health article on peritonitis]
* Genuit T and Napolitano L. 2004. [http://www.emedicine.com/med/topic2737.htm Peritonitis and Abdominal Sepsis]. Emedicine.com
* Health square. 2004. [http://www.healthsquare.com/mc/fgmc9043.htm Peritonitis].
{{Gastroenterology}}
[[Category:Peritonitis| ]]
[[Category:Inflammations]]
[[Category:Diseases involving the fasciae]]
[[Category:Medical emergencies]]
[[Category:Surgery]]
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