• Primary bacterial peritonitis is caused mainly by hematogenous spread or transluminal invasion in patients with advanced liver disease and reduced ascitic fluid protein concentration
• Surgical causes are classified as secondary bacterial peritonitis resulting from bacterial contamination originating from within the viscera
• Secondary bacterial peritonitis most commonly follows disruption of a hollow viscus
• Most common etiology in young patients is perforated appendicitis
• Most common etiology in elderly patients is complicated diverticulitis or perforated peptic ulcer
• Fever and chills
• Severe abdominal pain with rebound tenderness, guarding, and rigidity ("acute abdomen")
• Diminished bowel sounds
• Physical signs of peritonitis may be subtle in the very young or old and in patients who are immunosuppressed
• Abnormal liver profile or renal function test
• Mild elevation in amylase
• Elevated ESR and C-reactive protein
• Abdominal x-ray: Demonstrates free air and ileus pattern and may suggest the primary etiology
• Water soluble contrast study: Demonstrates the location of the perforated viscus
• Abdominal pelvic CT scan with IV and PO contrast: Best exam for characterizing source of bacterial peritonitis, although an operation should not be delayed to obtain this test in patients with an acute abdomen
• Primary bacterial peritonitis
• Etiology of secondary bacterial peritonitis:
-Perforated gastroduodenal ulcers
-Nonvascular small bowel perforation
-Large bowel perforation
-Acute necrotizing pancreatitis
• Familial Mediterranean fever
• Resuscitation with IV fluids and electrolyte replacement
• Operative control of the abdominal sepsis
• Systemic antibiotics
• Cardiorespiratory ICU support as indicated
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