Peritonitis, Bacterial

• • Bacterial peritonitis is a suppurative response of the peritoneal lining to direct bacterial contamination

  • Clinical manifestations include:

  • -Fever and chills

    -Tachycardia

    -Acute abdomen

    -Free air on plain films

Epidemiology

• • 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

Symptoms and Signs

• • Fever and chills

  • Tachycardia

  • Oliguria

  • 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

Laboratory Findings

• • Leukocytosis

  • Abnormal liver profile or renal function test

  • Mild elevation in amylase

  • Elevated ESR and C-reactive protein

  • Bacteremia

Imaging Findings

• • 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:

  • -Appendicitis

    -Perforated gastroduodenal ulcers

    -Diverticulitis

    -Gangrenous cholecystitis

    -Acute salpingitis

    -Nonvascular small bowel perforation

    -Large bowel perforation

    -Mesenteric ischemia

    -Acute necrotizing pancreatitis

    -Postoperative complications

    -Others

  • Familial Mediterranean fever

Rule Out

• • Primary bacterial peritonitis in patients with advanced liver disease (high operative mortality)

  • Nonoperative causes of peritonitis

  • -Pancreatitis

    -Pyelonephritis

    -Acute salpingitis

• • Thorough history and physical exam

  • CBC

  • Basic chemistries

  • Amylase and lipase

  • UA

  • Liver profile

  • Coagulation studies

  • Abdominal x-rays

When to Admit

• • All patients with bacterial peritonitis should be admitted for appropriate surgical and medical management

When to Refer

• • Primary bacterial peritonitis is ideally cared for nonoperatively by gastroenterologists

  • Secondary bacterial peritonitis should be managed by a general surgeon

• • Resuscitation with IV fluids and electrolyte replacement

  • Operative control of the abdominal sepsis

  • Systemic antibiotics

  • Cardiorespiratory ICU support as indicated

Surgery

Indications

• • Operative goal is to correct the underlying cause of abdominal sepsis:

  • -Perforated viscus

    -Ruptured appendix

    -Infected necrotizing pancreatitis

    -Gangrenous cholecystitis

    -Abscess drainage

Medications